Pediatric Health Nursing

Unit-IV
Communication/ Therapeutic Play While Caring For Children With Various Disease
Process

Faculty: Sadia saeed

RN, Generic Bsc.N
 Unit objectives:
After This Session the Learner will be able to discuss:
Guidelines for communication with children and families.
Role of play in growth and development of children.
Functions of play for hospitalized children.
Therapeutic play versus play therapy.
Play as a tool for nursing management
Importance of therapeutic play from Pakistani Perspectives
 INTRODUCTION
Communicating with children and family caregivers is a primary
source of data collection during a well-child visit or in any health
crisis situation. Communication occurs in all settings and focuses on
data collection as well as information related to immunizations,
developmental assessment, teaching, and anticipatory guidance.
Information about the child is derived from the child, the caregivers,
and the nurse’s observations of the child and family. Understanding
the developmental level of the child and influences on the child’s
and caregiver’s communication (e.g., family, culture, community,
age, & personality) are critical for communicating affectively.
 PURPOSE
Sometimes it is just about talking to and interacting with children
Establishing a therapeutic relationship
Supporting children
Eliciting and giving information
Explaining procedures
Listening to what they want to tell us
Obtaining information about how they ‘are feeling’ to help with
diagnosis
 CONTI...
To convey information.
To develop specific skills.
To develop situation for analysis.
Provide an opportunity for social interraction among
members.
 GENERAL MEASURES CONSIDERING DURING
COMMUNICATION
Be aware of child’s inability to communicate verbally because of
disabilities, developmental delays or traumatic scenarios and adjust your
approach to meet their needs.
Children may change their style of interaction, being passive or active,
which the nurse needs to be aware of when communicating.
Adopting the SOLER approach (face people Squarely; Open body
shape; Lean forward slightly; Eye contact; Relax).
Be prepared to come down to the child’s level (e.g. sitting on the floor)
when communicating directly with them.
Use different approaches such as play, humor or drawing to engage with
children.
 COMMUNICATING WITH THE FAMILY
Encourage parents to talk openly regarding their concerns.
Use open-ended questions.
Use careful, nonjudgmental statements.
Men may prefer a focus on cognitive, problem-solving talk.
Females may prefer a focus on the process rather than the outcome.
Be aware and considerate of generational differences.
Incorporate active listening skills.
Be aware and considerate of cultural differences.
 CONT…
When communicating, use silence, empathy, respect, genuineness,
and trust as nursing interventions.
Communication can be tricky with non traditional and noncustodial
parents. Follow the established policies and procedures the hospital
has in place.
Remember to observe and record nonverbal communication factors,
such as tone of voice, body language, and facial expression. Be
aware of your own nonverbal communication factors and make sure
you are not communicating unintended messages.
 CONT…
Allow family members to voice their understanding of the
current situation.
Clarify or provide teaching points to decrease
misunderstandings.
 COMMUNICATING WITH CHILDREN
The majority of the communication will take place between
practitioners and parents. However, the child cannot and
should not be excluded.
Make sure to incorporate active communication strategies
with the pediatric patient as well. Incorporate an
understanding of growth and development when
communicating with the pediatric patient.
 CONT…
Observe body language, facial expressions, and other
nonverbal gestures.
Incorporate play into nursing assessments and interactions
where appropriate.
Use special toys or games to assist with assessments.
 METHODS OF COMMUNICATION WITH
CHILDREN

Verbal—words, face-to-face interactions; infants cry, coo,

and respond to their environment; parents and caregiver
need to learn the cues of the infant or child
Be mindful of long pauses, rapid speech, and engaging the
appropriate individuals in the communication process.
Gear communication to the cognitive and developmental
level of the child.
 METHODS OF COMMUNICATION WITH
CHILDREN

Nonverbal—gestures, body language, posture, eye contact.

Be aware of cultural factors
Visual—can include signs, photos, and illustrations.
Play—allows children to express feelings and concerns in a
nonverbal manner.
 Children base their views on the relationships and experiences
within their daily lives.
 Infants and children with altered hearing may have delayed
communication.
 COMMUNICATING WITH INFANTS

Newborn to 12 months
This is a time of rapid physical and developmental growth.
The body systems are maturing, and skill development is
taking place.
Social development is influenced by the infant’s
environment and the attachment developed with their
parents and caregivers.
 CONT…
Infants are unable to verbalize needs, concerns, and discomforts.
Nonverbal behaviors, such as smiling, promote socialization.
Infants display crying and cooing.
Infants cry when they are hungry, when their diapers need to be
changed, when feeling pain or discomfort, and when feeling lonely or
wanting to be held.
Infants coo when they are content or happy.
Temperament and disposition
 CONT…
Infants are often quiet, observing the environment around them.
Infants respond to the nonverbal behaviors of adults: touch, sound,
and tone of voice.
Observe parents and child caregivers’ interactions and handling of
the infant:
Separation anxiety
Fear of strangers
If the child has attained understanding of object permanence, he or
she will know when a parent is missing
 CONT…
Quickly respond to the infant’s crying by feeding,
diapering, or picking up the infant.
Infants need to feel and touch the environment around
them.
 COMMUNICATING WITH TODDLERS AND
PRESCHOOLERS

Younger than 5 years old

This is a time of intense exploration of the child’s environment. The
young child learns more of his or her environment while also
exhibiting some negative behaviors, including tantrums (emotional
outburst).
This time can be overwhelming and challenging for parents and
caregivers but is an important period of development for the child.
Much cognitive, social, psychosocial, and biological growth and
development is occurring.
 CONT…
A tantrum (or temper tantrum
or tirade or hissy fit) is an
emotional outburst, usually
associated with children or those
in emotional distress, that is
typically characterized by
stubbornness, crying, screaming,
yelling, shrieking
 CONT…
Children of this age are typically egocentric, or unable to think from
another person’s point of view.
Use statements such as “good job” instead of “good boy/girl.”
Children of this age need to feel and touch the things around them to
gain knowledge of and experiment with unknown environments
Medical play may be useful in demonstrating how a procedure will
take place.
The child may practice or pretend that a doll is having a procedure
done.
 CONT…
If appropriate, allow the child to handle a stethoscope, pulse
oximetry, and blood pressure cuff and explore these items in a
nonthreatening environment.
Children of this age are very concrete and literal, and are often
unable to conceptualize that one word may have more than one
meaning.
 CONT…
“Stick” or “poke” refers to a needle insertion for the nurse, but the
young patient views a stick as a small piece of wood found in the yard.
Bleeding may be perceived as a child’s “insides leaking out.” Young
children are often comforted by an adhesive bandage used to cover an
open area.
When having an x-ray procedure, the child may smile when getting his
or her “picture” taken.
Children assume that inanimate objects feel and act as humans do. For
example, they might think that something inanimate could bite them.
 CONT…
The child may call an instrument “bad” if it has caused pain or
discomfort to them.
They are fearful of unfamiliar objects and environments.
When possible, allow the child to tour a facility or treatment room
prior to the actual treatment.
Preschoolers begin to develop skills in fantasy and pretend play.
This is a period of social, language, and behavioral development.
Children of this age are developing a sense of autonomy.
 COMMUNICATING WITH SCHOOL-AGE
CHILDREN (Ages 6 to 12 years )
This period of physical and psychosocial development includes many
milestones, such as entering school, communicating independently, and
beginning to conceptualize the environment.
Communication directly with children of this age is equally important
as communicating with their parents.
School-age children are energetic and want answers to the questions
they have. They want to develop connections and ties with information
learned and ask themselves and others why certain things occur and
happen.
 CONT…
Curious
Used to asking questions in school when they cannot understand
Want to know why or how things happen or occur
Gain knowledge by experience and by understanding what is
occurring
Enjoy having a job or task to complete
Eager to please, and want to complete a task independently
Work well with positive feedback
 CONT…
Tell the child that he or she is part of the medical team that will help
to get him or her well.
Assign daily jobs, such as an exercise or a task, so that the child can
assist with care.
Concrete
Unable to think abstractly
Examples should be given in a physical context in which the child
can see, feel, or hear a result.
May overreact if feeling threatened
 CONT…
Able to verbalize thoughts, feelings, or concerns
Encourage children to ask questions.
Older children may wish to journal their experiences.
Other children may serve as a support group.
Need play time
Playing will allow the child to communicate thoughts or
feelings in a nonthreatening environment.
Allow the school-age child to be an active participant in care.
 COMMUNICATING WITH ADOLESCENT
CHILDREN (AGES 13 TO 18)

This is a time of developing independence and maturity. The adolescent

child focuses more on social networks and friends.
The adolescent child may seek counsel and feedback from sources
other than parents and caregivers.
Behavior may fluctuate between adult and childlike.
Adolescents are independent with activities of daily living, but still
require adult supervision and input
Adolescents are becoming more independent, but still require adult
supervision and input.
 COMMUNICATING WITH CHILDREN

Nursing Care Guidelines

Allow children time to feel comfortable.
Avoid sudden or rapid advances, broad smiles, extended eye contact,
and other gestures that may be seen as threatening.
Talk to the parent if the child is initially shy.
Communicate through transition objects such as dolls, puppets, and
stuffed animals before questioning a young child directly.
Give older children the opportunity to talk without the parents
presence.
 CONT…
Assume a position that is at eye level with the child.
Speak in a quiet, unhurried, and confident voice.
Speak clearly, be specific, and use simple words and short sentences.
State directions and suggestions positively.
Offer a choice only when one exists.
Be honest with children.
Allow children to express their concerns and fears.
Use a variety of communication techniques.
 CHARACTERISTICS OF COMMUNICATIVE
DEVELOPMENT IN YOUNG CHILDREN

Perlocutionary Stage (0 to 8–9 Months) Child is reflexive to

stimuli. Child shows increasing purpose in action.
Emerging Illocutionary Stage (8–9 to 12–15 Months) Child
communicates intentionally with signals and gestures.

Conventional Illocutionary–Emerging Locutionary Stage (12–15

to 18–24 Months) Child communicates intentionally with gestures,
vocalizations, and verbalizations.
 CONT…
Locutionary, illocutionary, perlocutionary For example, me saying to
you "Don't go into the water" (a locutionary act with distinct
phonetic, syntactic and semantic features) counts as warning you not
to go into the water (an illocutionary act), and if you heed my
warning I have thereby succeeded in persuading you not to go into
the water (a perlocutionary act).
This taxonomy of speech acts was inherited by John R. Searle,
Austin's pupil at Oxford and subsequently an influential exponent of
speech act theory.
 CONT…
Nursing Care Guidelines Build a Foundation Spend time together.
Encourage expression of ideas and feelings.
Respect their views.
Tolerate differences.
Praise good points.
Respect their privacy.
Set a good example.
Communicating with Adolescents
 CONT…
Communicate Effectively Give undivided attention. Listen, listen,
listen.
Be courteous, calm, and open minded.
Try not to overreact.
If you do, take a break.
Avoid judging or criticizing.
Avoid the “third degree” of continuous questioning.
Choose important issues when taking a stand. After taking a stand:
Think through all options. Make expectations clear.
PLAY
 DEFINITION OF PLAY
Play is a pleasurable activity that is actively engaged in on a
voluntary basis, is intrinsically motivated and contains
some non-literal elements. (Cook and Cook,2007)
Play is the activity that has no serious motive and from
which there is no material gain. The distinction between
work and play however lies in the mental attitude.
Football can be play for children or can be work and means
of earning for the professional footballer.
 WHAT IS PLAY
Play is critical to the healthy growth and development of children.
One of the ways children learn about themselves, the people around
them, their environment, and their community.
By playing, a child will then learn how to process and make sense of
what sensations he/she receives whether it’s by sight, sound, taste,
smell, or touch.
Play relieves stress and boredom, connects people in a positive way,
stimulates, creative thinking and exploration, regulates emotions,
and boosts confidence.
 PARTEN’S STAGES OF SOCIAL PLAY

Unoccupied Play:
The child is not playing or watching anyone or anything in
particular.
They might stand or sit and just do nothing.
Onlooker Play:
The child spends most of their time watching others play.
They might talk to the players, but will not engage in the actual play
activity
 PARTEN’S STAGES OF SOCIAL PLAY
CONT…
Solitary play
The child plays alone.
No connection or conversation is made with anyone nearby.
Parallel play
The child plays alone but with toys that are shared with
others.
The child plays beside other children but communication
might be limited or none at all.
 PARTEN’S STAGES OF SOCIAL PLAY
CONT…

Associative play
The child plays with other children.
The play is not coordinated. They may talk and share toys but they
are still independent players.
Cooperative play
Children come together and play.
A group of children with a common goal or similar interests, acting
out adult situations or playing formal games.
 CHILDREN LEARN THROUGH PLAY

Develop physical skills:

– Gross motor skills are developed as a child learns to reach, grasp,
crawl, run, climb, and balance.
– Fine motor skills are developed as children handle some toys.
(Control of the hands and fingers improve)
 CHILDREN LEARN THROUGH PLAY
CONT…

Cognitive Development
– Learn to solve problems through play. – Learn colors, numbers,
size and shapes.
– Have the ability to enhance their memory skills as well as their
attention span.
– Able to move on to higher levels of thought as they play in a more
stimulating environment.
 CHILDREN LEARN THROUGH PLAY
CONT…

Develop Language Skills:

– Language develops as a child plays and interacts with others.
– Begins with: Parents playing cooing games with their children and
advances to practical levels such as telling make-believe stories and
jokes.
Develop Social Skills:
– Natural way for children to interact.
– Opportunities for cooperating, taking turns, sharing, listening, and
negotiating exist within the play context/rules.
 CONT…
Parental Involvement
Parents are their children’s first and best playmates.
Children tend to be more creative.
– Observe: Watch your child closely to learn what he or she can do
and has problems doing. Be aware of your child’s favorite activities.
– Follow: Join in and play with your child so that he or she knows
you are interested in what he or she is doing.
– Be creative: Use toys in different ways. Being creative will make
playing more fun for you and your child.
 PLAYTIME IS LEARNING TIME:

Play Time Classic Toys

Playtime has a unique way of helping children learn new
developmental and social skills.
Toys are tools that can help children learn about themselves and the
world around them.
Play Time Classic Toys: Dolls or Stuffed Animals, Blocks.
Young children can learn to practice their people skills manipulate
blocks and model behaviors that make basic towers through they see
in other people. building , designing, patterning, and creating.
 LEARNING THROUGH PLAY IN THE
CLASSROOM

Play as an avenue for learning

– Classroom environments can be altered to decrease children’s
stress levels.
– Play should be in a relaxed environment.
– Teachers can create environments that are more playful and less
stressful by allowing children to make choices about their activities.
– Allowing students to make decisions about what and how they
learn helps them find learning enjoyable.
– Freedom = Confidence in their growing abilities
 CONT…
Self-efficacy Literacy skills
Critical for literacy learning in influence what happens in life
language development. through actions they take.
With play, children develop, They develop the sense that their
understanding of language and how it allows they can have control
over them to interact with people.
 THERAPEUTIC PLAY:
Therapeutic play is the specialized play activity by which a child
acts out or expresses his unconscious feelings. It is a central
mechanism in which children cope, communicate, learn & master a
traumatic experience such as hospitalization.
 THERAPEUTIC PLAY VERSES PLAY
THERAPY
Several types of play therapy. They include Adlerian,
Cognitive Behavioral, Child-Centered, Sand Tray, and
Child-Parent Relationship Play Therapy approaches.these
specific approaches exists another concept:
non-directive versus directive play therapy.
It has important implication for overall(physical,
psychological, and psychosocial) development of any
children.
 CONTI..
Play therapy capitalizes on such therapeutic powers or
changing mechanisms within play and considers its
strategic use through trained professionals to promote
specific therapeutic outcomes within therapeutic contexts. it
also helps them to understand the past and also to prepare
for the future. this helps children develop con dence and
self-efcacy which leads to healthy outcomes including
reduction of anxiety and inculcation of more positive
behaviors
 CONTI...
Play therapy or play-based interventions are widely used to
facilitate communication between therapist and children
and to help children’s understanding of events. It is a better
medium of communication as play itself may create
emotional reactions and make such emotional reactions
more powerful. In therapy, therapist can use a puppet
animal or a telephone while interviewing the child to serve
this purpose.Child practitioners also use play in diagnostic
assessments based on the idea that children may act out
their true feelings with the help of carefully
 CONTI...
carefully slected material further, play therapy can also be
used in planning intervention with children. Here, therapist
tries to understand the feelings which a child express.Play
provides unlimited opportunities for the child to gain a
sense of competence and self-efcacy that boosts their
self-esteem. By engaging in activities such as construction
play and gameplay, children learn self-control skills.
Researches need to be conducted for further improvement
in theraputic play therapy.
 IMPORTANCE OF PLAY:
CHILD
 Enhance coping abilities
 Express fear, anxiety, tension, anger, fantasies.
 Understand hospital procedures.
 Communicate & reduce emotional trauma.
 Continue growth & development.
 Get rid of boredom.
 IMPORTANCE OF PLAY
HEALTH TEAM MEMBERS
§ Gain co-operation & trust of the child.
§ Diagnose child’s feelings & behavior.
§ Find out & correct misconceptions & beliefs
§ Reassure the parent
§ Promote parent participation in child care
 FUNCTIONS 0F PLAY
Provides diversion Outlet for creative ideas or
Brings about relaxation interests
Helps feel secure Opportunity for choices & be in
Lessen stress of separation & control
home sickness Accomplish therapeutic goals.
Release tension, expression of
feelings
Encourages interaction
Develop positive attitudes
towards others
 TYPES OF PLAYS
Emotional outlet/dramatic play: Used to improve & maintain
Used to express child’s anxiety physical health & body functions
Solve conflicts Selected to treat pathological
Diagnostic tool condition
Instructional play:
Instruction is given for
therapeutic play according to their
past experiences, coping abilities
& physiological status
Physiological enhancing play:
 CONT…
Non-directive play therapy:
Client centered or unstructured play therapy
If allowed to play freely, children resolve their own problem & work
towards their own solution
Few boundaries & can be used at any age
Directive play therapy:
Directions given for play
Causes faster change & more structured than non-directive play
Games chosen by the child, therapists give directions
 CATEGORIES OF PLAY
Physical play: environment
Social in nature- involves other Starts in infancy
children Move objects like puzzle pieces to
Provides exercise, which is essential understand it better, E.g.: Drops a toy,
for normal development,E.g. Run, Wait for the parent to pick it, clean it
jump etc. Expressive play: & return it, & they drop it again.
Gives opportunity to express feelings
Parents take an active role, E.g. Play
using colored pencils, crayons,
markers, water colors etc..
Manipulative play:
Children control or master their 01/28/2022
 CONT…
Symbolic play: Surrogate play:
Helps explain child’s problem in a For children who are severely ill
symbolic way Parent/another child is a surrogate
No rules, can use to reinforce, learn Watching the surrogate play,
about, & imaginatively alter painful stimulates the sick child
experiences Dramatic play:
Child act out situations experienced
by them
Either spontaneous, guided or
therapeutic
 COMMON PROBLEMS
Challenge, as child cant Should have no sharp edges &
voluntarily engage no small parts
Parents need to understand the Tossing ball to a child with cast
importance fall
Play activities vary depending Chasing ball falls, collisions
on cultural & socio-economic If toy is used for a long time,
circumstances can use it in unsafe way
Not knowing the group
languages
SAFETY ISSUES:
Should be washable
 NURSES RESPONSIBILITIES
Organize play activities
Flexibility in play time
Play materials should be placed in separate room
Age appropriate play articles should be provided
Involve all members for play
Interact during play
Observe & record child’s behavior
Protect & guide children when aggressive
Participate with the children during play
 NURSING CARE & FAMILY PRINCIPLES &
PRACTICES

PREVENTING OR MINIMIZING SEPARATION

Primary goal
Welcome the presence of parents
Family centered care
Provide support- both parents & child
Frequent parental visits
Leave a favorite article, if the parents can’t room-in
 CONT…
MINIMIZING LOSS OF CONTROL:
Promoting freedom of movements
Place child on parent’s lap during procedures
Mechanical freedom can be provided
Maintain child’s routines
Encouraging independence
Concept of self care
Promote understanding
Inform children about their rights
 CONT…
PREVENTING OR MINIMIZING FEAR OF BODILY INJURY:
Preparation of children for painful procedures
Manipulating procedural techniques
Stress the reason for a procedure & evaluate child’s understanding
Employ pain reduction techniques
 CONT…
STRATEGIES TO COPING & NORMAL DEVELOPMENT:
Focus on physiological, psychosocial & developmental needs
Promote effective coping
Provide developmentally appropriate activities like rooming in,
therapeutic play & therapeutic recreation & child life programs
ROOMING IN:
Have a parent stay in child’s hospital room
Parent should assist in child care
Communication between nurse & parent, so that parent’s desire for
involvement is supported
 CONT…
CHILD LIFE PROGRAMS:
Focuses on psychosocial needs of hospitalized child
Professional child specialist, Para professionals & volunteers –staff
Plan age appropriate play
Assist children in working through feeling about illness, E.g.
Playing with medical equipment
Child specialist & nurses together assist children in their needs
 CONT…
THERAPEUTIC RECREATION:
Planned recreation program for adolescents to meet development
needs during hospitalization
Telephone contact & visits from friends
Interaction with the teenagers
Physical activities that provide an outlet for stress recommended
Assist to regain control
Giving options & letting to choose promotes feeling of
independence
 CONT…
Acutely ill child may enjoy listening to stories
Children must be taught to take care of their toys
Nurse should participate in play activities
 PLAY AS A TOOL FOR NURSING
MANAGEMENT
It’s develope communicational skills for cunduct friendly child interview
inorder to indentifing issues.
It’s helpful in access , which kind of techniques we need to solve this problem.
Develope ability to observe and analyze situation and draw conclusion.
It’s give better understanding of matter,which help to release stress of making a
mistake.
Enhance self confidence ,which helpful in management.
Increase consciousness of cause and effect involved in a serquence of events.
Helpful for building therapeutic values.
 CONTI..
provide feeling of secure.
Enhance friendly and helpful environment.
Gain co-opreration and trust of the child and after cause study promote parent
participation in child care.
It can bring out data human behaviour and humanrelations, which are not made
available by other method.
Encourage interaction and development of positive attitudes
toward others.
 REFERENCES
1. Axline VM. Play Therapy-The Inner Dynamics of Childhood.
Worcestershire: Read Books Ltd.; 2013.
2. Schaefer CE, editor. The Therapeutic Powers of Play. Northvale, NJ: Jason
Aronson; 1993.
3. Piaget J. Play, Dreams and Imitation in Childhood. Abingdon: Routledge;
2013.
4. Schaefer CE, Drewes AA. Therapeutic powers of play and play therapy. In:
Drewes AA, editor. Blending Play Therapy with Cognitive Behavioural
Therapy: Evidence Based and Other Effective Treatments and Techniques.
Hoboken, New Jersy: John Wiley & Sons, Inc.; 2009. p. 3-16.
5. Isenberg J, Quisenberry NL. Play: A necessity for all children. Childhood
Educ 1988;64:138-45.