1. Chapter 29 Care of the Hospitalized Child

2. Care of the Hospitalized Child
Stressors when a child is in the hospital
Cause, treatment of the illness
Guilt about the illness
Past experiences of illness and hospitalization
Disruption in family life
Threat to the child’s long-term health
Cultural, religious influences
Coping methods within the family
Financial impact of the hospitalization

3. Care of the Hospitalized Child (cont.)
Child’s developmental level
Child-life program

4. The Pediatric Hospital Setting
Early childhood education about hospitals
Hospitals are part of the child’s community
Some have orientation programs
Families
Encouraged to help young children develop a positive attitude about hospitals
Avoid negative attitudes about hospitals
Honest answers to questions about death

5. The Pediatric Hospital Setting (cont.)
Pediatric unit atmosphere
Friendly, warm surroundings for children
Safe, attractive, and size-appropriate furniture
Colorful staff uniforms
Children wearing their own clothing or colorful pajamas
A separate room for procedures
A playroom and rooming-in facilities
Meals planned to include the child’s favorite foods

6. The Pediatric Hospital Setting (cont.)
Pediatric intensive care units
Admission can be overwhelming, especially if unexpected
Nurses should prepare family for how child will look
Give visiting schedule
Provide developmentally appropriate explanations of procedures
Provide positive reinforcements for the child, such as stickers and small badges

7. The Pediatric Hospital Setting (cont.)
Pediatric intensive care units (cont.)
Interpret technical information for family members
Promote the family relationship as much as possible
Encourage the caregiver to touch, talk to the child
Safety
Essential aspect of pediatric nursing care
Pediatric environment should meet all the safety standards
Child’s developmental level may add other safety concerns

8. The Pediatric Hospital Setting (cont.)
Infection control
Standard precautions
Blend of universal precautions and body substance isolations
Apply to blood, all body fluids, secretions, and excretions (except sweat), nonintact skin, and mucous membranes
Reduce the risk of transmission of microorganisms from sources of infection in hospitals
Used in the care of all patients

9. The Pediatric Hospital Setting (cont.)
Infection control (cont.)
Transmission-based precautions
Pertain to patients documented or suspected to have highly transmissible pathogens
Require additional precautions beyond those covered under standard precautions
Include three types: Airborne precautions, droplet precautions, and contact precautions

10. The Pediatric Hospital Setting (cont.)
Infection control (cont.)
Transmission-based precautions (cont.)
Child subject to social isolation
Encourage family caregivers to spend time with the child
If masks or gloves are part of the necessary precautions, the child may experience even greater feelings of isolation
Be alert to child’s loneliness and sadness

11. The Pediatric Hospital Setting (cont.)
Importance of caregiver participation
Separation can have damaging effects
Stages of response to the separation
First stage (protest)
Cries, refuses to be comforted, constantly seeks primary caregiver
Second stage (despair)
Becomes apathetic and listless, gives up
Third stage (denial)
Begins taking interest in surroundings, appears to accept the situation

12. The Pediatric Hospital Setting (cont.)
Rooming-in
Explain facility and rules to caregiver before admission
Explain provision for meals to the caregiver
Avoid seeming to expect caregivers to perform as health care technicians
Define caregiver’s role as a provider of security and stability for the child
Allow siblings to visit the ill child
Be aware of the caregiver’s needs

13. Question
Some hospital pediatric units have a program to make the hospitalization less frightening for both children and their parents. This program is overseen by whom?
a. Head nurse
b. Charge nurse
c. Child psychologist
d. Child-life specialist

14. d. Child-life specialist
Answer
d. Child-life specialist
Rationale: Many hospitals have a child-life program to make hospitalization less threatening for children and their parents. These programs are usually under the direction of a child-life specialist, whose background is in psychology and early childhood development.

15. Admission and Discharge Planning
Planned admissions
Preadmission preparation may make the experience less threatening
Answer questions, explore anxieties
Discuss common questions and feelings
Tell children that some things will hurt, but everything will be done to make the hurt go away
Be sensitive to cultural and language differences

16. Admission and Discharge Planning (cont.)
Emergency admissions
Leave little time for explanation
Physical needs assume priority over emotional needs
Nurses must be sensitive to the needs of child and family
Nurses must recognize child’s cognitive level and its impact on the child’s reactions
The staff must explain procedures and conduct themselves in a caring, calm manner

17. Admission and Discharge Planning (cont.)
The admission interview
Content
Identification, allergy bracelets
Client history
Physical examination

18. Admission and Discharge Planning (cont.)
The admission interview (cont.)
Focus of the admission interview
Previous experience with hospitals and health care providers
Understanding of the child’s condition
Expectations of the hospitalization
Available support systems when the child returns home
Disturbing or threatening concerns on the part of the caregiver or the child

19. Admission and Discharge Planning (cont.)
The admission physical examination
Occurs after orientation to unit
Caregiver may undress child for physical examination
Caregiver may stay with the child during physical examination

20. Admission and Discharge Planning (cont.)
Begins early in the hospital experience
Assesses the family’s level of understanding of the child’s condition and necessary home care
Teaches caregiver regarding giving medications, using special equipment, and enforcing necessary restrictions
Provides specific, written instructions for reference at home
Assures caregiver understanding of written materials

21. Question
There are several components to the admission interview. Which of the following is one of them?
a. Maintaining the confidentiality of other children on unit by orienting new patient to their room only
b. Assessment of caregiver’s understanding of caregiver’s disciplinary responsibilities
c. Determining what the child and caregiver understand about reason for hospitalization
d. Explaining that the child can have toys in their room but cannot take them out of the room

22. Answer
c. Determining what the child and caregiver understand about reason for hospitalization
Rationale: Through careful questioning, the interviewer tries to determine what the family’s previous experience has been with hospitals and health care providers. It is also important to ascertain how much the caregiver and the child understand about the child’s condition and their expectations of this hospitalization, what support systems are available when the child returns home, and any disturbing or threatening concerns on the part of the caregiver or the child.

23. The Child Undergoing Surgery
Surgery can frighten both child and caregivers
Outpatient surgery facilities eliminate separation of child from caregiver
Child who has surgery needs compassionate, thorough preoperative and postoperative care

24. The Child Undergoing Surgery (cont.)
Preoperative care
General aspects
Patient teaching
Skin preparation
Preparation of the gastrointestinal, urinary systems
Preoperative medication

25. The Child Undergoing Surgery (cont.)
Preoperative care (cont.)
Patient teaching
Determining child knowledge, learning ability
Correcting any misunderstandings
Explaining the preparation for surgery, what the surgery will “fix,” and how the child will feel after surgery
Preparation based on the child’s age, developmental level, previous experiences, and caregiver support

26. The Child Undergoing Surgery (cont.)
Preoperative care (cont.)
Patient teaching (cont.)
Making sure explanations are clear, honest, and simply expressed
Encouraging questions to ensure understanding
Prepare for tests and procedures
Prepare for postanesthesia unit
Prepare for postoperative pain

27. The Child Undergoing Surgery (cont.)
Preoperative care (cont.)
Skin preparation
May include a tub bath or shower
Special cleaning and inspection of the operative site
Gastrointestinal, urinary system preparation
May need cleansing enema
Nothing by mouth (NPO) four to 12 hours before surgery
Urinary catheterization may needed

28. The Child Undergoing Surgery (cont.)
Preoperative care (cont.)
Preoperative medication: Usually given in two stages
Sedative is administered about half to two hours before surgery
Analgesic–atropine mixture may be administered immediately before the patient leaves for the operating room
Take medications to clients room
Another staff member may accompany you to hold child

29. The Child Undergoing Surgery (cont.)
Postoperative care
Nursing care focuses: Careful observation for any signs or symptoms of complications: Shock, hemorrhage, or respiratory distress
Monitor, record vital signs according to postoperative orders
Keep child warm
First voiding
Anuria
Intake and output
Coughing, deep breathing, and position changes

30. The Child Undergoing Surgery (cont.)
Postoperative care (cont.)
Pain management
Children often undermedicated
Signs/symptoms of pain in children
Rigidity
Thrashing
Facial expressions

31. The Child Undergoing Surgery (cont.)
Postoperative care (cont.)
Pain management (cont.)
Signs/symptoms of pain in children (cont.)
Loud crying or screaming
Flexion of knees (indicating abdominal pain)
Restlessness; irritability
Physiologic changes
Assess with pain tool geared to child’s developmental age

32. The Child Undergoing Surgery (cont.)
Postoperative care (cont.)
Pain management (cont.)
Pain medication may be administered
Orally
Routine intramuscular or IV routes
Patient-controlled analgesia (PCA)
Programmed IV infusion of narcotic analgesia that the child may control within set limits

33. The Child Undergoing Surgery (cont.)
Postoperative care (cont.)
Pain management (cont.)
Comfort measures should be used in conjunction with analgesic administration
No child should suffer pain needlessly
Surgical dressings
Close observation of any dressings for drainage, hemorrhage
Reinforcing or changing dressings as ordered
Explain to the child what will be done and why

34. The Child Undergoing Surgery (cont.)
Postoperative care (cont.)
Postoperative patient teaching
As important as preoperative teaching
Encourage the caregivers and child to share their feelings about the surgery, any changes in body image, and their expectations for recovery and rehabilitation
Focuses on home care at discharge

35. Question
Jimmy is 6 years old. He has been admitted to your unit for gastric surgery the following day. The surgeon has ordered a preoperative enema to be given. When would you expect to give this enema?
a. Before the evening meal the day before surgery
b. The evening before surgery
c. Right before bedtime the night before surgery
d. About one hour before surgery

36. Answer b. The evening before surgery
Rationale: You would not give an enema just prior to a meal if you want the gastrointestinal tract cleaned out for surgery; you would never give an enema just prior to putting a child to bed for the night; and you would not give an enema one hour before the planned surgery because the child would receive a sedative one and a half to two hours before going to the operating room.

37. The Hospital Play Program
Play is the business of children
Play helps children come to terms with the hurts, anxieties, and separation that accompany hospitalization
Must not be allowed to harm themselves or others

38. The Hospital Play Program (cont.)
The hospital play environment
An organized and well-planned play area is important
If possible, adolescents should have a separate recreation room
Play therapy: Technique of psychoanalysis
Therapeutic play: Play technique used to help child better understand what will be happening to him or her in a specific situation
A play technique that play therapists, nurses, child- life specialists, or trained volunteers may use to help the child express feelings, fears, and concerns

39. The Hospital Play Program (cont.)
Play material
Chosen with safety in mind
Constant supervision necessary for safety
Hospital equipment useful for play therapy
Dolls or puppets
Other useful play materials include clay, paints, markers, crayons, stamps, stickers, sand art, cut-out books, construction paper, puzzles, building sets, and board games