Presented by Marlene Meador RN, MSN, CNE Hospitalized Child Presented by Marlene Meador RN, MSN, CNE

Child’s Reactions to Illness or Hospitalization Influencing factors Internal Age (cognitive development) Preparation & coping skills Culture Previous experience with healthcare system

Child’s Reactions to Illness or Hospitalization Influencing factors External Parent’s reaction to illness Sibling’s reaction to current illness/hospitalization

What age is most effected by separation anxiety? 0-8 months 9-36 months Preschool School aged Adolescent

Stages of Separation Protest Despair Detachment

Effects of Illness/hospitalization on the: Infant/Toddler Separation anxiety Fear of injury Loss of control

Effects of Illness/hospitalization on the: Preschooler Separation anxiety Fear of injury Loss of control Guilt and shame

Effects of Illness/hospitalization on the: School-age Child Separation anxiety Fear of injury/pain Loss of control

Effects of Illness/hospitalization on the: Adolescent Separation anxiety Fear of injury Loss of control Fear of the unknown

Regression Preschool-typically regress in comfort measures and toilet training, “temper tantrums” and toddler-like behaviors School age- may become more fearful of strangers and require more emotional support (crying or “baby talk”)

Clinical Judgment What are some psychological benefits of hospitalization for a child and family?

Clinical Judgment: How would a nurse best respond to a parent who is overly concerned about the child’s regression? How does toileting pattern and pacifier/bottle response differ from other regression?

What determines the family’s response to a child’s hospitalization?

Family’s Response to Hospitalization Perception Support system Coping mechanism Their perception- what is the perception of the illness or injury? Nurses need to structure care around the child and family’s needs and wishes as much as possible. This increases the family’s perception of control in a situation when they have little or no control. Give them choices when possible. Support mechanisms present- Does the family have adequate financial support (insurance-other) do they need additional support from social services, financial services. Can one or both parents take off work without penalty. What about care for siblings and the home? Coping mechanisms- does the family have adequate resources or experiences to draw from? What are some potential difficulties with the parenting role when a child is hospitalized? What about how siblings cope?

Families’ Response to Illness/Hospitalization Parents may become anxious Financial stressors Additional obligations Guilt

Developmental Approaches to the Hospitalized Child Page 891 BOX 35-2

Nursing Interventions: How does the nurse meet the needs of the hospitalized child in each age group? Infant Toddler-Preschool School- aged Adolescent P891 BOX 35-2 Discuss specific nursing interventions related to assisting these age groups: p 1154- Nurse should encourage parents to stay with child whenever possible. Infant- provide consistent nurse (same one each shift), a blanket or towel with parent’s scent (perfume/cologne), cuddle time if possible- talk to them in reassuring tones Toddler-Preschool- separation from parents major stressor- leave perfume scented clothing/blanket and a favorite toy. May also include photos and audio/video recording of the parent/s School-aged- these children have a more developed understanding of self and body. They can understand simple explanations and these children rely on parents/family when fearful of painful procedures. Include parents/family when possible (may worry about body returning to normal after illness/injury). understand time and need to have reassurance of approximate time parents will return. Adolescent- after 11 years old, more concerned with appearance and enhanced sense of body image. Control over self-care is important. Peer group is major influence and separation from school, friends and family are major stressors.

What is the best method for communicating with the family of a hospitalized child? What factors influence the family’s ability to interact with the hospital staff? What nursing interventions should receive highest priority when communicating with these families?

Nursing Interventions for the family of a hospitalized child: Augment coping mechanisms- (what specific factors influence client teaching?) Reinforce information and encourage questions (who would have difficulty with asking questions?) Anticipate discharge needs (when should this begin?) What are nursing measures to assist the family in coping with their feelings about their child’s hospitalization: p 1190- assures the family that it is appropriate for them to ask for help. Encourage them to keep a journal of questions and concerns. Include them in gathering assessment findings. They know their own child best and can often identify the child’s primary needs. “What is most important thing we can do for you today” PPEN Augment parents coping through teaching- provide written information (in correct native language) and repeat instructions and explanations often (without frustration or impatience) Reinforce and encourage questions- an open dialogue with the parents establishes trust between family and nurse. Also clarifies misunderstandings on the part of the parents and patient Assess at day of admission and anticipate discharge- discharge instructions should begin at time of admission and continue throughout the hospitalization.

PPEN Why is this an effective tool for assisting the child and the family? How would the nurse assist the child and family to arrive at the PPEN? Is this a static assessment?

Preparation for Hospitalization What nursing interventions prepare a child for hospitalization? Are the interventions the same for all children? Who should the nurse include in these preparations? What are some of the approaches the nurse can use in assisting the children and parents to prepare for hospitalization? Tour the hospital/video/photographs, written material when available; tailor prep to age of child; involve parents in the preparation. When is best time for providing this information?

Preparation Tour of the Hospital or surgical area Photographs or a videotape of medical setting and procedures Health Fairs Contact with peers who had similar experience

Promoting Coping and Normal Development Child life specialists: assist with preparing child for procedures, and to adjust to illness and hospitalization. Therapeutic play: emotional outlet, teaching strategy, assessment tool Anticipate child/family’s needs What is the role of the child life specialist? To prepare the child for special procedures; educate child and parent, answer questions about the procedure, provide anticipatory guidance this is a valuable resource trained specifically to assist the child and family to adjust to the illness and hospitalization. Describe the advantages of Therapeutic Play in meeting the child’s psychosocial and developmental needs during hospitalization including: a. Specific play techniques related to developmental age groups. It is a therapeutic way for the child to deal with hospitalization. While it is therapeutic, it is also an emotional outlet, teaching and enhancing cooperation. Emotional outlet play is called “dramatic play” where the child acts out the real-life stressors. This could include abuse, neglect or pain. Children might use this type of play with hammers, pegs, boxing gloves, anatomical dolls, drawing (colors selected are highly suggestive of feelings)

Difficult Families What is the nurse’s best response to a family identified as “difficult”? What additional information does the nurse require? What is COPE, and how is it helpful with families in crisis? How can the nurse identify and participate in the care of “difficult families”? Remembering that the child and the family bring experiences “baggage”. The child has fear and expectations. The parent has preexisting dynamics and communication styles, finances, coping styles How to deal with the family’s reaction: COPE- collaboration, objective, proactive, evaluate. Avoid the negative baggage, “It is unfortunate you are having these difficulties. What would you find most helpful at this time?” Convey genuine caring, concern and interest in the child’s wellbeing and never placate or condescend.

COPE: Convey genuine caring, concern and interest in the child’s wellbeing. C- collaboration O- objective P- proactive E- evaluate Avoid placating or condescending phrases. How to deal with the family’s reaction: COPE- collaboration, objective, proactive, evaluate. Avoid the negative baggage, “It is unfortunate you are having these difficulties. What would you find most helpful at this time?” Convey genuine caring, concern and interest in the child’s wellbeing and never placate or condescend.

Nursing Care of the Child with Special Needs: Special equipment- visually or hearing impaired, wheelchairs, Specialized care- feeding tubes, trachs/vents Assess family coping ability- who is primary caregiver Assess support systems Involve additional members of the healthcare team Discuss how children with special needs or disabilities require adapted care in the hospital. Children with visual or auditory disabilities may require special equipment to participate in ADLs. The nurse needs to make sure that these needs are met. The nurse needs to collect more information about the family; who does most of the care; involves many systems and people; balance condition r/t immediate needs with general well-being of the child

Play in the Hospital Setting

Safe place to just “be a child”

Advantages to play: Therapeutic play Motional outlet Instructional Improve physiological abilities Enhancing cooperation through play Rewards the child’s payment for a job well done!

Play as an assessment tool: When might a nurse use play as an assessment tool? Why is this and effective technique?

Child Life Specialist A person who plans activities to provide age-appropriate playtime for children either in the child’s room or in a playroom. Goal: Assist children to work through feelings about their illness

Pain Assessment What happens when you ask a patient of any age “what is your pain level?” How would you best assess a child’s pain?

Pain Assessment Infant- grimacing, poor feeding, restlessness, crying Toddler- clinging to parent, crying, pulling or rubbing area of pain, anorexia, vomiting, restlessness. What are signs and symptoms (assessment findings) of pain in the different age groups? Infant- grimacing, poor feeding, restlessness, crying Toddler-wanting to be held, crying, pulling or tugging at part of pain, not eating, vomiting, restlessness.

Pain assessment in the Neonate

Pain Assessment cont… Preschool- verbalize pain, guard injured extremity, anorexia, vomiting, sleeplessness. Adolescent- verbalize pain, may not understand “type” of pain. Possibly reluctant to call for help. Preschool-able to verbalize but generalized….my “stomach” need to be guided to discover the true area of pain; may vomit, not sleep. May guard or not move injured extremity. Adolescent-can verbalize, but may not understand the difference between the “type” of pain (cramping, sharp, etc), may be reluctant to call for help

Oucher Scale After determining that the child has an understanding of number concepts, teach the child to use the scale. Point to each photo, explain that the bottom picture is a “no hurt,” the second picture is a “little hurt,” the third picture is “a little more hurt,” the fourth picture is “even more hurt” the fifth picture is “a lot of hurt” and the sixth picture is the “biggest or most hurt you could ever have.” The numbers beside the photos can be used to score the amount of pain the child reports.

Pain Assessment Tools: FLACC- face, legs, activity, cry and consolability (p. 1215-1216) NIPS- neonatal pain during/after procedures- facial expression, cry quality, breathing patterns, arm & leg position, state of arousal What are different types of pain scales used in pediatrics? FACES, p 1216- smile to worst hurt (tears) / FLACC- face, legs, activity, cry and consolability p 1215 Table 42-6 , NIPS- measures neonatal pain with procedures. Measures facial expression, cry quality, breathing patterns, arm & leg position, state of arousal p 1213

FACES- smile to worst hurt (tears) Remember to ask “where” they hurt. To children, emotional feelings are a “hurt”.

Physiological response to pain: What happens to VS? How does the nurse assess anxiety in a hospitalized child? How does sleeplessness impact healing? What are the physiological consequences of unrelieved pain in children? Changes in vs., anxiety, fretfulness, anorexia, low grade fever, inability to rest slows healing. Related to metabolic needs of infants and children.

Nursing interventions: pharmacologic PCA- what age can use this most effectively? Ketoralac- why is this effective? What specific nursing interventions apply to this medication? Why are NSAIDS used with children? What lab values and contraindications are important for analgesic medications used with children? What are some of the pharmacologic interventions / and nursing care to assist the child in pain? PCA for school age child; hydrocodone, codeine, MS, Dilaudid per pump or IV push. Toradol (ketoralac) is effective to be given q 6 hrs IVP. NSAIDS for moderate to severe pain. Ibuprofen- why does this work well with children? What do we need to observe with medication administration in children?- Side effects/ contraindications/ what lab values and assessment findings are priority?

Nursing interventions: nonpharmacologic What actions should the nurse include with each of the following? Positioning for comfort (turning or elevation) Thermal therapy (heat or cold) Diversion therapy What actions would work best with an infant? What are some of the non-pharmacologic interventions / and nursing care to assist the child in pain? Reposition child to comfort, ice or heat, elevation of body part, divisional therapy (video games, coloring, board games, card games). What about an infant? Pacifier, rocking, riding in stroller, bouncy chair.

Pain Management The presence of the parent is an important part of pain management. Children often feel more secure telling their parents about their pain and anxiety

Pet therapy- play…

If you have any questions or concerns regarding this information please contact Marlene Meador via email mmeador@austincc.edu Or cell phone 512-422-8749