Pediatric Hospitalization

Perspectives & Practice in Pediatric Nursing

A Comprehensive Framework: Family-Centered Care, Health Promotion, and the Hospital Experience

  • Foundational Themes:

    • Family-Centered Care

    • Health Promotion

    • The Hospital Experience

The Philosophy of Care

  • Transition in Approach: From treating an isolated "patient" to partnering with the family as a core element of care.

Core Definition

  • Family-Centered Care:

    • "Family-Centered Care recognizes the family as the constant in a child's life, while the health care service system is temporary."

Key Concepts

  • Enabling:

    • Definition: Creating opportunities for family members to display their current abilities and acquire new competencies.

  • Empowerment:

    • Definition: Interaction allowing families to maintain control and recognize positive changes in their situation.

  • Atraumatic Care:

    • Definition: The provision of therapeutic care using interventions aimed at eliminating or minimizing psychological and physical distress.

    • Goal:

    • First, do no harm.

    • Prevent separation from family.

    • Promote control in healthcare situations.

    • Minimize bodily injury and trauma during care processes.

The Landscape of Child Health (US Data)

Demographics

  • Population of Children: 74 million children aged 0-17 years, representing 22% of the US population.

  • Economic Status: 18% of children live in poverty.

Improving Trends

  • Health Indicators:

    • Immunization rates: Increasing.

    • Adolescent birth rates: Declining.

    • Violent crime victimization: Improving.

Concerning Trends

  • Health Concerns:

    • Preterm Births: Slight increase noted.

    • New Morbidity: Associated with poverty, school failure, and violence among children.

Critical Disparities

  • Socioeconomic Factors:

    • Significant health outcome disparities shaped by race, ethnicity, and socioeconomic status (SES).

    • Statistic: Infant mortality rate for African American infants is twice that of white infants.

Pillars of Health Promotion

Frameworks

  • Guidelines:

    • Healthy People 2030

    • Bright Futures

Key Areas of Focus

  • Nutrition:

    • Human milk is preferred for all infants.

    • Lifelong eating habits are most effectively established within the first three years of life.

  • Oral Health:

    • Dental caries rank as the most common chronic disease in children.

    • Prevention Strategies: Good hygiene practices and fluoride treatment should begin with the first tooth eruption.

  • Development:

    • Importance of developmental surveillance unique to each stage of a child's growth.

    • Early Identification: Critical to ensure timely intervention for developmental delays.

  • Technology & Screen Time:

    • Emphasis on the context of media exposure: not solely on what is viewed but who is sharing the experience with the child.

    • Recommendations:

    • For children under 18 months: No screen time except for video chatting.

    • For children 2 to 5 years old: Screen time should be used sparingly and co-viewed by parents or caregivers.

Major Threats to Health: Mortality & Morbidity

Infant Mortality (<1 Year)

Risks

  • Drivers of Mortality:

    • Congenital anomalies

    • Short gestation/Low Birth Weight

    • Sudden Infant Death Syndrome (SIDS)

  • Note: Birth weight is identified as the major determinant of neonatal death.

Childhood Mortality (>1 Year)

Leading Causes

  • Main Driver: Unintentional injuries, including:

    • Motor Vehicle Accidents (MVAs)

    • Drowning

    • Burns

  • Adolescent Mortality: Homicide and suicide rank as the second and third leading causes of death in adolescents aged 15-19.

The New Epidemics

  • Obesity: Prevalence recorded at 18.5% (BMI ≥95th percentile).

  • Vaping: Noted as a national epidemic with a 78% increase in high school usage during 2018.

The Nurse's Toolkit: Clinical Judgment

Integrating Evidence-Based Practice (EBP) and the NCSBN Model

NCSBN Clinical Judgment Measurement Model Steps:

  1. Recognize Cues:

    • Filter relevant data from the patient's presentation.

  2. Analyze Cues:

    • Link immediate cues to the patient's history and possible complications.

  3. Prioritize Hypotheses:

    • Evaluate urgency and risk of each hypothesis.

  4. Generate Solutions:

    • Identify expected outcomes for proposed interventions.

  5. Take Action:

    • Implement interventions based on the chosen solutions.

  6. Evaluate Outcomes:

    • Compare actual outcomes against expected results to determine efficacy.

The Hospital Experience: The Crisis

Key Stressors for Children in the Hospital

  • Illness: Often the first crisis experienced by a child.

Major Stressors Encountered:

  • Separation:

    • Regarded as the primary stressor affecting children from middle infancy through preschool age.

  • Loss of Control:

    • Resulting from physical restrictions, alterations in routines, and dependency on healthcare providers.

  • Bodily Injury & Pain:

    • Associated fears include mutilation, bodily intrusion, and alterations to body image.

Vulnerability Factors

  • Age: Children aged 6 months to 5 years at the highest risk.

  • Gender: Male children show greater vulnerability.

  • Temperament: ‘Difficult’ temperament exacerbates stress response.

  • Multiple stressors further heighten the risk.

Stressor Deep Dive: Separation Anxiety

Stages of Response to Separation

  1. Stage 1: Protest

    • Age Range: Peak incidence is observed between 6 to 30 months.

    • Behavioral Indicators: Crying, screaming, and inconsolable distress.

  2. Stage 2: Despair

    • Behavioral Indicators: Withdrawn, sad demeanor, and disinterest in surroundings.

    • Clinical Trap: This behavior is often mistakenly interpreted as "good adjustment" but indicates distress.

  3. Stage 3: Detachment

    • Behavioral Indicators: Superficial adjustment, showing indifference to parents and caregivers.

    • Risk: This responses can lead to serious long-term implications for emotional development.

Stressor Deep Dive: Loss of Control

Developmental Impact Across Stages

  • Infants (Trust vs. Mistrust)

    • Need for consistent caregivers and established daily routines.

  • Toddlers (Autonomy)

    • Threat to independence through movement restrictions.

  • Preschoolers (Magical Thinking/Egocentric Behavior)

    • Perception that illness is a punishment for their actions or thoughts.

  • School-Age Children (Industry/Independence)

    • Fear of loss of competence, boredom, and disconnection from peer groups.

  • Adolescents (Identity)

    • Threat of isolation from peers and challenges to social status.

Stressor Deep Dive: Fear of Bodily Injury

Developmental Perspectives

  • Toddlers/Preschoolers:

    • Struggle with concepts of body boundaries having fears related to bodily integrity (“insides will leak out”), hence the importance of reassurance through Band-Aids and similar items.

  • School-Aged Children:

    • Express fears of internal injuries and feel a societal pressure to exhibit bravery.

  • Adolescents:

    • Concerns related to scarring and body image are prominent at this stage.

The Power of Language

  • Considerations: The cognitive level of the child shapes their understanding.

    • Example: "CAT Scan" might be misinterpreted as involving actual cats, requiring careful phrasing.

  • Recommendation: Using simple, age-appropriate terminology is essential for conveying medical information.

Nursing Interventions: Minimizing Stress

Approaches to Minimize Key Stressors

  • Preventing Separation:

    • Strategies include rooming-in to accommodate parents 24/7, providing transition objects like family blankets or photos, and assuring a nurse's presence when parents are absent.

  • Minimizing Loss of Control:

    • Strategies include promoting freedom of movement (using wagons/wheelchairs instead of beds), maintaining routines including schoolwork and rituals, and fostering independence by allowing choices in clothing and self-care activities.

  • Reducing Fear:

    • Preparation is essential; knowing what to expect reduces the fear of the unknown and helps minimize anxiety.

    • Modifying medical procedures based on age (e.g., using axillary temperatures instead of rectal) helps in minimizing discomfort.

The Therapeutic Value of Play

Context of Play in Pediatric Care

  • Concept: Play is recognized as the work of childhood and an integral part of healing and coping strategies for hospitalized children.

Playroom Rule

  • A designated area must be a "Safe Zone" where no medical or nursing procedures take place, allowing children to freely engage in play.

Therapeutic Play

  • Facilitators: Nurses and Child Life Specialists.

  • Nature of Play: Nondirective and designed to facilitate coping through activities like dramatic play using puppets, role-playing medical scenarios, or drawing.

Play Therapy

  • Facilitators: Trained therapists/specialists.

  • Method: An interpretive psychological strategy used to help analyze behavior, especially in emotionally disturbed children.

Caring for the Family Unit

Understanding the Family as Patients

  • Frame: Parents and siblings often represent the “hidden patients” within pediatric care dynamics.

Parental Reactions

  • Common emotional responses:

    • Feelings of helplessness, guilt, and anger.

  • Care Needs: Parents require personable care and empowerment.

  • Action Steps: Encourage participation in daily care tasks (like bathing or feeding) while enabling parents to rest and replenish their energy.

Sibling Reactions

  • Common feelings:

    • Jealousy, resentment, and guilt (worrying they have contributed to the illness).

  • Interventions:

    • Provide simple, honest explanations about the hospitalized child’s condition.

    • Arrange prepared visits to the hospital, and facilitate exchanges of “gifts” from the hospitalized child to siblings.

Special Contexts: High-Intensity Care

Challenges in High-Intensity Settings

Common Stressors

  • Isolation: Particularly in Intensive Care Units (ICU).

  • Emergency Admissions: Can induce high parental anxiety regarding survival and outcomes.

Strategies for Management

  • ICU Introductions: Introduce staff to the child before donning PPE to create familiarity.

  • Playful Adjustment: Children can dress up in personal protective equipment (PPE) to lessen fear of staff.

  • Environmental Considerations: Position beds closer to windows for light exposure and comfort.

Post-Emergency Strategies

  • Preparation and Support: Help parents transition after shock; provide counseling and use play/storytelling methods to help children process trauma.

Discharge Planning & Conclusion

Key Principles of Discharge Planning

  • Start Early: Discharge planning begins upon admission.

  • Assessment: Evaluate family resources, home setting, and available support systems.

  • Educational Approach (Stepwise):

    • Step 1: Observe the process.

    • Step 2: Participate with assistance.

    • Step 3: Demonstrate independently.

Conclusion

  • Pediatric nursing integrates the ART of caring—through the principles of atraumatic/family-centered nursing—with the SCIENCE of clinical judgment.

  • Through understanding developmental needs and stressors, nurses can transform potentially traumatic experiences into significant opportunities for personal and emotional growth for both children and families.