Nursing Care Of the

hospitalized child

Dr. Hanan Saca-Hazboun

NURS 333
Introduction
1. Child health care has changed dramatically in
recent years due to advances in medical
knowledge and understanding of emotional
response of children.
2. Modern concept of child health emphasizes on
continuous care of “whole child”.
3. According to UNICEF, assistance for meeting
the needs of children should no longer be
restricted to one aspect like nutrition, but it
should be broad based and geared to their long
term personal development ensuring holistic
health care of children.
⮚… Introduction
1. Increased public awareness, consumerism and
family participation in child care are newer
trends.
2. Medical science is advancing in every moment.
so, child health will also progress by various
movements towards the aim to improve the
survival and well being of all children.
⮚ Trends in pediatrics and pediatric
nursing
1. Child Health Care has changed dramatically in
recent years due to advances in knowledge and
understanding of emotional response of children.
2. Health exists when an individual meets
minimum physical, physiological, intellectual,
psychological and social aspects to function
appropriately for their age and sex level.
3. illness is the situations when individual
experiences a disturbance in any of these areas
that prevents functioning at appropriate level.
4. modern concept of child health emphasizes on
continuous care of “whole child”
⮚ GOBI FFF
⮚ currently UNICEF is promoting following
ways of child health revolution by a campaign
known as GOBI FFF
1. G - for growth charts to monitor child development
2. O - for oral rehydration to treat mild and moderate
dehydration
3. B - for breast feeding and
4. I - for immunization against 6 killer diseases, e.g.
measles, diphtheria, polio, pertussis, tetanus and
tuberculosis
5. FFF - family welfare; female child, food and nutrition
⮚ Hospitalization of the child
⮚ The act of putting a child in the hospital adds
stress to a child already coping with illness.
⮚ With hospitalization comes a
1. change from the usual state of health
2. Change in routine
⮚ Hospitalization

● The hospitals are necessary places for providing the

health care to the ill children.
● Hospitalization is Confusing, complex &
overwhelming
● Strategies needed to prepare children & families
1. Identifying needs
2. Assessment of nonverbal & verbal behaviors
3. Validating information
4. Providing appropriate interventions
5. Teaching & communicating
6. Evaluate child & family competence in
providing self care upon discharge
⮚ Family-Centered care
1. Family centered care is built on partnerships
between families and health care professionals.
⮚ Family-Centered care
1. The family is the primary unit for the delivery of
health services to infants/ children
2. The family environment is the greatest influence
on the child's health
3. A child is dependent on parents/family members
for physical necessities, emotional support,
intellectual stimulation
4. The family is the intermediary between the child
and the outside world
5. Health providers can support, encourage, and
enhance the competence of parents in their roles
as caregivers.
⮚ In family-centered care environment;
the nurse
1. Shares ongoing information
2. Provides care that promotes growth and
development in a safe environment
3. Ensures that health care is accessible and
responsive to family needs
4. Treats family with courtesy, dignity
5. Provides accurate information
6. Participates in the decision-making process
related to the child’s health
⮚ Nurse’s Role
1. Nurse is primary person in care of child
2. Introduction
3. Building a trusting relationship
4. Making decisions with family
5. Providing comfort & reassurance
⮚ Stressors associated with illness and
Hospitalization
1. Limited understanding
2. Disruption of usual routine
3. Regression common goes back to old
habits – incontinence; sucking of the thumb
4. Separation anxiety
5. Loss of control- restrained, confined, invasive
procedures
6. Fear & anxiety
7. Fear of bodily injury, mutilation or harm
⮚ Factors influencing the impact of
hospitalization on the child

1. Age
2. Developmental ability
3. Timing
4. Previous experience
5. Parental response
⮚ Preparation for Hospitalization
1. Educate what to expect to separate fantasy from
reality
2. Describe intervention & sequence of steps
3. Avoid use of medical terms
4. Allow child to handle equipment
5. Teach steps of procedure
6. Show the room the child will be in
7. Introduce to health care personnel
⮚ Preparation for Hospitalization
8. Rehearsal of what will happen
9. Tour of the unit
10. Video, DVD or coloring books explaining
procedure
11. Role playing
12. Give child a job to do
13. Explain sounds
14. Adapt to cognitive & developmental stage
⮚ Minimizing negative effects

1. Use of transitional items

2. Rooming-in, parents participate
3. Child-friendly environment
4. Therapeutic play
5. Atraumatic care
6. Allow child to manipulate equipment
⮚ Child’s Reaction to Hospitalization
● Fear of the unknown
1. Separation anxiety
a) Phase of protest: cry loudly, searches for parents with eyes, clings to
parents
b) Phase of despair: depressed, sad, inactive, child’s condition may
deteriorate due to refusal to eat or drink
c) Phase of detachment (denial): Child becomes interested in
environment, plays, seems to form relationships with caregivers and
other children. If parents reappear, the child may ignore them
2. Loss of Control 🡺 sleep pattern
3. Bodily injury and pain: Fear of pain or mutilation with invasive
procedures (preschoolers lack an understanding of body integrity)
● Anger
● Guilt
● Regression
⮚ Separation Anxiety (continued)
1. All children react differently

2. This is the greatest stress of hospitalization

and if this is avoided young children can
withstand other stressors

1. Hospitals are now making accommodations

for parents to stay with children ( no longer
considered “visitors”)
⮚ Loss of Control
1. This is the next great stress of hospitalization
and illness
2. Infants and toddlers want to maintain their
routines and habits from home or will develop
mistrust
3. Preschoolers feel loss of control from
restrictions, altered routines and dependency
⮚ Bodily injury & pain:
1. fears of bodily injury & pain are prevalent
among and recent research documents that
young children, react to painful stimuli. In caring
for children, nurses must understand the
developmental concepts of illness and pain
(Table 20-1) and developmental characteristics
of children's responses to pain.
⮚ Parental Responses to Stressors of
Hospitalization

⮚ Disbelief, anger, guilt

⮚ Especially if sudden illness
⮚ Fear, anxiety
⮚ Related to child’s pain, seriousness of illness
⮚ Frustration
⮚ Especially related to need for information
⮚ Depression
⮚ Stressors & Reactions of the Family of the
Child who is Hospitalized
● Parental reaction:
1. Initially parents may react with disbelief: If
illness is sudden & serious.
2. Following the realization of illness, parents react
with anger, guilt:
3. Fear, anxiety and frustration:
4. Depression: usually occurs when the acute crisis
is over.
● Sibling reactions
● Altered family roles
⮚ Factors Affecting Parents’ Reactions to
Their Child’s Illness 🡺
1. Seriousness of the threat to the child (The
cause of illness & its treatment).
2. Guilt about the illness
3. Previous experience with illness or
hospitalization (Past experience of illness &
hospitalization)
4. Medical procedures involved in diagnosis &
treatment (The threat to the child’s long-term
state of health)
⮚ Factors Affecting Parents’ Reactions to
Their Child’s Illness
5. Available support systems
6. Personal ego strength (depends of
developmental stage, self-esteem).
7. Previous coping abilities (Coping method
within the family)
8. Additional stresses on the family system
cultural & religious beliefs (influences)
9. Communication patterns among family
members
⮚ Preventing or
Minimizing Separation
1. Primary nursing goal
2. Especially for children younger than 5 years
3. Family-centered care
4. Parents are not “visitors”
5. Familiar items from home
⮚ MothersAre the Usual Family
Caregivers
⮚ Nursing Diagnoses for Child Undergoing
Surgery
1. Anxiety r/t surgery, fear of injury or bodily
mutilation, separation from family or friends,
changes in routine, painful procedures and
treatments and unfamiliar events and
surroundings AEB crying, fussing,
withdrawal or resistance
2. Risk for powerlessness r/t lack of control over
procedures, treatments and care & changes in
usual routine
⮚ Effects of hospitalization on the child
● Individual risk factors:
1. “Difficult” temperament
2. Lack of fit between child and parent
3. Age (especially between 6 months to 5 years)
4. Male gender
5. Below-average intelligence
6. Multiple & continuing stresses (e.g. frequent
hospitalization).
⮚ Individual Characteristics That Affect
Coping in Children
1. Gender
2. Age
3. Temperament
4. Preexisting conditions
5. Self-concept
6. Social skills
7. Genetic factors
8. Intelligence
9. Hardiness/Resilience
“Normalizing” the Hospital Environment
1. Promote freedom of achievement

2. Maintain child’s routine, if possible

3. Time structuring

4. Self-care (age appropriate)

5. Schoolwork

6. Friends and visitors

⮚ Maximizing Potential Benefits
of Hospitalization
1. Fostering parent-child relationships
2. Providing educational opportunities
3. Promoting self-mastery
4. Providing socialization
5. Supporting family members
⮚ Nurse Maintains Hand Contact
⮚ Temperament Theory:
Common ground
Various theoretical approaches agree
temperament:

1. is biologically based
2. refers to individual differences
3. is modifiable by environment
4. exhibits a relative degree of stability over
time
⮚ Temperament Theory:
Common ground
1. Temperament is behavioral style: the how of
behavior rather than the what or why.
Temperamental differences are present at
birth; they influence how children behave
toward individuals and objects in their
environments and how they are affected by
the environment.
2. Temperament characteristics explain in part
how individuals with many stresses may do
well while some with little or no stress have
difficulty.
⮚ Temperament Theory:
Chess & Thomas
1. Environment can influence the behavioral
expression of temperament, as well as its
underlying nature

1. Pioneering NYLS interviewed 133 parents of

3-month-olds, followed them for over 30
years

1. Identified 9 temperament traits by analyzing

contents of interviews (clinical significance)
⮚ Temperament

● Thomas & Chess

● A set of tendencies to respond in

predictable ways, across situations and
across time
● Nine temperament traits

1. Easy
2. Difficult
3. Slow to warm-up
⮚ Major Temperament Areas
A. Energy: Activity
Intensity –energy

B. Adjustability: how fast the infant

adjust
1. Adaptability:
2. Approach/Withdrawal:
3. Mood
⮚ C. Secondary Areas
(but still important areas)
● Sensitivity 🡺

● Regularity 🡺 Biological rhythmicity

● Distractibility (soothability)

● Persistence
⮚ Fit with Nurses’ Expectations

Parents doing care Nurses assisting

Child
focus of care

Parents being there Nurses being supervisor

⮚ Communicating with Children
Play is the serious business of
childhood
⮚ Infancy

1. Respond to physical contact

2. Gentle voice
3. Sing-song quality
4. High pitched
5. Need to be held, cuddled
⮚ Early Childhood < 7 years
egocentric, interpret words literally

1. tell them what “they” can do

2. let them touch equipment
3. nonverbal messages should be clear
4. maintain eye level
5. use quiet, calm voice
6. be specific, use simple words, short
sentences, be honest
⮚ School Age

1. want to know why an object exists

2. how it works
3. why it is being done to them
4. concerned about body integrity
⮚ Adolescents

1. give undivided attention

2. listen, be open-minded
3. avoid criticizing
4. make expectations clear
⮚ Pediatric physical differences
● See the video -
⮚ Central nervous system differences in
neonates and infants
1. Poorly developed fiber
2. reflex jerks and tremors: some reflexes fade at
six months
3. poorly developed cortical functions such as
memory, reasoning, speech, vision, hearing,
sensation, abstraction & patterns of responses
4. immature thermoregulation system.
⮚ Pulmonary system differences in neonates
and young children
1. A large tongue in relation to mouth size
2. Higher trachea
3. Small, and short airways
4. Short and straight Eustachian tubes
5. High respiratory rates
6. High susceptibility to infection.
⮚ Chest immaturity and size factors that affect
respirations include
1. Underdeveloped intercostal muscles
2. Small ventilatory space.
3. Thin chest wall
4. Soft, flexible ribs and sternum.
⮚ Cardiovascular system differences in
children include:
1. Higher relative blood volume
2. Lower absolute blood volume
3. Tachycardia with stress
4. High neonatal hemoglobin.
5. Transient neonatal bradycardia.
6. Higher heart: in general, heart rates are higher in
young children with gradual decrease throughout
childhood.
7. Lower blood pressure: while blood pressure in
life gradually increasing throughout childhood.
⮚ Illness increases most of these needs.
For example
1. Fluid needs increase particularly when fever,
vomiting or diarrhea are present.
2. Caloric requirements increase about 10% for
each centigrade elevation in temperature. This
increase metabolism.
3. Increase in oxygen demands.
4. Increase in respiratory rate result is
tachypnea.
5. Increase in fluid loss and hence increase risk
of dehydration during illness.
⮚ Significant gastrointestinal system include
1. Larger food needs
2. Greater caloric requirements
3. Air swallowing
4. Regurgitation
5. Higher risk of aspiration
⮚ In the renal system the differences
1. Ease of dehydration and over-hydration
2. Greater risk of drug toxicity
3. Smaller bladder capacity
4. Smaller absolute urine volume
5. Larger proportionate urine output/per kg/per
body weight