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Hospitalized Child 1
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HOSPITALIZED CHILD
1. INTRODUCTION
Based on the theory that hospitalization can be an unnecessary stress to
children, only those who cannot successfully be managed on an ambulatory
basis are now admitted to the hospital. This was not always true. For example
most children with head injuries automatically stayed overnight for observation.
Currently unless a child is unconscious or shows other signs of neurologic
injury he or she is sent to home to be observed by parents for signs of increased
ICP. This policy requires that time be spent in teaching parent skills such as
how to take a pulse or evaluate consciousness. Teaching them requires patience
because parents under stress can have difficulty comprehending instructions
however because psychological trauma as well as excessive health care costs
are prevented by allowing a child to return home it is important teaching.
Often illness and hospitalization are the first crises children must face.
Children during the early years are particularly vulnerable to the crises of illness
& hospitalization because stress represents a change from usual state of health
and environmental routine and children have a limited number of coping
mechanisms to resolve stressors, children’s reaction to these crises are
influenced by their developmental age, previous experience with illness,
separation or hospitalization, innate and acquired coping skills, the seriousness
of the diagnosis and the support system available.
MEANING OF ILLNESS AND HOSPITALIZATION TO CHILD
Infant
Charge in familiar routine and surroundings response with global reaction.
Separation from love object.
Toddler
Fear of separation, desertion, separation anxiety highest in this age group.
Relates illness to a concrete condition, circumstances or behavior
Preschool
Fear of bodily harm or mutilation, castration, intrusive procedures.
Separation anxiety less intense than toddlers but strong.
Causation same as toddler, often considers own role in causation ie, illness
as a punishment for wrong doing.
School Age
Fears physical nature of illness
Concern regarding separation from age mates and ability to maintain
position in peer group.
Perceives an external cause for illness, although located in body.
Adolescent
Anxious regarding loss independence. Control, identity concern about
privacy.
Perceives malfunctioning organ or process as cause of illness. Able to
explain illness.
B. PREPARING THE ILL CHILD AND FAMILY FOR
HOSPITALIZATION
Many childhood illness, such as febrile convulsions, appendicitis and asthma
attacks strike suddenly making advance preparation for hospital admission
impossible. However, when hospitalization is planned ahead of time, for
orthopedic second stage surgeries, preparation is possible. As a rule, parents
eagerly seek guidance from nurses or what and how much to tell their
children about an anticipated admission. The preparation a parent makes for
a child obviously varies according to the child’s age and individual
experience. No matter what the child’s age however, parents should be
encouraged to above all convey a positive attitude. The nurse can provide
further health teachings and clear up all misunderstandings.
1) Preparing the infant
As because the infant cannot understand explanations, preparation has to be
minimal.
Special items such as favorite toy, blanket, should be packed.
This objects provide care giver should spend a great deal of time with an
infant.
2) Preparing the toddler and pre-schooler
Three chief fears of the toddler and pre-schooler are fear of unknown, fear of
abandonment and separation and fear of mutilation.
These children need preparation clearly aimed at alleviating these fears.
Bringing a favorite toy can be a help.
Child could be encouraged to play hospital with dolls
3) Preparing school age and adolescent
Both school age and adolescents need factual explanations of what will
happen during hospitalization.
A hospital orientation program in which facts of hospitalization are
discussed
Interact the child with another child who had undergone through the same
condition.
4) Preparing the child of a different cultural background
Make the assurance that proper care will be provided to the child without
any differentiation.
5) Preparing disabled and chronically ill child
Help children to maintain a contact with their families and school friends
during a long hospitalization period, as they are staying in hospitals for long
term care through phone calls, letters & open visiting.
PREPARING FAMILY CARE GIVERS
Planning for hospitalization begins as soon as parents know that
hospitalization will be necessary.
Easing parental anxiety regarding illness and hospitalization is important
because infants and children can keenly sense a parent’s stress.
As a part of preparation parents should ask questions about the
hospitalization so that they become familiar with the situations. It will help
to reduce anxiety.
Advise parents to ask about the diagnostic procedures required length of
hospital stay, etc.
EFFECT OF HOSPITALIZATION ON CHILD
Children may react to the stress of hospitalization before admission, during
hospitalization and after discharge. A child’s conception of illness is even
more important than age and intellectual maturity in predicting level of
anxiety before hospitalization. This may or may not be affected by the
duration of condition or prior hospitalization. Therefore nurses should avoid
over estimating the illness concept of children with prior medical experience.
Individual risk factors
A number of risk factors make certain children more vulnerable than others
to the stress of hospitalization.
It has also been noted that rural children exhibit significantly greater degree
of psychological upset than urban children, because urban children are
familiar with hospitals.
Because separation is such an important issue of hospitalization for young
children nurses should be alert to children who passively accept all changes,
these, children need more support and care.
The stressors of hospitalization may cause young children to experience
short and long term negative out comes.
Adverse outcome may be related to the length & number of admissions,
multiple invasive procedures and the anxiety of the parents.
Common response includes regression, separation anxiety, apathy, fears,
sleeping disturbances, especially children younger than 7 years of age.
Supportive practices such as family centered care, and frequent family
visiting, may lessen the detrimental effect of such admissions.
A child’s pain experience indicates how the overall hospitalization is
experienced.
Increasing length of hospitalization because of complex medical and nursing
care, elusive diagnosis, and complicated psychosocial issues.
Without special attention, to meet child’s psychosocial developmental needs
in hospital environment the detrimental consequences of prolonged
hospitalization may be severe.
What the hospital means to pediatric patient depend upon their stage of
maturity and depend upon how accustomed they are to being left with
friends.
If they regard the separation as a punishment of wrongdoing, they will be
less able to cope with it than if they know the real reason for hospitalization.
Infants may be emotionally disturbed by hospitalization
Not only they are separated from parents but also they will have sensory
deprivation. If the nursing personal do not take the time to provide care.
If the child doesn’t have close physical contact with another human being
may result in emotional trauma.
Beneficial effects of hospitalization
The most obvious effect is the recovery from illness.
Hospitalization provides an opportunity for the children to master stress and
feel competent in their coping abilities.
Hospital environment can provide new socialization experience.
Child can broaden their inter personnel relationships.
Psychological status of child also maximized.
CHILDS REACTION TO HOSPITALIZATION AND PROLONGED
ILLNESS
Illness threatens both physiological and psychological development of
children.
Sickness causes pain, restraint of movement, long sleep less periods,
restrictions of feeds. Separation from parent home environment, which may
result emotional trauma.
Hospitalization and prolonged illness related growth and development and
cause adverse reaction in the child based on stage of development.
Reactions of neonates
Interrupts the early stages of development of a mother child relationship and
family integration.
Impairment of bonding and trusting relationship.
Inability of parents to love & care for the baby and inability of baby to
respond to parents and family members.
Reactions of infants
Infant’s reactions are mainly separation anxiety and disturbances in
development of basic trust.
Emotional withdrawal and depression are found in the infants of 4 to 8
months of age.
Interference of growth and delayed development is also found.
Older infants have limited tolerance due to separation anxiety which is found
as fear of strangers, excessive cry, clinging & over dependence on mother.
Reaction to toddler
Toddler reactions are found as protest, despair, denial and regression.
Toddle protest by frequent crying, shaking crib, rejecting nurses.
Attention, urgent desire to find mother, showing signs of distrust with anger
and fears.
In despair, toddler become hopeless, looks sad, cry continuously and use of
comfort measures like thumb sucking, fingering lip, and tightly clutching
toy.
In denial, the child reacts by accepting care without protest.
Toddlers react by regression in an attempt to control stress
Found to stop using newly acquired skills & may return to the behavior of an
infant during illness.
Reactions of pre-school child
Pre-school child adopts various defense mechanisms to adjust with stress.
They react by exhibiting regression, projection, displacement identification,
aggression, denial & fantasy.
They simply shows similar behavior of toddlers.
Reactions of school-aged
School aged children are concerned with fear, worry, mutilation, fantasies,
modesty & privacy.
They react with defense mechanism like regression, negativism, depression,
phobia, un-realistic fear or denial symptoms and conscious symptoms and
conscious attempts of mature behavior.
Reaction of adolescent
Adolescents are concerned with lack of privacy, separation from peers or
family & school interference with body image or independence or self
concept & sexuality.
They react with anxiety related to loss of control & insecurity in strange
environment.
They may show anger and demanding or un co-operative behavior
They may adopt mental mechanisms like intellectualization about disease,
rejection of treatment, depression, denial/withdrawal.
D. EFFECTS OF HOSPITALIZATION IN CHILDREN AND FAMILY
1) Stressor’s of hospitalization and children’s reaction
Major stressors of hospitalization includes, separation, loss of control, bodily
injury, and pain children’s reactions to these crisis are influenced by their
developmental age, their previous experience with illness, separation or
hospitalization their innate and acquired coping skills, the seriousness of the
diagnosis and the support system available.
a) Separation anxiety
The major stress from middle infancy throughout the pre-school years,
especially for children ages 16 to 30 months is separation anxiety, also called
anaclitic depression.
During the phase of protest children react aggressively to the separation from
the parent. They cry & scream for their parents and in-consolable by others.
During the phase of despair the crying stops and depression evident, less
active, un-interested in play
Third stage is detachment also called denial, the child is finally adjusted to
the loss, becomes interested with the surroundings and forms new
relationships.
This behavior is a sign of resignation and i9s not a sign of contentment
The child detaches from the parent in an effort to escape the emotional pain
of desiring the parent’s presence and copes by forming shallow relationship
with others being increasingly self centered, and attaching primary
importance to material objects.
Health team member understand the meaning of each stage of behavior and
should label as positive or negative.
Eg. The loud crying of the protest phase as a bad behavior during quite
withdrawn phase of behavior, health team member may think that child is
settling in.
Detachment behavior as a proof of adjustment & child is considered as ideal
patient.
Early childhood
Separation anxiety is the greatest stress imposed by hospitalization during
early childhood.
Children in the toddler stage demonstrate more goal oriented behaviors.
They may demonstrate displeasure on parent’s return or departure by temper
tantrums or regression to primitive levels of development.
Temper tantrums, bed wetting or other behaviors are expression of anger or
response to stress.
Pre-schoolers are more secure interpersonally than toddlers, they can tolerate
brief period of separation from their parents and are more inclined to develop
trust in other significant adults.
The stress of illness usually renders pre-schooler less able to cope with
separation.
They may show separation anxiety by refusing to eat, experiencing difficulty
in sleeping, crying quietly for their parents withdrawing from others.
They will express indirectly by breaking toys, hitting other children.
Later childhood and adolescence.
In school age child being away from family higher than any other fear
associated with hospitalization.
Hospitalization increase their need of parental security and guidance.
Middle and late school age children may react more due to separation from
usual activities and peer groups than to the absent of their parents.
Feelings of loneliness, boredom, isolation and depression are common.
School age children have irritability and aggression towards parents
withdrawal from hospital personnel, inability to relate to peers, rejection of
siblings, subsequent behavioral problems in school.
b) Loss of control
The major areas of loss of control in terms of physical restriction, altered
routine or rituals, and dependency.
Infants
In hospital setting, routines may be established to meet hospital staffs need
instead of infant needs.
Inconsistent care and deviation from infant’s routine may lead to mistrust
and decreased sense of control.
Toddlers
Toddlers are striving for autonomy, and this goal is evident in most of their
behaviors.
When their ego-centric pleasures meet with obstacles toddlers react with
negativism, especially temper tantrums.
Loss of control results from altered routines and rituals.
It can cause regression to toddlers.
Enforced dependency is a chief characteristic of toddler during sick role
most toddlers react negatively and aggressively to this.
Prolonged loss of autonomy may result in passively to this.
Prolonged loss of autonomy may result in passive withdrawal from
interpersonal relationships. And regression in all areas of development.
Preschoolers
Pre schoolers also suffer from loss of control caused by physical restriction,
altered routines, and enforced dependency.
Their specific cognitive abilities which make them feel omnipotent and all
powerful; also make them feel out of control.
This loss of control is a critical influencing factor in their perception of and
reaction to separation, pain, illness hospitalization.
School age
Because of their striving for independence and productivity school age
children are particularly vulnerable to events that may lessen their feeling of
control and power.
Altered family roles, physical disability, fears of death, abandonment, or
permanent injury, loss of peer acceptance, lack of productivity and inability
ot cope with stress according to perceived cultural expectation may result in
loss of control.
One of the most significant problems of this age is boredom.
When physical or enforced limitation curtails their usual abilities to care for
themselves, school age children generally respond with depression, hostility
and frustration.
Adolescents
Adolescents struggle for independence, self assertion, and liberation centers
on the quest for personal identity. Anything that interferes with this poses a
threat to their sense of identity and result in loss of control.
BODILY INJURY AND PAIN:
In caring for children nurses must have an appreciation of a child’s concerns
about bodily harm and reactions to pain at different developmental periods.
Infants
Infants may express pain by squirming, writhing, jerking and failing some
infants may cry loudly, where as others are easily calmed by gentle hug.
Older infants react intensely with physical resistance and un-co-
cooperativeness. They may refuse to lie still or try to escape with motor
activity they have achieved.
Toddlers
Toddlers reaction to pain are similar to those seen during infancy. They will
react with intense emotional upset and physical resistance to any actual or
perceived experience. Behaviors indicating pain include grimacing clenching
teeth or lips, opening their eyes wide, rocking, rubbing & acting
aggressively.
Young children become restless and overly active is a consequence of pain.
They usually able to localize the specific painful area.
Pre-schoolers
Reactions to pain tend to be similar to those seen in toddler hood
Physical and verbal aggressions are more specific.
Instead of showing total body resistance, preschoolers may push the
offending person away, try to secure the equipment and lock them
safely
some times they may verbally abuse the nurse
pre-schools can locate pain & can use appropriate pain scales.
School age
They will have a fear of illness itself, disability & death.
Fear of intrusive procedures in genital area.
School age children verbally communicate their pain in respect to location,
intensity and description.
By 9-10 years of age they show less fright or over resistance and aggression
are less likely at this age unless the adolescent is totally up prepared for a
procedure.
They are able to describe pain experience & can use any of the pain
assessment tools.
They may be reluctant to disclose their pain.
PLAY ACTIVITIES FOR ILL HOSPITILIZED CHILD
FUNCTIONS OF PLAY IN THE HOSPITAL
Provides diversion & bring about relaxation.
Helps the child feel more secure in strange environment
Helps to lessen the stress of separation & the feeling of home sickness.
Provides a mean for release of tension & expression of feelings.
Encourages interaction & development of positive attitude towards others.
Provides an expressive outlet for creative ideas or interests.
Provides a mean for accomplishing therapeutic goals.
Places child in active role & provides opportunity to make choices & be in
control.
Play in infancy
Pleasure by touch & manipulation.
5-6 months – infant repeat activities
9 months – repetitive games (pat-a-cake)
12 month - recognition & acknowledgement of other
Play in 2nd year
2 to 3 year – fascination with working part of toys talking on toy phone
involve parents
Third year – child taught to share
Conflict below parents & child.
Pre-school – competition, mastery of tasks
Genders roles (House, Doctor)
School – Foot ball, basket ball.
NURSING CARE OF HOSPITISED CHILD AND FAMILY
(PRINCIPLES AND PRACTICE)
PREVENTING OR MINIMIZING SEPARATION
Primary goal is to prevent separation particularly in children younger than 5
years of age.
Welcome the presence of parents at all time throughout the child’s
hospitalization.
Many hospitals developed a system of family centered care.
During the time of separation behavior, nu8rse provide support throught
physical presence
If behaviors of detachment are evident, the nurse maintains the child’s contact
with the parents by frequently talking about them, encouraging child to
remember them etc.
When helping parents with the fears of separation, nurses should suggest the
way of leaving and returning.
Parental visits should be frequent
If the parents can’t room-in they can leave a favorite article from home the
children gain comfort and re-assurance from them.
MINIMIZING LOSS OF CONTROL
Feelings of loss of control results from separation, physical restriction,
changed routine, enforced dependency and magical thinking.
Promoting freedom of movement during procedures can be completed by
placing child in parents lap.
Mechanical freedom can be provided by transporting child in wheel chairs, or
beds with mechanical freedom.
Maintaining child’s routine: One technique that can minimize the disruption
in child’s routine is time structuring.
It include scheduling the child’s day to include all those activities that are
important to the child and nurse such as treatment procedures, school work,
exercise, television etc. together nurse, parent and the child then plan a daily
schedule with times and activities written down.
Encouraging independence; promoting children’s control involves
maintaining independence and the concept of self-care can be most
beneficial. Self care refers to the practice of activities that individuals
personally initiates and perform on their own behalf individuals personally
initiates and perform on their own behalf in maintaining health and well
being. Self care activities are encouraged in hospitals other approaches
include jointly planning care, time structuring, making choices in food
selection & bedtime etc.
Promoting understanding- Anticipatory preparation and providing
information help greatly to lessen stress and prevent lack of understanding.
Informing children about their rights foster greater understanding any may
relieve the feelings of powerlessness.
PREVENTING OR MINIMIZING FEAR OF BODILY INJURY
Preparation of children for painful procedures decreases their fears.
Manipulating procedural techniques also minimizes fear
For children, who is fear of mutilation of body parts, the nurse repeatedly
stress the reason for a procedure and evaluate child’s understanding.
Employ pain reduction techniques.
STRATEGIES TO COPING & NORMAL DEVELOPMENT
During hospitalization care of the child focuses not only on meeting
physiologic needs, but also on meeting psychosocial and developmental
needs.
Several strategies may be used to help children adapt to the hospital
environment, promote effective loping & provide developmentally
appropriate activities.
These strategies include child life programs, rooming in, therapeutic play, and
therapeutic recreation.
a) Child life programs
If focus on the psychosocial need of hospitalized children.
Professional child life specialists, para professionals, & volunteers staff these
departments.
A child life specialist plan activities to provide age appropriate play time for
children either in playroom or child’s room.
Some of the activities are designed to assist children in working through
feeling about illness.
Eg: Playing with medical equipment
Child specialist & nurses formulate plan together to assist children with
particular needs.
b) Rooming-In
is the practice of having a parent stay in the child’s hospital room & care for
the hospitalized child.
Some hospitals provide cots, others have special built-in beds & in some
institutions parent stays in a separate room on the unit.
Parent who is rooming in may want to perform all of the child’s basic care or
help with some of the medical care.
Communication below nurse & parent is important so that the parent’s desire
for involvement is supported.
Therapeutic play
Play is an important part of the childhood.
The stress of illness & hospitalization increase the value of play.
Not only is normal development facilitated by play, but play sessions can
provide a means for the child to learn about health care, to express anxieties
to work through feelings & to achieve a sense of mastery over control over
frightening or little understood situations.
Play presents an opportunity to deal with the fears & concerns of health
experiences are called therapeutic play.
Through therapeutic play the nurse may assess the child’s knowledge of his
or her illness.
A common technique involves using body line drawing or stories & asking
the child to draw or talk about illness or injury means to him/her.
Child may be asked to draw a picture or make a story enabling the nurse to
assess fears & other emotions.
The good enough-draw-A-Person test help the nurse assess the congnitive
level of children below 3& 13 years of age.
The gillert index is another tool that help the nurse assess child’s knowledge
of the body.
The same techniques may be used in a slightly different way to teach the
child about surgery or plan activities that allow child to express fears & gain
mastery over the situation.
A variety of technique may be used to promote therapeutic play. Specific
techniques are chosen to reflect the child’s developmental stage.
Toddler, play is important for toddler. Through play the explore the
environment & learn to identify with significant people in their lives.
Play is also an acceptable way for toddlers to release tensions caused by
stress or aggressive impulses.
Toddlers should be approached slowly & the initial approach should be made
in their parent’s presence, if possible to decrease feelings of stranger anxiety.
Playing a variation of peek-a-boo or hide & seek using the curtain
surrounding the toddlers crib or bed help to promote realization of that
objects out of sight, such as parents, do return.
The use of transitional objects, such as a familiar blanket or stuffed animal,
can temporarily substitute for the security of parents.
The toddler who is restrained can be read familiar stories. Repetition of
stories promotes a sense of stability in the unfamiliar hospital environment.
A doll is familiar toy that can be used to recreate a stressful environment,
thereby providing an opportunity for the child to express & work through
feelings.
Other developmentally appropriate toys for toddlers include familiar objects
from home such as measuring cups or spoons, wooden puzzles, push & pull
toys.
Playing with safe hospital equipments (bandages, syringes without needles
etc) help toddlers to over come the anxiety associated with these items.
Pre-schooler
The nurse can intervene to reduce the stress produced by pre-schoolers fear
through the use of some kinds of play.
A simple body outline or doll can be used to address the child’s fantasies &
fears of bodily harm. Playing with safe hospital equipment may help pre-
schoolers to work through feelings such as aggression.
Pre schoolers like crayons & coloring books, puppets, felt & magnetic
boards, play dough, & recorded stories.
Both pre-schooler & school age children may enjoy play with a toy hospital.
School age child
Although play begins to lose its importance in the school age years, the nurse
can still use some techniques of therapeutic play to help the hospitalized
Child deal with stress.
School age children often regress developmentally during hospitalization,
demonstrating behaviors characteristics of an earlier state, such as separation
anxiety & fear of bodily injury.
Body outlines & occasionally dolls can be sued to illustrate the cause and
treatment of the child’s illness.
Terms for body parts that are suitable for older children should be used
drawings provide an out let for expression of fears & anger.
School age children enjoy collecting, organizing objects & often ask to keep
disposable equipment that has been used in their care. They may use these
items later to relive the experience with their friends.
Games, books, crafts, computers, provide an outlet for aggression & increase
self esteem in the school age child.
The type of play used should promote a sense of mastery & achievement.
THERAPEUTIC RECREATION
Many of the special play techniques used with younger children are not
suitable for adolescents.
Adolescents do need a planned re-creation program to assist them in meeting
developmental needs during hospitalization.
Peers are important and the isolation of hospitalization can be difficult.
Telephone contact with other teenagers & visits from friends should be
encouraged.
Interactions with other teenagers ate a pizza party or a video game or movie
night can help adolescents feel normal.
Physical activities that provide an outlet for stress are recommended. Even
adolescents on bed rest or in wheelchairs can play a modified form of basket
ball.
The independence of adolescence is interrupted by illness. Nurses can
provide choices for teenagers to assist them in regaining control.
Giving them options & letting them choose an evening recreational activity
can promote their feelings of independence.
Passes to leave the hospital for special activity may be possible.
The nurse in corporate play activities into the daily life of each pediatric patient
because play is a part of child’s total needs.
The nurse must consider, when planning activities for child, the age, interests
diagnosis & limitations imposed by illness.
An acutely ill child who is unable to play actively with toys may enjoy
listening to stories.
Telling a story rather than reading draws children into emotional involvement
with it.
The story teller can ask questions pass comments & can make the child a part
of it.
Other activities children can do are watching a plant grow, watching an
anthill or gold fish in a tank or watching supervised television programmes.
In the play area, children who are permitted out of bed should be free to
develop mental, motor & social skills and to express themselves. In a variety
of art media such as finger painting or molding with clay.
Domestic play re-assures them that their own homes are still there & that they
are missed.
Children usually select toys such as doctor, syringes with which they can
imitate the activities seen around.
Old cloth in such play can be used to restrain hands of a doll in case of
fractures to make bandages to promote healing.
Puppets are used to demonstrate procedures to children.
Such activities help children work out feelings about hospitalization.
Children also enjoy play telephone because they can pretend that they are
calling home.
They also can enjoy clay, paints, pounding boards on which they can express
their anger.
They enjoy tricycles, wagons, through the use of which they develop or
exercise their large muscles.
Children play areas cannot be kept clean & orderly as judged by adult
standars.
It the nurses are too concerned about the physical appearance of play area
during play time the children feel that the unit personnel do not approve o f
their play.
Children should be taught to take care of toys & a place must be provided to
store their toys.
Much can be learned from watching children play in a relaxed environment.
Their approaches to play & their relationship with peers, parents, adults
should be observed and recorded.
Also to be noted are the degree of their activities attention span, ability to
tolerate frustration, verbal abilities, concept formations.
In addition, nurse is able to note their comments about home, hospitalization,
general attitudes & behavior.
It will help the nurse to understand how well the child is coping with the
situations & crisis.
If the child handle it well, the experience may be of help in mastering
problem situations.
Nurse should have an opportunity to participate with children play activities.
Story telling-telling stories with themes.
Water play during bath.
Television-by instructing them about programs.
Needle play
Pre-post operative teaching
Art.