Care of the Hospitalized Child

1. Care of the Hospitalized Child Chapter 4

2. Preview Hospitalization may cause anxiety and stress at any age. Children are often too young to understand what is happening or are afraid to ask questions.

3. Preview Child is apprehensive. Family concerns: cause of illness, its treatment, guilt about the illness, past experiences of illness, hospitalization, financial impact, disruption of family life.

4. Preview The child may pick up on the fears of family caregivers, and these negative emotions may hinder the child’s progress. Children are tuned in to the feelings and emotions of their caregivers.

5. Preview The child’s developmental level also plays an important role in determining how he or she handles the stress of illness and hospitalization.

6. Preview The nurse who understands the child’s developmental needs may significantly improve the child’s hospital stay and overall recovery. Many hospitals have a child-life program to make hospitalization less threatening for children and their parents.

7. Preview Sometimes the best way to ease the stress of hospitalization is to ensure that the child has been well prepared for the hospital experience.

8. Early Childhood Education About Hospitals When the child is capable of understanding the basic functions of community resources and the people who staff them, it is time for an explanation.

9. Early Childhood Education About Hospitals Children can handle equipment, try out call bells, try on masks and gowns, have their blood pressure taken to feel the squeeze of the blood pressure cuff, and see a hospital pediatric bed and compare it with their bed at home.

10. Early Childhood Education About Hospitals Hospital staff members explain simple procedures and answer children’s questions. A tour of the pediatric department, puppet shows or show slides or videos about admission and care.

11. Early Childhood Education About Hospitals Families are encouraged to help develop a positive attitudes about hospitals. The family should avoid negative attitudes about hospitals.

12. Early Childhood Education About Hospitals Young children need to know more than a place where “mommies go to get babies.” It is also important to avoid fostering the view of the hospital as a place where people go to die.

13. Early Childhood Education About Hospitals A careful explanation of the person’s illness and simple, honest answers to questions about the death are necessary.

14. The Pediatric Unit Atmosphere An effort by pediatric units and hospitals to create friendly, warm surroundings for children has produced many attractive, colorful pediatric settings. Walls are colorful, often decorated with murals, wallpaper, photos, and paintings.

15. The Pediatric Unit Atmosphere Furniture is attractive, appropriate in size, and designed with safety in mind. The staff members wear colored smocks, or printed scrub suits. Research has shown that children react with greatest anxiety toward the traditional white uniform.

16. The Pediatric Unit Atmosphere Children wear their own clothing during the day. Colorful printed pajamas are provided for children who need to wear hospital clothing.

17. The Pediatric Unit Atmosphere Treatments are performed in a treatment room. Using a separate room to perform procedures promotes the concept that the child’s bed is a “safe” place.

18. The Pediatric Unit Atmosphere A playroom or play area should be a place that is safe from any kind of procedures. Some hospitals provide a person trained in therapeutic play to coordinate and direct the play activities.

19. The Pediatric Unit Atmosphere Most pediatric settings provide rooming-in facilities and encourage parents or family caregivers to visit as frequently as possible. This helps minimize the separation anxiety.

20. The Pediatric Unit Atmosphere Caregivers are involved in much of the young child’s care. They provide comfort and reassurance to the child Primary nursing is used so that the same nurse is with a child as much as possible, which allows an opportunity to establish a trusting relationship with the child.

21. The Pediatric Unit Atmosphere Planning meals that include the child’s favorite foods, within the limitations of any special dietary restriction, may perk up a poor appetite. Children may eat together at a small table.

22. The Pediatric Unit Atmosphere Younger children should be seated in high chairs or other suitable seats. Meals should be served out of bed, and in a pleasant atmosphere if possible. Some units use the playroom to serve meals to ambulatory children.

23. Pediatric Intensive Care Units Visiting may be restricted. Visiting hours should be flexible enough to accommodate the child’s best interests. The family should be encouraged to bring in a special doll or child’s toy to provide comfort and security.

24. PICU Most items can be sterilized after hospital use.

25. Pediatric Intensive Care Units The child’s developmental level must be assessed so that the nursing staff can provide appropriate explanations and reassurance before and during procedures.

26. Pediatric Intensive Care Units Positive reinforcements, such as stickers and small badges, may provide symbols of courage. The nurse also needs to interpret technical information for family members.

27. Pediatric Intensive Care Units The nurse should promote the relationship between the family caregiver and the child as much as possible. The caregiver should be encouraged to touch and talk to the child. If possible they may hold and rock the child; if not, he or she can comfort the child by caressing and stroking.

28. PICU Neonatal stroking might be prohibited due to all energy needed for growth, depends on circumstances.

29. Infection Control Microorganisms are spread by: Contact --(direct, indirect, or droplet), Vehicle-- (food, water, blood or contaminated products) Airborne-- (dust particles in the air) Vector-- (mosquitoes, vermin)

30. Infection Control Two levels of precautions: 1. Standard Precautions—are used in the care of all patients. 2. Transmission Based Precautions– include three types: airborne, droplet, and contact precautions. See Appendix A

31. Infection Control Handwashing conscientiously between seeing each patient, even when gloves are worn for a procedure.

32. Infection Control The child who is segregated by transmission based precautions is subject to social isolation. Feelings of loneliness and depression are common. Every effort must be made to help reduce these feelings.

33. Infection Control The nurse might read a story, play a game, or just talk with the child. Family caregivers should be encouraged to spend time with the child. The nurse might help them with gowning and other necessary precaution procedures.

34. Infection Control The nurse may encourage the family to bring the child’s favorite dolls, stuffed animals, or toys. Most of these items can be sterilized after use. For the older child, electronic toys and they should be encouraged to make phone calls to friends and family to keep up social contacts.

35. Infection Control For the school-age child the classmates can send cards to keep the child involved. If the child’s room has a window, move the bed so that the child can see outside.

36. Infection Control If masks or gloves are part of the necessary precautions, the child may experience even greater feelings of isolation. Careful explanations should help the child accept this. The nurse should always be alert to the child’s loneliness and sadness and should be prepared to meet these needs.

37. Importance of Caregiver Participation Young children have no concept of time, so separation from their primary caregivers is especially difficult for them to understand. Three characteristic stages of response to the separation have been identified: protest, despair and denial.

38. Importance of Caregiver Participation During the first stage (protest)—the young child often cries, often refuses to be comforted by others, and constantly seeks the primary caregiver at every sight and sound. When the caregiver does not appear, the child enter the second stage.

39. Importance of Caregiver Participation Second stage (despair)—becomes apathetic and listless. The child has given up.

40. Importance of Caregiver Participation Third stage (denial)—the child begins taking interest in the surroundings and appears to accept the situation. However, when the caregivers do visit, the child often turns away from them, showing distrust and rejection.

41. Importance of Caregiver Participation The child may always have a memory of being abandoned at the hospital. Childhood impressions have a deep effect.

42. Importance of Caregiver Participation One advantage of rooming-in is the measure of security the child feels as a result of the caregiver’s care and attention. The caregiver may participate in bathing, dressing, and feeding, preparing the child for bed, and providing recreational activities.

43. Importance of Caregiver Participation If treatments are to be continued at home, this is an excellent opportunity for the caregiver to observe and practice before leaving the hospital. Rules should be clearly understood before admission, and facilities to include meals for caregivers explained.

44. Importance of Caregiver Participation The primary caregiver’s basic role is to provide security and stability for the child. Many pediatric units also have recognized the importance of allowing siblings to visit the ill child.

45. Importance of Caregiver Participation Visiting policies usually require that a family adult accompany and be responsible for the child and that the visiting period is not too long. There also should be a policy requiring that the visiting sibling does not have a cold or other contagious illness and is up to date in immunizations.

46. Importance of Caregiver Participation The caregiver needs to be encouraged to leave for meals or a break or to go home, if possible, for a shower and rest. The child may be given a possession of the caregiver’s to help reassure him or her that the caregiver will return.

47. Admission & Discharge Planning The child feels in much better control if explained where they are going and why and has answered questions truthfully. Should be greeted in a warm, friendly manner and taken to the child’s room or to a room set aside specifically for the admission procedure.

48. Admission & Discharge Planning The caregiver and the child need to be oriented to the child’s room, the nursing unit, and regulations. See Box 4-1 on pg. 68!

49. Planned Admissions Candidates for hospital admission may attend open house programs. It is important for family caregivers and siblings to attend the preadmission tour with the future patient to reduce anxiety in all family members.

50. Planned Admissions Questions may be answered and anxieties explored during the visit. Staff can discuss common questions and feelings. Children are told that some things will hurt but that doctors and nurses will do everything they can to make the hurt go away. Honestly must be a keynote to any program of this kind. The preadmission orientation staff also must be sensitive to cultural and language differences and make adjustments whenever appropriate.

51. Emergency Admissions Emergencies leave little time for explanations. Physical needs assume priority over emotional needs. Nurses must be sensitive to the needs of the child and the family.

52. Emergency Admissions Recognizing the child’s cognitive level and how it affects the child’s reactions is important. The staff must explain procedures and conduct themselves in a caring, calm manner to reassure both the child and the family.

53. The Admission Interview An admission interview is conducted as soon as possible after the child has been admitted. An identification bracelet is placed on the child’s wrist. If the child has allergies, an allergy bracelet must be placed on the wrist as well.

54. The Admission Interview The nurse should be friendly and casual, remembering that even a well-informed child may be shy and suspicious of excessive friendliness. Children who know that the caregiver may stay with them are more quickly put at ease.

55. The Admission Interview The interviewer tries to determine previous experience with hospitals and health care providers and how much they understand about the child’s condition and their expectations of this hospitalization.

56. The Admission Interview What support systems are available when the child returns home and any disturbing or threatening concerns. Client history, and physical exam form the basis for the patients total plan of care while hospitalized.

57. The Admission Physical Examination After the child has been oriented to the new surroundings by perhaps clinging to the family caregiver’s hand or carrying a favorite toy or blanket, the caregiver may undress the child for the physical exam. If comfortable with helping, the caregiver may stay with the child while the physical exam is being completed.

58. Discharge Planning Planning for the child’s discharge and care at home begins early in the hospital experience. Health team members must assess the levels of understanding of the child and family and their abilities to learn about the child’s condition and the care necessary after the child goes home.

59. Discharge Planning It is necessary to provide specific, written instructions for reference at home. The anxiety often limit the amount of information retained from teaching sessions. If the treatment necessary at home appears too complex for the caregiver to manage, it may be helpful to arrange for a visiting nurse to assist for a period after the child is sent home.

60. Discharge Planning Shortly before the child is discharged, a conference may be arranged to review information and procedures with which the family caregivers must become familiar. The conference may or may not include the child. Questions and concerns must be dealt with honestly, and a resource such as a telephone number should be offered for questions that arise after discharge.

61. Discharge Planning The return home may be a difficult period of adjustment for the entire family. The preschool child may be aloof at first, followed by a period of clinging, demanding behavior. Other behaviors such as regression, temper tantrums, nightmares may demonstrate fear of another separation.

62. Discharge Planning The older child may demonstrate anger or jealousy of siblings. The family may be advised to encourage positive behavior and avoid making the child the center of attention because of the illness. Discipline should be firm, loving, and consistent.

63. The Child Undergoing Surgery Outpatient surgery facilities permit the patient to return home the day of the operation. This reduces or eliminates the separation of parents and children, one of the most stressful factors.

64. The Child Undergoing Surgery The child who has surgery needs sympathetic and thorough preoperative and postoperative care. When the child is too young, explanations should be directed to family caregivers to help relieve their anxiety and to prepare them to participate in the child’s care after surgery.

65. Preoperative Care General aspects of care include: Patient teaching Skin preparation Preparation of the GI and urinary systems Preoperative medications

66. Patient Teaching Health professionals involved in the child’s care must determine how much the child knows and is capable of learning, correct any misunderstandings, explain the preparation for surgery and what the surgery will “fix”, as well as how the child will feel after surgery. This preparation must be based on the child’s age, developmental level, previous experiences, and caregiver support.

67. Patient Teaching All explanations should be clear and honest and expressed in terms the child and the family caregivers can understand. Questions should be encouraged. Preoperative teaching should be conducted in short sessions rather than trying to discuss everything at once.

68. Patient Teaching Therapeutic play may be useful in preparing the child for surgery. Nurses explain the reason for withholding food and fluids before surgery so children do not feel they are being neglected or punished when others receive meal trays. May interpret surgery as punishment and should be reassured that they did not cause the condition.

69. Patient Teaching They also fear mutilation or death and must be able to explore those feelings, while recognizing them as acceptable fears. Children deserve careful explanation that the physician is going to repair only the affected body part. It is important to emphasize that the child will not feel anything during surgery because of the special sleep that anesthesia causes.

70. Patient Teaching Describing the post-anesthesia care unit (PACU or wake-up room) and any tubes, bandages, or appliances that will be in place after surgery lets the child know what to expect. If possible, the child should be able to see and handle the anesthesia mask and equipment that will be part of the post-operative experience.

71. Patient Teaching Role playing, adjusted to the child’s age and understanding is helpful. The older child or adolescent may have a greater interest in the surgery itself. Models of a child’s internal organs or individual organs such as a heart are useful for demonstration.

72. Patient Teaching A child needs to understand that several people will be involved in pre-operative, surgical and post-operative care. Explain what the people will be wearing (caps, masks, and gloves), and what equipment will be used (including bright lights) helps make the experience less frightening.

73. Patient Teaching Most patient experience postoperative pain, and children should be prepared for this experience. They also need to know when they may expect to be allowed to have fluid and food after surgery. Need to be taught to practice coughing and deep-breathing exercises--May be done with games that encourage blowing. Need to be taught to splint the operative site with a pillow helps reassure them that the sutures will not break and allow the wound to open.

74. Patient Teaching Children should be told where their family will be, and every effort should be made to minimize separation. Caregivers should be encouraged to be present when the child leaves for the operating room.

75. Skin Preparation Skin preparation may include a tub bath or shower with a special cleaning and inspection of the operative site. Shaving usually is performed in the operating room.

76. Skin Preparation If fingers or toes are involved, the nails are carefully trimmed. The operative site may be painted with a special antiseptic solution as an extra precaution against infection.

77. Gastrointestinal & Urinary System Preparation May order a cleansing enema the night before surgery, which is an intrusive procedure and must be explained to the child before it is given.

78. Gastrointestinal & Urinary System Preparation NPO 4 to 12 hours before surgery because food or fluids in the stomach may cause vomiting and aspiration particularly during general anesthesia. Should be told that food and drink are being withheld to prevent an upset stomach. The NPO period varies according to the child’s age; infants become dehydrated more rapidly than older children and thus require a shorter NPO period.

79. Gastrointestinal & Urinary System Preparation Pediatric NPO orders should be accompanied by an intravenous (IV) fluid initiation order. Loose teeth are also a potential hazard and should be counted and recorded according to hospital policy.

80. Gastrointestinal & Urinary System Preparation Urinary catheterization may be performed preoperatively, but usually it is done while the child is in the operating room. It is often removed immediately after surgery. Children who are not catheterized before surgery should be encouraged to void before the administration of preoperative medications.

81. Preoperative Medication Preoperative medications usually are given in two stages: A sedative is administered about 1.5 to 2 hours before surgery An analgesic-atropine mixture may be administered immediately before the patient leaves for the operating room.

82. Preoperative Medication When the sedative has been given, the lights should be dimmed and noise minimized to help the child relax and rest. Caregivers and the child should be aware that atropine could cause a blotchy rash and a flushed face.

83. Preoperative Medication Preoperative medication should be brought to the child’s room. Another nurse helps the child hold still. Medication should be administered carefully and quickly because delays only increase the child’s anxiety. Family caregivers should accompany the child to the operating room and wait until the child is anesthetized.

84. Postoperative Care Immediate postoperative period, the child is cared for in the PACU or the surgical ICU. Meanwhile the room in the pediatric unit should be prepared with appropriate equipment for the child’s return.

85. Postoperative Care When the child has been returned to the room, nursing care focuses on careful observation for any signs or symptoms of complications: shock, hemorrhage, or respiratory distress. Vital signs are monitored, the child is kept warm, dressings, IV apparatus, urinary catheters, and any other appliances are noted and observed. IV flow sheet is begun that documents the type of fluid, the amount of fluid, the rate of flow, and any additive medications, the site, and the site’s appearance and condition.

86. Postoperative Care The first voiding is an important milestone in the child’s postoperative progress because it indicates the adequacy of blood flow; it should be noted, recorded, and reported. Any irritation or burning also should be noted, and the physician should be notified if anuria (absence of urine) persists longer than 6 hours.

87. Postoperative Care Postoperative orders may provide for ice chips or clear liquids to prevent dehydration. Frequent repositioning is necessary to prevent skin breakdown, orthostatic pneumonia, and decreased circulation. Coughing, deep breathing, and position changes are performed at least every 2 hours.

88. Pain Management Infants and young children cannot adequately express themselves and need help to tell where or how great the pain is. Children experience pain as keenly as adults do.

89. Pain Management The nurse must be alert to indications of pain—changes in behavior such as rigidity, thrashing, facial expressions, loud crying or screaming, flexion of the knees (indicating abdominal pain), restlessness, and irritability. Physiologic changes, such as increased pulse rate and blood pressure, sweating palms, dilated pupils, flushed or moist skin, and loss of appetite.

90. Pain Management Some may try to hide pain because they fear an injection or because they are afraid that admitting to pain will increase the time they have to stay in the hospital.

91. Pain Management Various tools have been devised to help children express the amount of pain they feel and allow nurses to measure the effectiveness of pain management efforts. These tools include the faces scale, the numeric scale, and the color scale, yellow, red, or black = mild to severe. Bottom of pg. 73 is the pain scales.

92. Pain Management Pain medication may be administered orally, by routine IM or IV routes, or by patient controlled analgesia (PCA) . PCA may be used for children 7 years of age or older who have no cognitive impairment and undergo a careful evaluation. IM injections are avoided if possible. Vital signs must be monitored, and the child’s level of consciousness must be documented frequently following the standards of the facility.

93. Pain Management Comfort measures should be used along with the administration of analgesics. Encouraged to become involved in activities that may provide distraction. No child should be allowed to suffer pain unnecessarily. Appropriate non-pharmacologic comfort measures may include position changes, massage, distraction, play, soothing touch, talk, coddling, and affection.

94. Surgical Dressing Postoperative care includes close observation of any dressings for signs of drainage of hemorrhage and reinforcing or changing dressings as ordered.

95. Surgical Dressing Dry dressings increase the child’s comfort. If there is no physician’s order to change the dressing the nurse is expected to reinforce the most original dressing by covering it with a dry dressing and taping the second dressing in place. If bloody drainage is present, the nurse should draw around the outline of the drainage with a marker and record the time and date. In this way the amount of additional drainage can be assessed later.

96. Surgical Dressing Detailed procedures for these techniques and the supplies to be used can be found in the facility’s procedure manual. The nurse must explain to the child what will be done and why before beginning the dressing change. Some dressing changes are painful—if so, the child should be told that it will hurt and should be praised for behavior that shows courage and cooperation.

97. Patient Teaching Postoperative patient teaching is as important as preoperative teaching. Explanations and instructions given earlier must be repeated because the child’s earlier anxiety may have prevented thorough understanding.

98. Patient Teaching Now that tubes, restraints, and dressings are part of the child’s reality, they need to be discussed again. If caregivers know what to expect and how to aid in their child’s recovery, they will be cooperative during the postoperative period. The caregivers and child should be encouraged to share their feelings about the surgery, any changes in body image, and their expectations for recovery and rehabilitation.

99. Patient Teaching Before discharge, teaching is focused on home care, use of any special equipment or appliances, medications, diet, restrictions on activities, and therapeutic exercise. Caregivers should demonstrate the procedures or repeat information so the nurse can determine if learning has occurred. The nursing process is used to assess the needs of the child and the family to plan appropriate postoperative care and teaching.

100. The Hospital Play Program Play is the business of children and a principal way in which they learn, grow, develop, and act out feelings and problems. Playing is a normal activity.

101. The Hospital Play Program Play helps children come to terms with hurts, anxieties, and separation that accompany hospitalization. May express frustrations, hostilities, and aggressions through play without the fear of being scolded by the nursing staff. Children who keep these negative emotions bottled up suffer much greater damage than those who are allowed to express them where they may be handled constructively.

102. The Hospital Play Program Children, however, must not be allowed to harm themselves or others. Children rely on adults to guide them and set limits for behavior because this means the adult care about them. It is important to make it clear that the child’s action, not the child, is being disapproved when behavior correction is necessary.

103. The Hospital Play Environment An organized and well-planned play area. It should provide a variety of play materials suitable for the ages and needs of all children. The selection and kind of play may usually be left unstructured. If possible, adolescents should have a separate recreation room or area—where they may gather to talk, play pool, eat snacks….

104. The Hospital Play Environment Rules may be clearly spelled out and posted. Some play programs may be cut due to cost-containment efforts. Nurses must be creative in providing play opportunities for children. Children in isolation may be given play material, providing infection control precautions are strictly followed.

105. Therapeutic Play Play therapy is a technique of psychoanalysis that psychiatrists or psychiatric nurse clinicians use to uncover a disturbed child’s underlying thoughts, feelings, and motivations to help understand them better. Therapeutic play is used to help the child express feelings, fears, and concerns.

106. Therapeutic Play The leader must decide carefully whether to initiate an activity for a child or let the child advance at a self-set pace. Other children provide the best incentive by doing something interesting, so that the timid child forgets his or her apprehensions and tries it, or another child says, “Come and help me with this,” and soon the other child becomes involved.

107. Therapeutic Play A fearful child trusts a peer before trusting an adult, who represents authority. The leader shows the child around the playroom, indicating that the children are free to play with whatever they wish and that the leader is there to answer questions and to help when a child wishes help. When group play is initiated, the leader may invite but not insist that the timid child participate—must give the child time to adjust and gain confidence.

108. Play Material Play material should be chosen with safety in mind. No sharp edges and no small parts. Should be inspected regularly. Constant supervision of children while they are playing is necessary for safety.

109. Play Material Simulated hospitals also serve an educational purpose—they may help a child who is to have surgery, tests, or special treatments to understand the procedures and why they are done. Other useful materials include clay, paints, markers, crayons, stamps, stickers, sand art, cut-out books, construction paper, puzzles, building sets, and board games.

110. Play Material Tricycles, small sliding boards, and seesaws may be fun for children who can be more physically active. Books for all age groups are also important. The use of hand puppets does much to orient or reassure a hospitalized child. A child often finds it easier to express feelings, fears, and questions through a puppet than to verbalize them directly. A ready sense of magic can let the child make believe that the puppet is really expressing things that he or she hesitates to ask.

111. Safety Safety is an essential aspect of pediatric nursing care. The pediatric nurse must have safety in mind at ALL times. Accidents occur more often when people are in stressful situations.

112. Safety The child’s age and developmental level must be considered. Toddlers are explorers and love to put small objects into equally small openings. Toddlers must also be protected from climbing and falling. Toddlers and preschoolers must be watched to protect them from danger.

113. Safety Nurses also must encourage family members to keep the crib sides up when not directly caring for the infant in the crib. One unguarded moment may mean that the infant falls out of a crib. Box 4-2 pg. 78 presents a summary of pediatric safety precautions. Make sure to read on your own!!!!