Care of the Hospitalized Child - NUR 320
CARE OF THE HOSPITALIZED CHILD
Factors Affecting Perception of Hospitalization
Age: Children of different ages perceive hospitalization in unique ways.
Developmental Stage: Each developmental stage influences how children understand and react to hospitalization.
Cognitive Development: Cognitive abilities shape a child’s understanding of illness, treatment, and hospital experiences.
Previous Experiences: Past experiences with healthcare can affect a child’s response to hospitalization.
Coping Skills: Individual coping mechanisms impact how effectively a child can manage the stress of hospitalization.
Preparation: The extent to which a child is prepared for the hospitalization affects their perception and reaction.
Effects of Hospitalization on the Child
Reaction to Stressors: Reactions can occur before, during, and after the hospitalization.
Individual Risk Factors: Different children may exhibit different levels of risk for adverse reactions.
Beneficial Effects of Hospitalization: Some children might experience positive outcomes such as improved health.
Coping Mechanisms: Coping strategies may include regression to previous developmental stages.
Family Stressors and Reactions: Families also experience stress related to the child’s hospitalization.
Parental Reactions: Response of parents can vary based on their own emotional state and coping abilities.
Sibling Reactions: Siblings may express concerns or behavioral changes due to the hospitalization of a brother or sister.
Pediatric Patient Threats/Fears & Corresponding Nursing Interventions
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Bodily Injury/Pain:
Explain all procedures to the child.
Premedicate with analgesic as ordered.
Use topical analgesics for atraumatic care.
Demonstrate the use of equipment and allow safe handling to decrease fear.
Separation from Parents:
Minimize separation whenever possible.
Allow parents to remain with the child.
Understand and recognize the phases of separation anxiety.
Fear of the Unknown:
Provide appropriate explanations to relieve anxiety.
Assess learning and the effectiveness of the education provided.
Loss of Control/Autonomy:
Encourage child’s independent decision-making and expression of feelings.
Provide opportunities for questions and self-care engagement.
Offer choices (e.g., choosing between Spiderman or Batman stickers).
Stressors & Nursing Interventions
Main Stressors Across Age Groups:
Separation Anxiety:
Three Phases:
Protest Phase: Crying, screaming, inconsolable behavior.
Despair Phase: Crying stops, signs of depression or withdrawal.
Detachment/Denial Phase: The child appears to be managing but has emotionally disconnected.
Most Intense Age Group: Toddlers experience the most intense separation anxiety.
Management: Encouraging parental presence can help minimize or manage this stressor.
Loss of Control:
Promote developmentally appropriate freedom and autonomy.
Maintain routine and effective communication to promote understanding.
Nursing Care of Hospitalized Child
Priorities and Nursing Plan:
Include age-appropriate play and/or diversional activities that provide an outlet for expression.
Types of Play:
Unstructured Play: Natural play without specific goals.
Therapeutic Play: Structured play intended for healing and coping.
Evaluation of play activities.
Involvement of a child life specialist.
Atraumatic care to reduce psychological and physical distress.
Maximize potential benefits of hospitalization (education, relationships, self-mastery).
Family-centered care to include families in the child's care and support.
Atraumatic Care
Definition: Therapeutic care that minimizes or eliminates psychological and physical distress experienced by children and families during healthcare encounters.
Techniques for Improvement:
Therapeutic Communication: Goal-directed, focused, and purposeful interaction.
Therapeutic Play: Engaging the child in play to cope with hospitalization.
Education: Provide understanding of procedures and treatments.
Cultural Humility: Considering cultural backgrounds in care.
Child Life Specialist Involvement: Implementing distraction and diversional activities to lessen anxiety.
Diversions & Distractions
Suggested distraction techniques include:
Pointing toes inward and wiggling.
Squeezing the nurse's hand.
Counting out loud.
Singing songs or engaging in sing-alongs.
Pointing to pictures on the ceiling or around the room.
Blowing bubbles.
Playing music.
Utilizing therapeutic play activities.
Family-Centered Care
Principles:
Respect for the child and family as a unit.
Recognition of impacts of hospitalization on family dynamics.
Identification and expansion on family strengths.
Support and advocate for family preferences and unique needs.
Maintain flexibility in care.
Effective communication and education to empower families.
Connection to supportive resources.
Collaboration with families, encouraging their involvement in care plans.
Family-Centered Care: Goals and Benefits
Goals:
Provide a sense of control to families.
Increase parent/caregiver participation in care.
Enhance overall family experiences.
Decrease healthcare costs and shorten recovery time.
Improve compliance with treatment plans.
Enhance pain management and reduce anxiety.
Foster improved communication between healthcare teams and families.
Incorporate cultural assessments to respect diversity.
Enhance literacy skills for better understanding.
Support all family members including siblings during hospitalization.
Serve as advocates for families.
Inpatient Settings
Description: Overview of various types of inpatient settings for pediatric patients include:
Medical/Surgical Unit: General care for children undergoing surgery or illness.
Isolation: For patients with contagious illnesses.
Emergency Admissions: Immediate care for acute conditions.
Intensive Care Unit (ICU): For life-threatening conditions requiring constant monitoring.
Pediatric Intensive Care Unit (PICU): Specialized care for critically ill children.
Cardiac Intensive Care Unit (CICU): Focused care for children with heart conditions.
Neonatal Intensive Care Unit (NICU): Care for premature and ill newborns.
Outpatient Settings
Description: Refers to care provided in settings outside the hospital including:
Ambulatory care clinics for wellness visits.
Urgent care for non-life-threatening emergencies.
Same-day surgery facilities for minor surgical procedures.
Laboratories for diagnostic testing.
Observation units for short-term monitoring of acute illnesses (24-48 hours).
School-based or community clinics focusing on health promotion and preventive care.
Home care for post-discharge support.
Rehabilitation services aimed at helping patients regain function.
The Admission Process
Overview: Key steps in the admission process include:
Collaboration with family to obtain pertinent history and information.
Identification of chief complaints and history of present illness (HPI).
Review of systems (ROS) and medical records from previous healthcare facilities.
Engaging patients and families as historians for history-taking.
Initial physical assessment and measurement of weight in kg.
Special Considerations
Importance of Sibling Support: Recognizing siblings' feelings and needs during hospitalization.
Managing Unexpected Hospitalizations: Supporting families through situational crises caused by unexpected hospitalizations.
Coping Strategies: Implementing coping and relaxation strategies for families.
Special Needs
Focus Areas: Consider the impact of cognitive, developmental, or sensory impairments on children and their families.
Long-term Support Needs: Families with children with disabilities may require ongoing support and resources, addressing concerns beyond just the diagnosis.
Role of Nurses: Nurses can assist families in finding resources to help promote optimal functioning and enhance quality of life.
Developmental Disorders
Definition: Broad term describing various intellectual or cognitive disabilities including:
Fetal Alcohol Syndrome (FAS) and Autism Spectrum Disorder (ASD).
Autism Spectrum Disorders (ASDs)
Overview: Complex neurodevelopmental disorders characterized by:
Persistent deficits in social communication and interaction, presenting significant challenges.
Current prevalence: 1 in 36 children in the US (CDC, 2023).
Etiology: The causes remain unconfirmed with ongoing research.
Clinical Manifestations: Includes social difficulties, language issues, and behavioral concerns.
Diagnostic Evaluation: Should include routine and formal screening beginning at 9 months (per AAP guidelines).
Example screening tool: MCHAT (Modified Checklist for Autism in Toddlers).
Prognosis: Early identification and intervention (e.g. therapy) are critical for successful outcomes.
Nursing Care Management:
Support families in coping and utilize family-centered strategies.
Connect families with clinical and community resources.
Employ a multidisciplinary approach in care.
Implement safety precautions for self-injurious behaviors.
Provide anticipatory guidance for families and caregivers.
Cognitive Impairment
Definition: Intellectual disability that limits cognitive and/or functional capacities, typically measured by an IQ less than 70-75.
Approximately 6 million children in the US are affected.
Onset occurs during childhood or prior to 18 years of age.
Potential Causes: Genetic factors, environmental influences, complications during pregnancy or birth, and acquired childhood diseases.
Cognitive Impairment: Potential Signs
Delayed Developmental Milestones: Indicators of cognitive impairment may include delays in reaching expected developmental milestones.
Speech and Language Challenges: Effects on communication skills and ability to express oneself.
Associated Disabilities: Cognitive impairment often coexists with other disorders (e.g., ASD, ADHD, seizures, cerebral palsy, sensory deficits).
Behavioral Manifestations: Children may exhibit a wide range of behaviors—ranging from self-injury to social isolation and depression.
Autism vs Intellectual Disability
Feature | Autism | Intellectual Disability |
|---|---|---|
Skill Profile | Peaked skill profile | Flat skill profile |
Imitative Skills | Lack of imitative skills | Imitation skills exist |
Social Behavior | Limited social initiation | Social behaviors present |
Communication | Abnormal communication and language | Limited language, but sufficient for communication |
Seizures | Development of seizures possible in adolescence | Usually no seizures |
Older Age Concerns | limited inidcation for worsening, comorbidities | Alzheimer-type dementia in adulthood |
Down Syndrome
Overview: A genetic condition caused by a chromosomal anomaly (Trisomy 21).
Prevalence: Affects approximately 5,000 babies born annually in the US.
Manifestations: Results in a wide range of developmental, intellectual, and physical delays or anomalies.
Fragile X Syndrome
Definition: A chromosomal mutation of the FMR1 gene located on the X chromosome.
Prevalence: The second most common genetic cause of cognitive impairment after Down Syndrome.
Associated Conditions: Often linked with developmental and learning disabilities.
Sensory Impairment: Hearing
Definition: Hearing impairment can range from slight to profound levels.
Etiology and Severity: Factors affecting hearing impairment include:
Conductive Hearing Loss: Most common type caused by issues affecting sound amplification (e.g., recurrent otitis media).
Sensorineural Hearing Loss: Caused by damage to inner ear structures or auditory nerve disrupting sound processing.
Working with a Child Who Has a Hearing Impairment
Best Practices:
Encourage the use of hearing aids, ensuring they are in place before speaking.
Maintain direct eye contact with the child to aid in lip reading.
Speak clearly and at a moderate pace; avoid raising voice unnecessarily.
Eliminate background noises that could hinder communication.
Use visual aids (pictures, gestures) to enhance understanding.
Provide access to interpreters for complex discussions, especially using American Sign Language.
Sensory Impairment: Visual
Definition: Covers both partial sight and legal blindness.
Types of Visual Impairment:
Partial Visual Impairment: Limited sight that does not allow for safe mobility or interaction.
Severe Permanent Visual Impairment: Significant visual challenges that require adaptation to the environment.
Causes and Common Issues:
Trauma, infections, or conditions lead to visual concerns.
Common Problems: Amblyopia (lazy eye) and strabismus (crossed eyes) potentially leading to amblyopia if untreated.
Working with a Child Who Has a Visual Impairment
Recommendations:
Orient children to the hospital environment upon admission.
Establish communication by identifying yourself and explaining actions beforehand.
Use familiar language when describing objects and environments.
Maintain consistent item placement within the space to facilitate orientation.
Description of noises and sounds aids understanding of the environment.
Allow children control over their situation while supervising for safety.
Nursing Assessment of the Child with Disabilities
Assessment Focus:
Evaluate intellectual skills and adaptive functioning levels.
Assess social interaction and competence in ADLs (activities of daily living).
Utilize a mix of questioning and demonstrations during assessment.
Engage with children in a direct yet respectful manner, suitable to their developmental level.
Utilize extra time and a systematic approach to assessment, from least invasive to most invasive.
Nursing Strategies & Goals
Patient-centric Goals:
Prioritize patient safety and advocacy throughout care.
Tailor education for both children and families on managing disabilities.
Teach self-care skills to promote independence and comfort in patient engagement.
Promote optimal development through supportive strategies.
Encourage play, exercise, socialization, and peer engagement.
Establish predictable routines to foster a sense of security.
Offer resources for coping and adjustment mechanisms for families.
Provide information on sexuality and future planning regarding developmental trajectories.
The Nursing Focus
Objective: The nursing plan centers on enhancing the child's quality of life and functional capabilities within their context of needs.
Case Scenario Questions
Scenario: Parent Concern About a child with intellectual disability not understanding like siblings.
Effective Nurse Response: Educate about using simple, concrete explanations while incorporating play-based learning strategies.
Scenario: Anxious Parents of a Preschooler with intellectual disability.
Effective Strategy: Acknowledge their hard work, provide supportive information, and resources for external support.
Scenario: Assessing a Child with ASD.
Effective Strategies: Engaging in discussions about daily routines and observing ADLs directly can yield valuable insights on functionality.
Scenario: Supporting Hospitalization Tolerance for a Child with ASD.
Effective Strategies: Regularly assess the child's behavior and maintain established routines and familiar items for comfort.
Nursing Considerations for the Child with Cleft Lip and Palate
Key Aspects of Care:
Techniques for safe feeding and preventing aspiration during feeding.
Prepare for and educate families about surgical interventions, post-operative care, and infection prevention.
Engage in speech and feeding therapy for development support.
Surgical Treatment of the Throat
Tonsillectomy Indications: Treatment for recurrent throat infections.
Nursing Care Considerations: Includes pre and post-operative education, assessment, and vigilance for complications such as postoperative hemorrhage:
Symptoms to monitor include excessive swallowing, increased pulse with decreased blood pressure, and signs of fresh bleeding.
Appropriate positioning (prone or side lying) post-surgery is critical.
Pediatric Nursing Interventions and Skills
Informed Consent Process:
Parents typically provide consent for interventional procedures, with stipulations protecting their right to refuse consent at any time.
Special circumstances include varying custody scenarios, minors’ rights, and criteria for mature minors capable of consenting.
Key Elements: The patient's understanding of their condition and treatment must be comprehensive, supported by a witness to the consent process.
Legal and Ethical Considerations
Information Required for Informed Consent: Detailed descriptions of conditions, treatments, risks, benefits, alternatives, and rights to refuse treatment.
Preparation for Diagnostic and Therapeutic Procedures
Focus on Psychologic and Physical Readiness: Primarily involves age-appropriate psychological preparation supplemented by physical readiness strategies including parental support and trust-building.
Safety Considerations
Environmental Safety: Ensuring identification bands, preventing falls, and infection control measures.
Restraint Techniques: Utilizing appropriate methods based on patient needs while ensuring comfort and safety during procedures.
Hygiene & Skin Integrity
Practice Areas: Includes bathing, oral hygiene, hair care with emphasis on parental involvement to foster bonding and reduce feelings of helplessness.
Monitor Skin Integrity: The need for ongoing assessment and prevention of skin integrity issues underlines nursing vigilance.
Positioning for a Procedure
Goals of Positioning: Minimize patient movement and discomfort, utilizing proper analgesia and restraint if required.
Measurement of Intake and Output
Importance of Accurate Measurement: Ensures proper fluid management, utilizing techniques appropriate for pediatric patients.
Intravenous Access
Challenges and Solutions: Identifying common complications such as infiltration in pediatrics and discussing the importance of securing access sites with age-appropriate strategies.
Alternative Feeding Techniques
Techniques Overview: Details on various feeding methods including NG tubes and TPN alongside necessary preparations and family teaching guidelines.
Procedures Related to Elimination
Clinical Techniques: A focus on age-appropriate enemas and ostomy management as it pertains to surgical and post-surgical care.
Procedures for Maintaining Respiratory Function
Methods of Support: Detailing inhalation therapies, oxygen therapy management, and providing critical assessments for breathing functions through ETCO2 monitoring and related procedures.
Chest Tubes
Purpose and Placement: Description of when and how to use chest tubes effectively, including pre-procedure assessments and ongoing monitoring post-placement.