Peds N176 - Care of a Hospitalized Child

What are nursing considerations/ interventions for an adolescent? What stage or Eriksons is the child in?

***Identity vs Role Confusion*** Assess knowledge.Encourage questioning regarding fears, or risks. Involve in decision-making.Ask if patient wants parent there. Make as few of restrictions as possible - let them be on their phones, wear their own clothes. Suggest ways of maintaining control. Accept regression to more childish ways of coping. Give positive reinforcement. Provide privacy for care. Encourage to wear street clothes and perform normal grooming. Allow favorite food to be brought in if not on a special diet

What are nursing considerations/ interventions for a school aged child? What stage of Eriksons is the child in?

***Industry vs. Inferiority*** Ascertain what child knows. Clarify scientific terminology and how body functions - explain on their level. Direct questions more to the child when teaching them (help master over feelings of inferiority). Use audiovisuals, pictures, body outlines. Suggest ways of maintaining control (i.e.: deep breathing relaxation). -child life therapy. Gain cooperation. Give positive feedback. Include in decision-making (time to do it, preferred site).Encourage active participation (removing dressings, doing care). Plan child's day if possible with child's input. Maintain clear and consistent limits. Allow for privacy. Allowing the child to dress up as a doctor or a nurse helps prepare the child for the hospitalization experience. This helps the child adjust to treatment, care, and the recovery process.

What are nursing inventions/ considerations for an infant? What stage of Erikson's is the child in?

***Trust vs. Mistrust*** Encourage parent to visit / rooming in. Encourage parents to participate in care, Teach parents procedures they are capable of doing. Discuss arrangements for care of other family at home. Try to simulate home routine. Try to assign same nurse**. Allow parents to be present during procedures and comfort afterwards. Keep frightening objects from view. Provide swaddling, soft talking to soothe. Play close attention to light and sound stimulation. Allow non-nutritive sucking for comfort - pacifier.

What are nursing considerations/ interventions for a preschooler? What stage of Eriksons is the child in?

**Initiative vs. Guilt** Acknowledge child's fears regarding hospitalization .Orient to the hospital, spend time with child to build trust. Encourage presence of parent if possible and encourage to participate in care. Provide comfort and support .Nutrition - assess food likes (hamburger, PBJ sandwich, etc) Give small portions. Make environment comfortable and accept messes. Encourage intake of fluids with games.Provide consistent environment ; Reinforce coping behavior. Provide with as much mobility as possible. Provide play and divisional activities. Avoid intrusive procedures as much as possible. Assess child's perception by asking to draw a picture and tell about it

What is a toddler's response to hospitalization?

**Separation anxiety- major stressor for this age. Nurses experience protest and despair in this group. Fear of injury and pain.Regressive behavior.

What are nursing considerations/ interventions for an older infant/ toddler? What stage of Erikson's is the child in at this age?

*Autonomy vs. Shame and Doubt* Encourage parent to room in and if have to leave, leave when awake and leave something of meaning with child for support. Provide warmth and support. Explain to parent stage child is in - *child wants control, throws a temper tantrum*. Bring infants security object -- favorite toy, blanket. Set limits, give choices on simple decisions - allowing to pick out their own food from the menu if not NPO. Teach parents child may regress, may promote potty chair if child is trained. Offer frequently (4x per shift). *Promote ritualistic behavior for bedtime*. Teach parents about hazards (crib, chair, toys, equipment) be sure to supervise when out of crib.

Describe the advantages of Therapeutic Play in meeting the child's psychosocial and developmental needs during hospitalization.

- Differs from normal play in its design and intent. Members of the healthcare team guide it and activities are planned to meet the physical/ physchological need of the child. - It can provide an emotional outlet, instruct and improve physiologic abilities. Supervised play with medical equipment helps reduce fear and separate reality from fantasy. - Allows for emotional expression and enhances development, used to educate children and prepare them for procedures.

What are the various types of settings where care is given to ill children?

- Hospital: 24-hour observation, Emergency hospitalization, Outpatient and day facilities, Rehabilitative care, Medical-surgical unit, Intensive care unit - Community -based settings: Dr.'s office - School-based clinics: health screenings, health care advice, emergency care - Home

What are effective ways to communicate with families?

- Include all involved family members- let family establish who family is - Develop open lines of communication - Encourage families to write their questions* - Respect and encourage feedback from families - Avoid assumptions about core family beliefs and values

What are common communication strategies that assist the nurse in working with children and their family?

- Orient to hospital - Assess what parent/child know of illness and treatment - Assess teaching needs, keep updated on condition of child - Reinforce and encourage questions - Discuss ways the parents can participate in the care - Assess & discuss family support, make referrals

What is regression and how can the nurse best assist the child/family to adapt to hospitalization with a child experiencing regression.

- appearance of behavior more appropriate to an earlier stage of development; often used to cope with stress or anxiety - parents should be told child may continue with behavior for a period of time after discharge, child may need more emotional support while parent slowly returns child to normal routine. - If child regressed in toileting, parent should wait until child has returned to a daily routine and then being toileting again. Behavior appropriate for the childs age should be reinforced.

What safety issues and National Patient Safety goals are relevant when caring for children in health care settings?

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What clinical manifestations would alert the nurse to child abuse or neglect?

1) Dress - appropraite for weather; excessively dirty 2) Hygiene - dirty teeth, matted hair, broken fingernails 3) Posture and movement - crouching in corner, slow concentrated movements 4) Communication - uses one syllable words, seeking approval for answers, waiting for someone else to answer 5) Facial characteristics - fearful, anxious, tearful, sad 6) Psychosocial state - demanding, bizarre, overly dramatic or condescending 7) Hx inconsistent with physical findings 8) Activity reportedly leading to the trauma seems inconsistent with the age and condition of the child 9) Delay in seeking medical tx for the trauma 10) Hx of other emergency visits 11) Bruises or fractures in various stages of healing noted on radiography 12) Injuries rarely found in children (long bone or rib fracture) when the history is not appropriate for the injury 13) Patterns of injury indicating that a specific object caused the injury (belt marks/cigarette burns)

What are some approaches to facilitate successful communication interactions based on age and related developmental milestones? 1) Infant 2) Toddler 3) Preschool 4) School age 5) Adolescent

1) Infant 0-12 months: Calm voice, slow approach, talk to baby as performing procedure 2) Toddler 1-2yo: Toddlers words, picture books, prep for procedure IMMEDIATELY BEFORE procedure 3) Preschool 3-5yo: Offer choices, use toys, describe procedure as it is about to be done 4) School age 6-12yo: Photos & videos to explain procedures, engage in conversation, prep for procedure 1-5 days in advance if possible 5) Adolescent 12+: Videos, charts & photos to explain procedures, support independence and privacy, Prep up to 1 wk in advance of procedure if possible

Describe briefly each type of play 1) therapeutic play 2) emotional outlet play 3) teaching through play 4) cooperation play 5) unstructured play

1) Therapeutic Play: Guided by members of the helath care team and is planned to meet the physical and pyschological needs of the child. Can provide an emotional outlet 2) Emotional Outlet Play (Dramatic Play): Child acts out or dramatizes real-life stressors (ex: abuse, neglect, painful procedures) 3) Teaching Through Play: Use play as a preop teaching before a new or painful procedure. Hospital equipment often used. 4) Cooperation Play: Nurse should develop age-appropriate growth and development activities when planning care. Nurse can reward child for cooperation 5) Unstructured Play: Child can control events, ideas and relationships in a playroom

What are the 7 important elements to include in an assessment? Which is most important?

1. Chief complaint** 2. History of present illness or injury 3. Past history 4. Current health status 5. Review of body systems 6. Psychosocial data 7. Developmental data

How does the nurse prioritize assessment findings in the pediatric patient? What are the elements included in priority 1, priority 2 and priority 3 problems?

1st Level: Airway, Breathing,Circulation, VS - abnormalities are very crucial in children. (A temp too low is just as serious as an elevated temp.) 2nd level: (PERSON) Psychological problems, Elimination problems (has not voided after surgery, no wet diapers, no BM, diarrhea),Risk of Infection,Signs and symptoms of untreated medical problems, Nutrition problems 3rd level: (PREVENTATIVE/ EDUCATION) Health concerns that do not immediately threaten the physiological status of the child such as (knowledge deficit / Patient teaching), Coping, Health maintenance, Activity, Rest

How would the nurse adapt the physical assessment of the pediatric patient based on age and developmental level?

Birth - 6mo:Let parent hold, use soft voice, rattle, pacifier if necessary,auscultate when quiet Infant 6mo - I yr: Let sit in parents lap, distract with toys, may have stranger anxiety Toddlers 1-2 yo: Nurse should sit or stand next to parent and ask parents to assist, encourage exploration of books/toys, leave dressed as long as possible, allow them to play with instruments Preschool 3-5yo: Head to toe order of exam, leaving most invasive last, praise child for cooperating, allow them to play with instruments School age 6-12yo: Encourage talking, head to toe order of exam, use gown or drape and be sensitive to modesty, open and simple questions, talk about body and personal care while examining Adolescent 12+: Non-condescending approach, straight forward, ask who they want present in the room, head to toe exam, Pt should be undressed and gowned, examine genitals in middle of the exam

What are some of the pharmacologic interventions / and nursing care to assist the child in pain?

Analgesics - Patient-controlled analgesia - Topical anesthetic cream: EMLA Nonsteroidal antiinflammatory drugs Opioids Conscious sedation Epidural analgesia

What is an infants response to hospitalization?

At about 6 months of age are acutely aware of the absence of parent and become fearful of unfamiliar persons. They can sense the anxiety their parents are experiencing. Accustomed to having basic needs of food and sleep met by parent and constraints of hospitalization results in loss of needs being met.

How does the nurse prepare and support a child undergoing a procedure?

Before: offer child ways to cope with discomfort or pain (child life therapist, listening to music, etc), use developmentally appropriate words to describe the procedure, give the child as much choice as possible over what will happen During: After: Praise the child for attempts at cooperation even if they did not do what you asked, provide opportunity for child to vent about feelings from the procedure, if parents were not present during procedure - reunite with parents, reward child age appropriately - ex: stickers

What are some of the non-pharmacologic interventions / and nursing care to assist the child in pain?

Behavioral distraction, Assorted visuals, Breathing techniques, Comfort measure; Repositioning, holding, (Touching, massaging; Warm or cold compresses, Diversional talk,Guided imagery, Biofeedback, Progressive muscle relaxation

What tools are utilized in assessing pain according to the child's age and developmental abilities?

CRIES pain scale (0-6 mo) COMFORT behavior scale (infants & children in critical care), FLACC (infants & preverbal or nonverbal children) FACES pain rating scale (3yr +) Numeric rating scale (NRS) (9yr+) Oucher pain scale (3-12yr) Poker chip tool (4-12 yr) Visual analop scale (VAS)(7-18yr)

How are procedures and treatments adapted to meet the needs of children of different age groups?

Change the sequence of the physical exam of a young child by: delaying any painful or frightening procedures until the end of the assessment.Perform assessments that will not disturb the child first *Adapt the physical examination to the child's age and developmental level *

What are some common stressors affecting hospitalized children and their responses to illness, hospitalization, and related care.

Fear of the unknown Separation anxiety Fear of pain or mutilation Loss of control Anger Guilt Regression

What specific age group is most impacted by separation anxiety?

Infants and toddlers (6 mon - 30 mon )

Care is moving from ______ to ______

Inpatient to Outpatient

How would the nurse adapt the assessment of a child from the assessment of the adult?

Least invasive to most invasive

What are considerations and strategies to gain cooperation from the child during a physical assessment?

Perform assessment in appropriate area- No painful procedures in patients room. Minimize stress and anxiety associated with assessment Foster a trusting parent-child nurse relationship Praise the child for positive behaviors Allow maximum preparation of the child Preserve essential security of parent -child Be aware of growth and development and promote health teaching and recognition of deviations from the norms.

What is a preschooler's response to hospitalization?

Separation anxiety generally less than the toddler Less direct with protests; cries quietly May be uncooperative Fear of injury Loss of control Guilt and shame - child thinking they did something to deserve their sickness

What is an adolescents response to hospitalization?

Separation from friends rather than family more important Fear of altered appearance* Will act as though not afraid when they really are. Give them some control to avoid a power struggle - ex: sleep

What is a school-aged child's response to hospitalization?

Separation: may have already experienced when starting to school Fear of injury and pain Want to know reason for procedures and like being involved and wants to make choices. Asks "why?"

During assessment of pain in children, what clinical manifestations would be exhibited in each of the following age groups? a. ) Infant b. ) Toddler

a) Infant: based on behavioral and & certain physiologic indicators. Behaviors such as crying, fist clenching, grimacing, wrinkling of the forehead, fusiness and restlessness. Facial expression = most consistent cue. b) Toddler: tends to cry longer than the infant. may ask for parents, use words like "ouch, hurt" & even verbalize negative emotions about the nurse. older toddler can localize pain and point to body part that hurts. Generalized restlessness, guarding the site and touching painful areas are signs of pain. may demonstrate regression by lying in a fetal position in the parents lap, may avoid eye contact or look sad.

How does each of the following affect a child's response to hospitalization? a) parents response to hospitalization b) preparation for child and family c) coping skill

a) Parents response to hospitalization: Children know when their parents are upset and will become increasingly anxious is parent is anxious. A parent who does not answer the childs questions or who does not tell the truth for fear it will frighten the child only confuses the child and weakens the childs trust in the parents. Some parents cannot be honest with their child because of their own fears and insecurities. May lead to change in roles (Dad has to be mom). Family members are anxious and fearful (money, fear, transportation, other children at home - single mom) b) Preparation: Preparation sessions should be planned, teaching is more effective if the nurse and family develop trust. Honesty and use of appropriate language based on childs age is imperative. c) Coping skills:

During assessment of pain in children, what clinical manifestations would be exhibited in each of the following age groups? a) preschool d) adolescent

a) Preschool- egocentric. They relate only to the present and have trouble associating discomfort with any positive outcome and it can intensify their pain experience. Are able to describe the location and intensity of pain. Tend to think pain will magically go away and experiencing pain is punishment for some previous thought or deed. May cry & struggle in an attempt to escape a procedure. Can regress to earlier more comfortable behaviors such as thumb sucking or withdrawal and not participate in activities. b) Adolescent: an think abstractly and understand cause and effect. can describe pain intensity and feelings about pain, can discuss strategies to help manage their pain, able to perceive and understand pain at a physical, emotional and cognitive level. Regression may occur at this age in relation to pain. Tend to think that others focus on their behaviors therefore they main suppress manifestations of pain and may not report pain because they believe that the nurse knows when they hurt. Signs may include increased muscle tension, withdrawal, and decreased motor activity. Will use words such as "Sore, like an ache, pounding, miserable"

Describe the stages of separation: a) Protest b) Despair c) Detachment

a) Prostest - child is agitated, resists caregivers, cries and is inconsolable b) Despair - child feels hopeless and becomes quiet, withdrawn and apathetic c) Detachment - child becomes interested in the environment, plays and seems to form relationships w/ caregivers & other children. IF parents reappear, child may ignore them. (usually seen with long term care)