Nursing Care of the Hospitalized Child

Nursing Care of the Hospitalized Child

Psychological and Developmental Impact of Hospitalization

• Developmental Perspectives on Hospitalization:     

• - Infants and Young Children: They lack the cognitive capacity to understand the reasons for their hospitalization.     

• - Toddlers: This group is striving for a sense of autonomy but is confronted with physical limitations, restrictions, and the alteration of established rituals and routines.     

• - Preschool Children: Often engage in magical thinking. They may believe that their illness or hospitalization is a direct punishment for a specific behavior or action, causing them to feel they caused the separation from their family.    

•  - School-Aged Children: Possess a better capacity to understand medical information if explanations are provided in a straightforward, developmentally appropriate manner.

• Separation Anxiety Reactions: The reaction to separation from primary caregivers occurs in three distinct stages:     

  • - Protest: Behavioral manifestations of distress upon separation.    

  •  - Despair: A period of grief and mourning following the initial protest.    

  •  - Detachment/Denial: A defense mechanism where the child appears to have adjusted but has actually detached from the parent to escape the pain of separation.

Family-Centered Care (FCC)

• Core Philosophy: Applying the principles of family-centered care helps reduce negative consequences of hospitalization for both the child and the family.

• Key Elements:    

•  - Constant Presence: Recognizing that the family is the constant in the child's life while the hospital experience is temporary.    

•  - Empowerment: Families must be supported to learn all aspects of the child’s care and empowered to participate actively in that care.    

•  - Partnership: A professional partnership must be established based on respect, support, education, and encouragement.

• Factors in Family Assessment: Respect must be given to the family's:     

  • - Level of function     

  • - Connectedness     

  • - Spirituality     

  • - Cultural diversity     

  • - Economic level     

  • - Education level

Bill of Rights for the Child in a Pediatric Health-Care Setting

1. Right to evidence-based, quality health care based on national standards.

2. Right to dignity, respect, and emotional support.

3. Right to confidentiality and privacy.

4. Right to the application of family-centered care.

5. Right to religious and spiritual expression.

6. Right to clear communication and use of interpreter services.

7. Right to developmentally appropriate play and creative expression.

8. Right to participate in informed decisions.

9. Right to prompt pain assessment and symptom treatment and management.

10. Right to access to the health-care institution's mission statement.

11. Right to know the health-care institution's fees and charges.

12. Right to access to interdisciplinary teams and social workers.

13. Right to a second opinion on treatment plans or options.

Hospital Settings and Nursing Considerations

• Unit Environment:     - Some hospitals lack separate pediatric units and use designated beds within adult environments.     - Orientation to the hospital environment is essential for the child and family.

• Admission Procedures: Similar to adult admissions but with pediatric-specific inquiries:   

•  - Toileting times and patterns.    

•  - Specific pain responses.     

• - Eating habits and preferences.     

• - Special needs.     

• - Inclusion of comfort items (e.g., stuffed animals, blankets).

• Sleep Management:     

• - Posting a sign stating the child is napping is appropriate to ensure uninterrupted rest.     

• - Maintain normal bedtimes as much as possible.     

• - Acknowledge that sleep is often disrupted by nighttime vital signs, weight checks, and phlebotomy.

• Bed Selection and Safety:     

• - Young Infants: Require an open crib or an incubator.     

• - Older Infants: Placed in standard cribs.     

• - Toddlers and Mobile Infants: Must be in cribs with high tops to prevent climbing out and sustaining injuries.

• Safety Measures:     - Follow hospital policy for identification (name bands) and security devices.     - Keep young unattended children close to the nursing station.     - Keep all medical supplies out of reach or locked up.     - Children must not touch monitoring or infusion equipment.     - Parent Education: Teach parents how to use call bells, what signs and symptoms (S/S) to report, how to use crib side rails, and warn against co-sleeping with infants/toddlers in "big beds."

Play Therapy and Medical Play

• Daily Requirement: Play should be offered daily regardless of diagnosis, age, or developmental level.

• Six Functions of Play:     1. Creativity     2. Sensorimotor Development     3. Intellectual Development     4. Socialization and Moral Development     5. Self-Awareness     6. Distractibility from stress, anxiety, and tension

• Developmental Play Types:     

  • - Infants: Mirrors, mobiles, musical toys, and varied textures.     

  • - Toddlers: Multisensory/whole-body play; imitation of adult roles (e.g., firefighter, police officer, ballerina, nurse, rock star, mother, teacher); fantasy toys (train sets, blocks, dress-up).     

  • - Preschoolers: Puzzles, games, simple arts and crafts to foster interaction and imagination.     

  • - School-Aged: Games involving family, staff, or visitors.     

  • - Adolescents: Focus on peer contact and technology to maintain connection.

• Medical Play: Structured play with therapeutic goals.     

  • - Allows expression of fear and anger (e.g., giving a doll a shot with a toy syringe).     

  • - Anatomically correct dolls help children understand procedures or surgical outcomes.     

  • - Requires clinical supervision, cleaning procedures, and safe storage.

Pain Management in Children

• Communication: By $5$ years of age, most children can describe the location and severity of symptoms.

• Physiological Consequences of Untreated Pain:     - Decreased oxygen saturations.     - Increased heart rate and blood pressure; heart rate variability.     - Decreased peripheral skin blood flow.     - Increased caloric consumption; potential for hypoglycemia.     - Prolonged hyperglycemia due to stress response.

• Psychosocial Consequences of Untreated Pain:     - Mistrust of the health-care team and environment.     - Poor motor performance and adaptive behavior.     - Potential for learning disorders and cognitive defects.     - Temperament changes.

Myths About Pain in Infants and Children

• Myth: Infants do not feel pain. Fact: Infants have a definitive presentation of pain.

• Myth: Young children cannot describe/localize pain. Fact: Children with language skills can talk about pain and can accurately place their hand over the hurting area.

• Myth: Infants/children do not need pain medication. Fact: They require medication just like adults.

• Myth: Children become easily addicted. Fact: Narcotics used appropriately for pain do not cause addiction in children.

• Myth: Assessment is difficult. Fact: Accuracy is achieved using age-appropriate objective and subjective tools.

• Myth: Children always tell the truth about pain. Fact: They may lie to avoid injections or foul-tasting oral medications.

• Myth: Vital signs do not demonstrate pain. Fact: Pulse, RR, and BP may increase while oxygen saturation decreases.

• Myth: Narcotics should never be given. Fact: Morphine is a standard treatment for severe pediatric pain.

• Myth: Newborns/fetuses don't feel pain. Fact: Even fetuses in the womb react to painful stimuli.

• Myth: Children have more severe side effects than adults. Fact: Side effects are similar to those in adults.

• Myth: A playing child is not in pain. Fact: Children use play as a coping mechanism even in severe pain.

Pain Assessment Tools and Protocols

• QUESTT Protocol (Baker and Wong, 1987):     - Q: Question the child.     - U: Use appropriate pain tools.     - E: Evaluate the pain experience (physiological and behavioral).     - S: Secure parents' and caregivers' involvement.     - T: Take all influencing factors into account.     - T: Take action, report, and re-evaluate.

• Pain Assessment by Developmental Age:     - Neonates: Rigidity, thrashing; Tool: CRIES.     - Infants: High-pitched crying, pushing stimulus away; Tools: CRIES or FLACC.     - Toddlers: Word-level verbalizations, uncooperative, screaming; Tools: CRIES or FLACC.     - Preschoolers: May misrepresent location, describes pain but not intensity; Tools: CRIES, FLACC, OUCHER, or Wong-Baker FACES.     - School-Aged ($6-10$): Stalling, clenched teeth, body stiffness; Tools: FLACC or Wong-Baker FACES.     - Older School-Aged ($11-13$): Tool: Numerical version of Wong-Baker FACES.     - Adolescents: Expressive words, less protesting; Tools: Wong-Baker FACES (Numerical) or Adolescent Pediatric Pain Tool (APPT).

Specific Pain Scale Criteria

• CRIES Neonatal Scale ($32-60$ weeks):     - Crying (0-2)     - Requires O2 for saturation > $95\%$ (0-2)     - Increased Vital Signs (HR/BP) (0-2)     - Expression (0-2)     - Sleepless (0-2)     - Scoring: Total score > 4 requires pharmacologic intervention.

• FLACC Scale ($2$ months to $7$ years):     - Face: 0 (smile) to 2 (clenched jaw).     - Legs: 0 (relaxed) to 2 (kicking/drawn up).     - Activity: 0 (quiet) to 2 (arched/rigid).     - Cry: 0 (none) to 2 (steady screams/sobs).     - Consolability: 0 (relaxed) to 2 (difficult to comfort).     - Interpretation: $0$ = relaxed; $1-3$ = mild; $4-6$ = moderate; $7-10$ = severe.

Pharmacological Management and Safety

• Medication Guidelines:    

•  - Mild pain: Nonopioids and NSAIDs.     

• - Moderate to severe pain: Opioids.     

• - Routes: Prefer Oral or IV to avoid the distress of injections.

• Drug Dosages (Table 26.3):     

• - Acetaminophen: $10-20\,mg/kg$ PO every $4-6\,hr$ (Max $5$ doses in $24\,hr$).     

• - Ibuprofen: $5-10\,mg/kg$ every $4-6\,hr$.     

• - Morphine: $0.05-0.2\,mg/kg$ IV every $2-4\,hr$.     

• - Codeine: $0.5-1\,mg/kg$ PO every $4-6\,hr$.     

• - Oxycodone: $20-30\,mg$ PO every $3-4\,hr$.     

• - Meperidine: $1-2\,mg/kg$ IM every $3-4\,hr$.     

• - Methadone: $0.1-0.2\,mg/kg$ PO.

• Safety Protocols:  

• - Use current and accurate weight for all calculations.     

• - Double check dosages with another nurse.     

• - Monitor for respiratory depression (Hourly Respiratory Rate check for IV narcotics).     

• - Document both pharmacological and nonpharmacological interventions.

Nursing Care Plan and Goals

• Nursing Diagnoses: Acute pain; Potential for injury.

• Five Components of Pain Goals:     

• 1. Patient-oriented: "The child…"     

• 2. Future-oriented: "The child will…"     

• 3. Measurable: "…state a pain scale value of less than two…"     

• 4. Time-oriented: "…by noon today."     

• 5. Realistic: Do not create unachievable goals.

• Nonpharmacological Interventions:     - Repositioning     - Distraction and play therapy     - Parental holding/cuddling (or presence for teens)     - Decreased environmental stimuli (noise, smells, lights)     - Massage, warm/cold packs, and warm blankets