NURSING CARE OF A FAMILY WITH AN ILL CHILD

Illnesses that require the attention of healthcare professionals are outside the usual occurrences of
childhood, so most children typically have little knowledge about them. Helping a child and family
prepare for or adjust to such an experience is a fundamental nursing role. This role goes well beyond
just providing information on what to expect throughout an illness. It involves providing emotional
support as well. Studies from the 1980s and 1990s found that family visitation was associated with lower
anxiety levels among adult postanesthesia care unit (PACU) patients, and similar results have been
found among pediatric patients. The literature has repeatedly shown that unrestricted visitation in
healthcare settings increases family satisfaction, improves children’s morale, and can improve
communication among the staff, the patient, and the family. In response to this, children and families
should be enrolled in orientation programs before hospital admission, and nurses should advocate for
the use of therapeutic play and be more open to parental visiting and overnight stay policies, even in
intensive care areas, if these are not already in effect.

THE MEANING OF ILLNESS TO CHILDREN

The response of children to illness depends on their cognitive ability, past experiences, and level of
knowledge. It parallels cognitive development (see Chapter 28). From early school age, children
generally know quite a bit about the workings of their major body parts. As general guidelines, early
grade-school children are usually able to name the function of the heart, lungs, and stomach. However,
children are not able to see the body as a system until the age of 10 to 11 years (Bibace & Walsh, 1980).

Younger children may think the cause of illness is magical or that it occurs as a consequence of breaking
a rule. With this perspective, they may also think getting well again is possible only if they follow another
set of rules, such as staying in bed and taking medicine. By fourth grade, children are generally aware of
the role germs play in illness but may be fooled by thinking that all illnesses are caused by germs.
Because of this, they may see a passive role for themselves in getting well because illness comes from
outside influences. At about eighth grade, children are able to voice an understanding that illnesses can
occur from several causes, such as being susceptible to chickenpox because they did not get a vaccine.
This understanding is due to the formal logical stage that Piaget (1930) described. Where there is
differentiation between self and other.

An illness in a child is a stress, especially if it includes hospitalization (Foster, Whitehead, & Maybee,
2016). Knowing how children of each age view illnesses affects the planning of nursing care and
influences how explanations should be worded. For example, saying you are going to “stick” a child for
blood work could be interpreted by young children as meaning you are actually going to put a stick in
their arm. Saying a child will receive dye for a test could be interpreted as meaning the child will “die”
during the procedure. Explanations of procedures can sound confusing if words sound alike or have
double meanings (e.g., “drawing” as in making a picture vs. “drawing” blood). Because of these distorted
perceptions, explanations of procedures do not always relieve children’s stress.

DIFFERENCES IN RESPONSES OF CHILDREN AND ADULTS TO ILLNESS

Keeping in mind that children are not just small adults is important when evaluating how children react
to illness, perceive an illness, or react to health care (Illness is potentially traumatic because of the
unknown and because of the pain and discomfort that may be involved. Children need extra attention
and reassurance to calm their fears.). Their body images, for example, as evidenced in their drawings,
are different from those of adults. They may have difficulty telling which body parts are indispensable
and which are not (this is why it is wise to talk to preschool and early school-age children about “fixing”
body parts, such as tonsils, rather than “taking them out”).

Inability to Communicate

Very young children do not have the vocabulary to describe symptoms. Children younger than 5 years of
age have a great deal of difficulty describing a headache. Dizziness and nausea can be equally
bewildering because young children do not know the words to express these phenomena. By the time
children reach school age, most can describe symptoms with accuracy. They may intensify their
concerns if they believe someone expects symptoms to be more serious. They may minimize symptoms
if they are afraid that an illness will interfere with an activity they want to do; thus, it is important to
evaluate a child’s symptoms as much by observation as by a child’s report. A crying, whining preschooler
who is “just not herself” probably has a symptom she cannot describe. A school-age child who guards
her abdomen (i.e., keeps abdominal muscles rigid) is in pain just as clearly as a child who verbalizes a
source of discomfort.

Inability to Monitor Own Care and Manage Fear

Adults who are ill often ask questions about medications prescribed for them or procedures they are
scheduled to undergo. If a hospitalized adult knows he is to receive a diuretic three times a day and by
10 AM has not been offered it as yet, he usually reminds someone of the oversight. School-age and
younger children cannot monitor their own care this way because they may not know which medicine or
procedures they are scheduled to receive. If they do know, they may be confused about the time. In
addition, children have fears that adults do not experience. For example, by 8 to 9 months, the infant
fears separation above all else; the toddler and preschooler enlarge their fears to include separation, the
dark, intrusive procedures, and mutilation of body parts. The school-age child and adolescent may be
concerned about the loss of body parts, loss of life, and loss of friends. Adults have fears also, but most
have prior experiences to draw from, making coping easier. Children in a strange environment, such as a
hospital, have not learned coping skills as yet and so require proportionally more support and active
intervention to manage their stress and fears. Otherwise, hospitalization, particularly if it follows trauma
from unintentional injury, can result in posttraumatic stress disorder (PTSD) or the development of
characteristic symptoms, such as difficulty falling asleep, outbursts of anger, difficulty concentrating,
difficulty completing tasks, or experiencing symptoms such as stomach aches or headaches

Nutritional Needs

Children differ from adults in many ways. In addition to psychological differences, there are major
physiologic differences in the way illnesses affect children compared with adults. Children have greater
metabolic demand, breathe in more air per pound of body weight than adults do, have a higher surface
to body mass ratio (Centers for Disease Control and Prevention [CDC], 2015a), and are at greater risk for
insensible fluid loss when they are sick. For example, children need more nutrients (calories, protein,
minerals, and vitamins) per pound of body weight than adults because their basic metabolic rate is
faster, and they must take in not only enough to maintain body tissues but also enough to allow for
growth. The infant, for example, requires 120 kcal/kg of body weight per day; the adult requires only 30
to 35 kcal/kg of body weight per day. An ill child who must limit food intake because of nausea or
vomiting, therefore, may require hospitalization for intravenous therapy, even though this might not be
necessary for an adult under the same circumstances.

Fluid and Electrolyte Balance

In the adult, extracellular water (the water held in plasma and outside body cells) represents
approximately 23% of total body water; in a newborn, extracellular water is closer to 40%. This means
that an infant does not have as much water stored in the cells as an adult and so is more likely to lose a
devastating amount of body water with diarrhea or vomiting. The full implications of both vomiting and
diarrhea are discussed in Chapter 45.

Systemic Response to Illness

Because a child’s body is continually growing, young children tend to respond to disease systemically
rather than locally. The child with pneumonia, for example, may be 2166brought to an emergency
department not because of a cough (although the child may have one) but because of accompanying
systemic symptoms such as fever, vomiting, and diarrhea. In fact, nausea and vomiting occur so
frequently in children with any type of illness that these symptoms do not have the diagnostic value that
they may have in adults. Systemic reactions of these kinds can delay diagnosis and therapy and can
cause increased fluid and nutrient loss, circumstances that compound the initial illness.

Age-Specific Diseases

Most adults have achieved immunity to common infectious diseases; children, however, are very
susceptible to illnesses such as measles, mumps, and chickenpox. Febrile children between the ages 6
and 60 months who do not have an intracranial infection or metabolic disturbance are typically
diagnosed with “febrile seizure”

CARE OF THE ILL CHILD AND FAMILY IN THE HOSPITAL

Research has raised awareness about the psychological trauma children and their parents face when
hospitalized. This trauma can have lasting effects after discharge, undermining the child’s recovery and
the overall well-being of the family (Franck et al., 2015). The caregivers of a child admitted to an
intensive care unit (ICU), neonatal intensive care unit (NICU), or general pediatric unit are likely to
experience a high degree of stress during their child’s hospitalization both because of the severity of
their child’s illness and the high-tech pediatric ICU (PICU) or NICU setting. The child in an acute care
setting is much more apt to have invasive procedures compared with children on a general pediatric
floor, which can also increase anxiety not only for the child but also the parent. A child’s type of surgery
is also related to parental anxiety and should be taken into consideration when speaking with the family

THE EFFECT OF HOSPITAL SEPARATION AND CHILDREN: DECREASING SEPARATION ANXIETY

Social/emotional development begins early in infancy. Babies display sadness, happiness, and anger at a
young age, and they begin to change their facial expressions to register changes in their emotions
around 5 months. During this period, infants also become attached to parents and caregivers. When in
the presence of strangers, infants fix their eyes on them, become restless, perhaps thrash arms or legs,
and begin to cry. This activity peaks at approximately 9 months of age. It is a developmental milestone
that shows that an infant is able to distinguish a primary caregiver from other persons. The timing of
separation anxiety can vary widely from child to child. Within the hospital setting, that anxiety may be
relieved by establishing a primary nurse.

In many instances, toddlers and preschoolers can be as affected by separation as infants and even
express their feelings better, louder, and longer. Although many toddlers and preschoolers attend day
care and have had prior experiences with separation, others may have had only limited experiences
being away from their parents. Being hospitalized may be the first time they are away from parents in a
strange setting or away from home overnight. The effect of separation can become especially intense in
young children before they are able to understand time, because statements such as “Mom will visit
again tomorrow” or “Dad will be here by 6 o’clock” are meaningless unless they know what “tomorrow”
or “6 o’clock” means.

School-age children and adolescents react better than younger children to the separation imposed by
hospitalization because they have experiences they can use for comparison. They have been to school
for whole days, perhaps they have stayed with a grandparent or a friend overnight, and they may have
been to a summer camp. This can make hospitalization a time for developing self-esteem and
confidence in their ability to be independent. Even in light of this, ill school-age children and adolescents
appreciate their parents being near them and reassurance that their parents will be there to support
them through this crisis.

Remember that being separated may create an equally difficult time for parents. You may need to spend
time with them, assuring them that their child will receive comprehensive, evidence-based care at all
times, even if they have to leave for a commitment or to care for other children at home.

To appreciate why preventing separation is so important, it is helpful to review the research that
provided the foundation for this method of care. Spitz (1945) was one of the first researchers who
documented the effects of separation on children. He observed children in a penal nursery and in a
foundling home who had been separated from their mothers for both short and long periods of time.
From this observation, he was able to document that infant’s growth and development slowed the
longer they were away from their parent. Bowlby (1951) conducted additional studies with children
separated from their parents during World War II. Building on Spitz’s and Bowlby’s work, Robertson
(1958) applied these effects to the hospitalization of children and supplied labels for separation effects.
Although defined over 50 years ago, these findings are still applicable to children today.

Reducing the ill effects of separation and hospitalization to the extent possible should be a high priority
for all healthcare providers (Hilton, 2014). Nurses play a major role in this on both direct care and
management levels. Unfortunately, even despite the best preparation by parents or nurses, not all of
these effects of hospitalization can be prevented.

PREPARING THE ILL CHILD AND FAMILY FOR HOSPITALIZATION

Preparing for hospitalization involves disseminating developmentally appropriate information,

facilitating communication and developing trusting relationships with healthcare professionals (Koller,
2008). Many childhood illnesses such as febrile seizures, appendicitis, poisonings, and asthma
exacerbations are acute, making advance preparation for hospital admission impossible. However, when
hospitalizations such as elective surgeries are scheduled, advance preparation is possible with programs
such as preoperative orientation. The preparations parents make for a child obviously vary depending
on the child’s developmental age and experiences.

Depending on the age of the child, there may be anxiety if the child is told about an approaching
hospitalization too far in advance. Conversely, few things are more frightening for children than to hear
a conversation halt as they enter a room or to hear adults spelling out unknown words. As a rule,
therefore, children between 2 and 7 years of age should be told about a scheduled ambulatory or
inpatient hospitalization as many days before the procedure as the child’s age in years. For example, a 2-
year-old should be informed 2 days before hospitalization; a 4-year-old, 4 days before; and so forth.
Children older than 7 years of age can be told as soon as the parents are aware of it.

On the day of hospital admission, it is important for you to ask the parents what preparation they have
done to ensure the child and family accurately understand the child’s condition and upcoming
procedures. Based on that, you can provide further health teaching and clear up any misunderstandings
as necessary (Box 36.2).

Many hospitals sponsor hospital orientation programs for children’s groups or school groups during
which hospitalization is discussed. These programs are beneficial because they lay a foundation for all
children about what to expect during a hospitalization; then, if they must be admitted on an emergency
basis, they may not be so frightened. Programs are offered by nurses at the hospital or on visits to
children’s groups or schools (Fig. 36.2). Box 36.3 provides guidelines for setting up hospital tours or
discussions for early school-age children.

Guidelines for Conducting Hospital Tours With Early School-Age Children

1) Keep groups small (about 10 children per group) so individual reactions to the presentation can
be assessed.
2) Allow or encourage parents to join the tour so their concerns about the hospital can also be
relieved.
3) Conduct the tour for only 20 to 30 minutes to meet the short attention span of children.
4) Use an indirect method to present various aspects of a hospital that would be exceptionally
anxiety producing such as the intensive care unit (ICU) or an operating room by using puppets,
films, or a PowerPoint slide show. Include nonthreatening features such as a hospital playroom.
5) Present explanations about hospitalization in concrete terms and at the child’s level of
understanding. Include only what the child will see, hear, and feel.
6) Avoid dwelling on unpleasant and threatening events or intrusive procedures, such as blood
drawing or anesthesia, that may create apprehension.
7) Allow children opportunities to ask questions.
8) Allow children opportunities to play with dolls and hospital equipment to decrease anxiety and
satisfy curiosity.