Pediatrics - Quiz #3

Activities of the School Nurse

> Conduct health screenings (such as vision, hearing, and scoliosis) > Assess growth and development > Provide emergency first aid, care for acute and chronic illnesses, such as medication administration and diabetes monitoring > Train and educate staff on cardiopulmonary resuscitation (CPR), first aid, and health issues > Assess, monitor, and refer students with communicable diseases > Educate on health promotion and disease prevention (such as immunizations; bike and car safety; decreasing high-risk behaviors, such as smoking, drinking, drug use, and sexual activity) > Serve as a resource for health issues and education > Act as a liaison between health care provider and school > Reinforce client and family health education (such as discharge instructions, self-care measures) > Monitor long-term illness in students > Network with community agencies and make necessary referrals

Strategies to Reduce Fear Associated with Hospitalization

> Describe the procedure and equipment in terms the child can understand > Review the steps of the procedure or steps involved with the use of the equipment > Use a night light in the child's room (if dark) > If possible, allow the child to hold the caregiver's or nurse's hand or a favorite toy > Allow caregiver to accompany child if possible

Stage 2 of Separation Anxiety

> Despair > occurs if the parents do not return within a short time > The child displays hopelessness by withdrawing from others, becoming quiet without crying, and exhibiting apathy, depression, lack of interest in play and food, and overall feelings of sadness.

Stage 3 of Separation Anxiety

> Detachment (Denial) > During this phase, the child forms coping mechanisms to protect against further emotional pain. This occurs more often in long-term separations. > During this stage, the child shows interest in the environment, starts to play again, and forms superficial relationships with the nurses and other children. > If the parents return, the child ignores them. A child in this phase of separation anxiety exhibits resignation, not contentment. It is more difficult to reverse this stage, and developmental delays may occur.

Types of Restraints

> Elbow Restraint: - Prevents child from flexing and reaching face, head, IV, and other tubes > Position the restraint so that it does not rub against the axilla. Check pulse, temperature, and capillary refill. > Jacket (Vest) Restraint: - Jacket worn by child with ties attached to the child's back and to side of bed. Used to keep the children flat in bed (after surgery or safe in chair) > Ensure that the child can turn his head to side and that the head of the bed is elevated if possible. Place ties in back so child cannot manipulate them.

Promoting Control for Hospitalized Patients and Family

> Encourage child and parents to identify areas of concern to help determine priority needs. > Encourage parent and child to participate in care activities to promote feelings of control. > Incorporate aspects of child's routine at home and use terms similar to those used at home to foster a sense of normalcy. > Offer child choices as much as possible, such as options for foods, drinks, hygiene, activities, or clothing (if appropriate) to promote feelings of individuality and control. > Allow child opportunities for being out of bed or room within limitations as appropriate to foster independence. > Work with child, as age and development allow, and family to set up a schedule to promote structure and routine.

Adolescents Response to Illness/Hospitalization

> Adolescents fear injury and pain. > Since appearance is important to them, they are concerned with how the illness or injury will affect their body image. > Typically, adolescents do not like to be different; they like "being cool," which means being in control and not showing how afraid they really are. > Adolescents typically do not experience separation anxiety from being away from their parents; instead, their anxiety comes from being separated from friends. > Loss of control is a key factor affecting the behavior of adolescents who are ill or hospitalized. Anger, withdrawal, or general lack of cooperation may occur due to the feelings of loss of control. > In addition, their desire to appear confident may lead them to question everything that is being done or that they are asked to do. > Their feelings of invincibility may cause them to take risks and be noncompliant with treatment.

School-Agers Response to Illness/Hospitalization

> After 11 years of age, there is an increased awareness of physiologic, psychological, and behavioral causes of illness and injury. > Typically, the school-age child has a more realistic understanding of the reasons for the illness and can better comprehend explanations. > School-age children are concerned about disability and death, and they fear injury and pain. They want to know why procedures and tests are being performed. > They can understand cause and effect and how it relates to their illness. They are uncomfortable with any type of sexual examination. > They may feel that friends will forget them if they remain ill or in the hospital for a long time. Some school-age children may regress and become needy, demanding their parents' attention or playing with special "comfort toys" they used at a younger age. > Illness or hospitalization presents loss of control by limiting their activities, making them feel helpless and dependent. This may result in feelings of loneliness, boredom, isolation, and depression. > The key is to give them opportunities to maintain independence, retain a sense of control, enhance self-esteem, and continue to work toward achieving a sense of industry.

Possible Nursing Diagnoses for Coping with Hospitalization

> Altered Family Functioning > Delayed Growth and Development Risk > Caregiver Fatigue Risk

Factors Affecting Child's Response to Illness and Hospitalization

> Amount of separation from parent/caregiver > Age > Developmental level > Cognitive level > Previous experience with illness and hospitalization > Recent life stresses and changes > Type and amount of preparation > Temperament > Innate and acquired coping skills > Seriousness of the diagnosis/onset of illness or injury (e.g., acute or chronic) > Support systems available, including the family and health care professionals > Cultural background > Parents' reaction to illness and hospitalization

Telephone Triage

> An essential component of primary care. > Pediatric office nurses often fill this role. > When parents feel comfortable with the providers in their child's medical home office, they often call for advice to treat their child at home. A telephone triage nurse needs excellent assessment and critical thinking skills along with solid training and education. The triage nurse needs to assess the child's entire situation, including current signs and symptoms, history, and home treatment. > The triage nurse needs to determine whether the child requires emergency care, an office visit, or home management. > Good listening and the ability to maintain a calm voice when talking to parents are skills necessary for successful telephone triage > The triage nurse should not discourage parents from bringing the child into the office to be seen; triage is not meant to keep children out of the office, and if a parent is very concerned, that is reason enough to be seen.

Educating the Child and Family

> An important role of the home care nurse is empowering children and their families through education > Encourage the family to participate in the child's care.

Anxiety and Fear

> Anxiety often stems from the rapid onset of the illness or injury, particularly when the child has limited experiences with disease or injury. > Normal fears of childhood include the fear of separation from their parents and family or guardians, loss of control, and bodily injury, mutilation, or harm > Therefore, when the child is in the hospital, he or she becomes distressed about the unfamiliar environment; health care procedures, especially the use of needles or associated pain that may occur; and situations such as the strange words being used, ominous-looking equipment, strangers in unusual attire (e.g., surgical caps, masks, gowns), unfamiliar and frightening noises and smells, or the sounds of other children crying. > This exposure to people, situations, and procedures that may be new to them and cause them pain leads to increased anxiety and fear

Promoting Growth and Development

> Assess child's developmental stage to establish a baseline and determine appropriate strategies. > Use unstructured and therapeutic play and adaptive toys to promote developmental functioning. > Provide a stimulating environment when possible to maximize potential for growth and development. > Praise accomplishments and emphasize child's abilities to foster self-esteem and encourage feelings of confidence and competence. > Include parents in techniques to foster growth and development to promote feelings of control in their child's care.

Easing Caregiver Role Strain

> Assess parental behavior to identify role strain. > Provide emotional support and encourage talking about feelings, fears, and concerns to promote trust in nurse as a source of emotional support. > Arrange for and/or encourage respite care for child: provides parent with time away from continual care. > Consult social services to identify community resources available for caregiver support (home health, support group, etc.). > Encourage parent to meet own needs and find personal time to increase energy level and self-esteem, ultimately enhancing the quality of care given.

Caring for Hospitalized Newborns/Infants

> Avoid separation from the primary caregiver if possible to decrease fear and minimize separation anxiety; this will also promote healthy attachment. Arrange for volunteers to provide consistent comfort to the baby if the parent or primary caregiver cannot stay with the infant. > Assess the infant's facial expression as it is the most consistent indicator of pain or bodily injury.

Promoting Nutrition in Hospitalized Child

> Check with the nurse about any restrictions related to your child's diet. Find out if intake and output are being monitored. • Encourage your child to eat his or her favorite foods. • Assist your child with eating or drinking as necessary; be present at mealtimes to promote socialization. • Frequently offer small cups of fluid and finger foods; avoid giving large quantities at one time. • Try offering fluids at different temperatures at different times for variety. • Remember that children can ingest greater amounts of thin liquids (e.g., gelatin or carbonated drinks) than thicker liquids (e.g., cream soups or milkshakes). • Include ice chips as fluid intake. Ice is approximately equivalent to half the same amount of water (e.g., 1 cup of ice equals a half cup of water). • Use straws (unless not allowed) and brightly colored utensils, cups, or dishes to provide contrast and stimulation. • Offer the child choices; allow the child to choose what he or she wants from the menu. • Talk with the dietitian to see if any special preferences can be addressed. • Offer praise to your child for what he or she eats or drinks. • Never punish the child for not eating or drinking. • Encourage the older child to help keep track of what he or she eats and drinks.

Impact on the Problem

> Children with special needs may use or need prescription medication, medical care, mental health services, or education services more than other children of their same age. They may be limited in abilities and may need physical, occupational, or speech therapy > It can be challenging for the family of a child with special needs to navigate the system and obtain all of the services their child requires. > When an infant is born very prematurely, when a child is injured and requires long-term rehabilitation and special care, or when a child is diagnosed with a complex chronic health condition, the parents are often devastated initially. > The parents of medically fragile children may feel they must adapt to the risk and protect their child. > While the infant or child is still in the hospital, nurses can help parents build on their strengths, empowering them to care for their medically fragile infant or special needs child. Education is paramount and should begin as early in the hospitalization as possible > Most children with chronic illness, or those who are dependent on technology, progress through stages of growth and development just as typical children do, though possibly at a slower pace > The exception is the child with significant psychomotor retardation, though some developmental progression may occur.

Maximizing Family Functioning

> Encourage parents and family members to verbalize concerns about child's illness, diagnosis, and prognosis to promote family-centered care and identify areas where intervention may be needed. > Explain therapies, procedures, child's behaviors, and plan of care to parents to promote understanding of the child's status and plan of care, which helps to decrease anxiety. > Encourage parental involvement in care to promote feelings of the parents being needed and valued, providing them with a sense of control over their child's health. > Identify support system for family and child to identify resources available for coping. > Educate family and child on additional resources available to promote a wider base of support to deal with the situation. > Suggest ways that parents can divide time between child and other siblings to prevent feelings of guilt. > Provide support and positive reinforcement to promote family coping and foster family strength. > Encourage frequent visits by family members, including siblings as appropriate to promote ongoing family functioning. > Stress the need for adequate rest, sleep, exercise, and nutrition for family members to promote family health and minimize stress of hospitalization on family. > Assist with referrals for resources and help from additional family members and friends as necessary to allow for respite or relief of care responsibilities. > Encourage family to maintain usual routine as much as possible to minimize the effects of hospitalization on family functioning. > Enlist the aid of a CLS to work with any siblings to provide support and education and to address the needs of a sibling of a hospitalized child.

Caring for Child in Isolation

> Encourage the family to visit often, and help them to understand the reason for the isolation and any special procedures that are required. > Introduce yourself before entering the room and allow the child to view your face before applying a mask, if possible.

Providing Unstructured Play

> Encourage unstructured play as it allows children to control events, ideas, and relationships. > Encourage parents to bring small toys and favorite stuffed animals from home to make the child feel more comfortable in the strange environment of the hospital. > Many children enjoy diversional activities such as playing board games or electronic games, reading books, and watching TV, videos, or DVDs > Infants and toddlers enjoy manipulating blocks and playing with stacking toys. The preschooler may enjoy coloring, dollhouses, or playing with plastic building blocks such as Legos. School-age children and adolescents may enjoy playing video games, putting together a puzzle, or building a model geared toward their developmental level.

Applying Restraints

> Ensure that the restraint fits properly. > Secure the restraints with ties to the bed or crib frame, not the side rails. > Use a clove-hitch type of knot to secure the restraints with ties (this allows for quick, easy access and release of the restraint). > Check restraints 15 minutes following initial placement and then every hour for proper placement. > Assess the temperature of the affected extremities, pulses, and capillary refill, initially after 15 minutes and then every hour after placement. > Remove the restraint every 2 hours to allow for range of motion and repositioning, with documentation of this process and any findings. > Encourage parent participation, providing continuous explanations about the reasons for the restraints and tentative time frame for use. > Offer positive reinforcement to the child and parents. > Review the criteria for removing the restraints; document removal and continued assessment.

Safety During Hospitalization or Procedures

> Ensure the child has an identification band in place at all times. > Sometimes in implementing interventions an armband is removed, so make sure it is attached to another extremity. > Monitor children closely to avoid accidents such as a child pushing the wrong knob, picking up a piece of equipment or supplies left in the bed or room, or climbing out of bed

Educating the Child and Family

> Every interaction the nurse has with the child or family provides an opportunity for teaching. > Assess the child's and family's knowledge of the illness and hospital experience > Determine the child's usual patterns of behavior and explain to the parents about the child's reaction to hospitalization.

Community Health Nursing

> Ex: Department of Health and Human Services > Community health nurses work in geographically and culturally diverse settings. They address current and potential health needs of the population or community. They promote and preserve the health of a population and are not limited to particular age groups or diagnoses. Public health nursing is a specialized area of community health nursing. > Epidemiology can help determine the health and health needs of a population and assist in planning health services. Community health nurses perform epidemiologic investigations to help analyze and develop health policy and community health initiatives.

Community Based Nursing

> Ex: School Nurse > changes in health care such as strained health care funding, shorter hospital stays, and cost containment, have led to a shift in responsibilities of care for children from the hospital to homes and communities. > Community-based care has been shown to be a cost-effective way to provide care. > It emphasizes wellness and prevention. Increases in disposable income and the longevity of children with chronic and debilitating health conditions have also contributed to the continued shift of health care to the community and home setting > Advances in technology have allowed for improved monitoring of children in community settings and at home, as well as allowed complicated procedures, such as intravenous administration of antibiotics, to be done at home. > Another major reason for the increase in community care of children is that an acute care setting is not an ideal environment for children's development. Caring for children at home and within their community not only improves their physical health but also allows for adequate growth and development while keeping them within their family.

Family Members' Needs

> Family-centered care recognizes the need to treat the child in the context of the family, including siblings. > Addressing Parent's Needs - Help parents and caregivers to work through their feelings in order to decrease anxiety, thus decreasing the child's anxiety level. The philosophy of family-centered care places the family at the core of care; the family is the primary and continuing provider of care for the child. - View the parents as vital members of the health care team and partners in the care of the ill child. > Addressing Siblings Needs: - Address the siblings' possible feelings of guilt. Use educational materials, allow time for visits, send photographs back and forth between siblings, and allow siblings to talk on the phone.

Nutrition

> Frequently, the ill or hospitalized child experiences a loss of appetite, which can affect the child's nutritional status. This may be compounded by other problems such as nausea and vomiting and nothing by mouth (NPO) restrictions for testing or surgery. > If possible, schedule procedures or treatments away from mealtimes.

Hospitalization in Childhood

> Hospitalization is often confusing, complex, and overwhelming for children and their families. > These strategies include identifying the needs of children and families through astute assessment of nonverbal and verbal behaviors, then validating the information with accurate interpretation and providing appropriate responses and interventions. > Although the nurse implements these strategies throughout the interaction with the child and family, a critical time to ensure the best outcome for the child and family is during the admission process. The nurse assesses the learning needs and abilities of the child and family. For the interventions to be successful, the nurse must communicate and teach in the most effective method for the individual child and family. The nurse also evaluates the child's and family's competence in performing specific activities prior to discharge. > Four Phases: Introduction, Trusting Relationship, Decision Making, Providing Comfort and Reassurance > All these phases are interconnected.

Providing Basic Care for the Hospitalized Child

> If parents are present, allow them to provide care for the child to decrease the child's stress. > A good time to assess the skin is during bath time. > Never leave a child alone in a bathtub. > Pay close attention to the ears, between skin folds, the neck, the back, and the genital area for alterations in skin integrity > For infants, DO NOT USE TALCUM POWDER

Children and Coping Skills

> Ignore or negate the problem - Breathing techniques such as blowing bubbles, pinwheels, or party noise makers > Stoicism, passive acceptance - Distraction with books or games > Acting out—yelling, kicking, screaming, crying - Imagery with tapes or scenarios > Anger, withdrawal, rejection - Music > Intellectualizing - Teaching before events or procedures

Children's Reactions to Illness and Hospitalization

> In general, children are more vulnerable to the effects of illness and hospitalization because this is a change from their usual state of health and routine. > They also have limited understanding and coping mechanisms to assist them in resolving the stressors that might occur during this time. > Hospitalization and illness create a series of traumatic and stressful events in a climate of uncertainty for children and their families > The stressors that children experience in relation to hospitalization and illness may result in various reactions. Children react to the stresses of hospitalization before admission, during hospitalization, and after discharge. > Besides the physiologic effects of the health problem, the psychological effects of illness and hospitalization on a child include anxiety and fear related to the overall process and the potential for bodily injury, physical harm, and pain > Also, children are separated from their homes, families, and friends and what is familiar to them, which may result in separation anxiety > There is a general loss of control over their lives and sometimes their emotions and behaviors. > The result may be feelings of anger and guilt, regression (return to a previous stage of development), acting out, and other types of defense mechanisms to cope with these effects.

Previous Experiences

> In general, children's lack of understanding and experience of illness, hospitalization, and hospital procedures contributes to their anxiety level. > For example, the child who associates the hospital with the birth of a sibling may view this experience as positive. > However, the child who associates the hospital with the serious illness or death of a relative or close friend will probably view the experience as negative. > The type of experience may contribute to increased anxiety and fear if the child must be admitted to the hospital.

Role of Community Based Nurse

> In the community or home care setting, the nurse provides direct care for the child but spends more time in the role of educator, communicator, and manager than the nurse in the acute care setting. > In home care, the nurse spends alot of time in the supervision or management role. > Roles: Physical Care, Communication, Education. Discharge Planning, Care Coordination, Advocacy, and Resource Management > In the community-based setting, teaching is often focused on assisting the child and family to achieve independence. > Successful discharge planning begins upon the child's admission to the facility. > Modern pediatric health care focuses on an interdisciplinary plan of care designed to meet the child's physical, developmental, educational, spiritual, and psychosocial needs. > Nurses provide care coordination through the implementation of this interdisciplinary plan in a collaborative manner to ensure continuity of care that is cost-effective, quality oriented, and outcome focused. > To best serve the child and family, the community-based nurse must be an advocate and educator, but avoid becoming a personal friend by following the concept of professional boundaries and maintaining a therapeutic nurse-patient relationship > Medical waiver programs are state level -> state-run programs that use federal and state funds to pay for health care for people with certain medical conditions. > Without medical waiver programs, many children with special needs would either go without health care or would be institutionalized in order to qualify for Medicaid. > These waivers allow children to receive care at home, no matter there parent's income. (Kate Beckett) > The community-based nurse performs less direct physical care than the nurse in the acute care setting. Requires excellent assessment skills. Assessment includes child, environment, and community. Nurse is more autonomous role -> after data collection, the community-based nurse will often decide whether to initiate, continue, alter, or end physical nursing care.

Strategies for Preoperative Teaching

> Infants/Toddlers: - Toddlers: provide information as close to the day of surgery as possible to prevent undue anxiety - Encourage parents to use a soft tone of voice and stroking and secure, comfortable holding positions to promote calm - Remind parents to use positive facial expressions - Encourage the parent or caregiver to stay with the child as much as possible - Use terms that the child and parents can understand > Preschoolers and School-Age Children: - Preschoolers: provide information 1-2 days before surgery - School-Agers: provide information 3-5 days before surgery - Provide factual explanations using terms the child and parents can understand - Incorporate pictures and other visual aids in explanation - Tailor the timing of education to meet the child's learning needs, allowing enough time for the child to ask questions. > Adolescents: - Provide detailed explanations of the procedure at least 7-10 days beforehand - Answer questions honestly, ensuring privacy at all times - Remain available for questions or concerns arising before or after surgery

Nursing Considerations for Providing Safe Care

> Infants: - Maintain close supervision of the infant. - Keep one hand on the infant when crib sides are down. - Keep crib rails up all the way when the infant is in the crib. - Avoid leaving small objects that are harmful or that can be swallowed in the crib. - Encourage family members to stay with infant - Encourage the family to maintain home routines while in the hospital, planning nursing care around the usual feeding and sleep times. > Toddlers: - Keep crib side rails up with overhead crib protection intact when the toddler is in the crib. - Never leave a toddler alone in the room unless secured in the crib. - Always have someone with the toddler when ambulating. - Expect and plan for regression in areas of toilet training, eating, and other behaviors. - Expect increased temper tantrums in general and intense reactions to intrusive procedures. - Provide close supervision while encouraging independence. - Give simple directions with choices appropriate to the hospital situation. > Preschoolers: - Keep bed in low position with the side rails up when the preschooler is in bed. - Instruct the child to call the nurse or caregiver for help getting out of bed. - Encourage the preschooler to be involved in care by providing choices and opportunities for the child to help. - Explain activities in simple, concrete terms, being cautious with the words you use because of the preschooler's fantasies and magical thinking. - Expect reactions to pain and bodily injury to be verbally aggressive and specific. > School-Agers: - Keep the bed in the low position with the side rails up while the child is in the bed, explaining that this is a hospital rule, not a punishment. - Provide opportunities for the child to be involved in care. - Allow children to select their meals, assist with treatments, and keep their rooms neat. - Allow visits with other children if the condition allows. - Encourage parents to tell the child when they will return. - Plan care around the child's usual home routines (meals, sleep). - Encourage the child to do schoolwork. > Adolescents: - Be aware of the adolescent's whereabouts. The teen may not wish to stay in the room but may become confused about where the room or unit is located in the hospital. - Allow teens to interact with others. - Alter hospital routines as possible to allow the teen to sleep in or stay up later at night. - Provide others close to their age as roommates. - Encourage visits from friends. - Provide emotional support for feelings of being alone or away from friends; be alert for regression, which may result in the teen becoming emotional. - Answer questions honestly and with appropriate information. - Give the teen a sense of control by allowing choices. - Be sensitive to concerns about being "different."

Phases of Hospitalization

> Introduction: - involves the initial contact with children and their families and it establishes the foundation for a trusting relationship. - Use favorite toys and common television shows to establish rapport. Allow the child to participate in the conversation without the pressure of having to comply with requests or undergo any procedures. > Trusting: - can be built by using appropriate language, games, and play such as singing a song during a procedure, preparing the child adequately for procedures, and providing explanations and encouragement. - Get down to the child's level and play on his or her terms. > Decision Making: - the nurse gives some control over to the child by allowing him or her to participate in making certain decisions. - it is imperative to decide how much control the child will have during treatment, how much information to share with the child about upcoming events, and whether parents should participate - Reinforce the child's use of coping strategies that lead to healthy outcomes by providing options whenever it is safe to do so > Providing Comfort and Reassurance: - praising the child and providing opportunities to cuddle with a favorite toy. This phase helps the nurse re-establish trust and provide comfort to the child to increase positive outcomes.

Home Healthcare

> It is important that the nurse practices family-centered home care that focuses on increasing support for the emotional and developmental needs of the child. > It encourages families to care for their children at home while health care professionals provide the support, empowerment, education, and expertise in caring for the child that they need. In family-centered home care, the family and health care professionals build a partnership of trust to meet the needs of the child. The nurse must value the role of the family and regard family members as the ultimate experts in caring for their child. > In home care, the family is extensively involved in the child's care, and the home care nurse is there to facilitate this. > The goals of nursing care in the home setting include promoting, restoring, and maintaining the health of the child. Home care focuses on minimizing the effects of the illness or disability, along with providing the child or family with the means to care for the illness or disability at home.

Caring for Hospitalized Toddlers

> Maintain the home routine related to meals and sleep or a nap to provide structure and help decrease the toddler's feelings of loss of control. > Watch for separation anxiety and autonomy

Emergency Departments

> Major cause of injury = accidents (unintentional) > Many times, a family's first experience with the acute care setting is the emergency department. Due to the situation, the child and family may experience increased anxiety, and it may become overwhelming as uncertainties develop and critical decisions are made. The family may be frightened, insecure, and in a state of shock. > The family is often ill-prepared for the visit, having little money or clothing with them. > Siblings may be present if the parents did not have time to arrange other child care. > Due to the fast pace of the emergency department, the family may be hesitant to ask questions, so it is important for the nurse to keep the family and child well informed. > Families may have a strong fear of the unknown and may be terrified that the child will die or be permanently disabled. > Help the family to identify their concerns and their support systems. Prepare them for what they will experience. > Provide comfort such as holding, touching, talking softly, and other appropriate interventions according to age and developmental level.

Guidelines to Address Effects of Hospitalization

> Minimizing Fear and Anxiety: • Prepare the child and family for hospitalization and procedures. • Explain everything to the child and their families before it occurs • Use age-appropriate communication techniques. Include the family in this process so they can help the child cope with fears. • Allow time for children to play out their fears and concerns. • Talk to the child and parents using a soft, friendly, comforting tone of voice. • Have a calm, empathetic approach when caring for the child. > Minimizing Separation Anxiety: • Know the stages of separation anxiety and be able to recognize them. • Remember that behaviors demonstrated during the first stage do not indicate that the child is "bad." • Encourage the family to stay with the child and always use a family-centered approach to care. • Help the child cope, and intervene before the behaviors of detachment occur. > Addressing Loss of Control: • Minimize physical restrictions, altered routines and rituals, and dependency issues, because they produce loss of control. • Allow as much independence as possible within the constraints of the diagnosis. • Allow the child to participate in care and decisions regarding care whenever possible.

General Impatient Unit

> Often, the admission procedure and treatment actually occur simultaneously. > General units (accepting all ages) often lack child-oriented services, such as play areas, child-size equipment, and staff familiar with caring for children.

Pediatric Intensive Care Units

> PICU = specializes in caring for children in crisis > Families will be faced with an unfamiliar, high-tech environment and interaction with a large team of care providers. > The child will likely experience pain, unusual noises, and increased stimulation and will probably undergo uncomfortable procedures. > The nurse should welcome families (if institutional policy permits) and encourage them to stay with the child and participate in care. Explain everything to the parents and, when appropriate, to the child.

Parents' Response to Child's Illness and Hospitalization

> Parents who do not tell children the truth or do not answer their questions confuse and frighten them and may weaken the child's trust in the parents. > Children take in their parents' anxiety and concern. Even whispers can set off children's imaginations. > It is important for children to believe that someone is in control and that the person can be trusted. Some parents, however, have their own fears and insecurities. Thus, a child's reaction is often related to the parents' reaction to the illness and hospitalization. > The relationship between the family and the health care staff may either add to or ease the child's stress. This relationship can contribute significantly to the quality of the environment. > Health care personnel must assume responsibility for the care of ill or hospitalized children by maintaining good partnerships with families.

Providing Oral Hygiene

> Part of basic care > Wipe the infant's gums with a wet cloth after each feeding. > Assist children in brushing and flossing their teeth after each feeding or meal and before bedtime.

Techniques for Preparation to Reduce Anxiety

> Perform nursing care on stuffed animals or dolls and allow the child to do the same. > Avoid the use of medical terms. > Allow the child to handle some equipment. > Teach the child the steps of the procedure or inform him or her exactly what will happen during the hospital stay. > Show the child the room where he or she will be staying. > Introduce the child to the health care personnel with whom he or she will come in contact. > Explain the sounds the child may hear. > Let the child sample the food that will be served. > All techniques used to prepare the child for hospitalization should emphasize the philosophy of atraumatic care

Preparing the Child and Family for Surgery

> Preparation provides reassurance and comfort to the child and allows him or her to know what will happen and what is expected of him or her. > The parents should be allowed to stay with the child until surgery begins. Parents should also be allowed to be with the child when he or she wakes up in the postanesthesia recovery area. > Preoperative care for the child who is to undergo surgery is similar to that for an adult. The major difference is that the preparation and teaching must be geared to the child's age and developmental level. > Preoperative preparation programs allow children and their families to experience a "trial run" in a supportive environment to help reduce anxiety, increase knowledge, increase comfort level, and enhance coping skills

Preschoolers Response to Illness/Hospitalization

> Preschoolers may understand that they are in the hospital because they are sick, but they may not understand the cause of their illness. Preschoolers fear mutilation and are afraid of intrusive procedures since they do not understand the body's integrity. > They interpret words literally and have an active imagination. > Egocentric thinking -> they believe that some personal deed or thought caused their illness, which can lead to guilt and shame > Magical thinking, as well as concrete and egocentric thinking -> limits their ability to understand, so communication and interventions must be on their level. > disruptions in family relationships can lead to challenges > The preschooler may constantly ask for his or her parents or ask to call the parents. He or she may quietly cry, refuse to eat or take medication, or generally be uncooperative. > Because the preschooler cannot participate in typical activities and explore the environment as usual, the child's normal creative, curious nature may give rise to a variety of fantasies that may present challenges.

Promoting Schoolwork and Education During Hospitalization

> Promote schoolwork while the child is in the hospital.

Stage 1 of Separation Anxiety

> Protest > occurs when the child is separated from the parents or primary caretaker. > can last hours to days > The child reacts aggressively to this separation and exhibits great distress by crying, expressing agitation, and rejecting others who attempt to offer comfort. The child may also display anger and inconsolable grief.

Schools

> School nursing is a specialized practice of professional nursing and focuses on improving students' health, development, and safety to improve their achievement and success. > School nurses work to remove or minimize health barriers to learning to provide students with the best opportunity for academic success. > The population of students has changed over the years. Access to public schools for children with disabilities is mandated. Due to improvements in technology, children with chronic conditions or special needs live longer and enter school. > There has been an increase in the number of children with psychiatric conditions such as depression, attention deficit/hyperactivity disorder, and more serious conditions such as bipolar disorder. > nurses in the school setting develop Individualized Health Plans (IHPs). It is the position of the National Association of School Nurses that school nurses develop an IHP which formalizes the plan of support for a student with complex health care needs > It is a written agreement developed as part of an interdisciplinary collaboration of school staff along with the student, the student's family, and the student's health care provider. The plan describes the student's needs and how the school plans to meet these needs. > Examples of students who may need an IHP are students with asthma, serious allergies, chronic conditions such as type 1 diabetes, physical disabilities, attention deficit/hyperactivity disorder, and medication needs.

Providing Hair Care

> Shampooing may be done at the bedside with specially adapted equipment, at a readily accessible sink while the child is sitting in a chair or lying on a stretcher, or in a tub or shower. Commercial no-rinse shampoos may be available for use.

Reactions of Siblings

> Siblings of children who are hospitalized may experience jealousy, insecurity, resentment, confusion, and anxiety. They may have difficulty understanding why their sibling is ill or getting all the attention, leaving little for them. > They may wonder if their sibling is going to die or ever return home. They may worry that their sibling's illness is going to happen to them. > Certain age groups, such as preschoolers, may feel that they caused the illness. Little information or understanding about what is happening, combined with their magical and egocentric thinking, contributes to their fears that they may have caused the illness or injury by their thoughts, wishes, or behaviors.

Key Concepts

> Stressors associated with hospitalization and illness include separation from family and routines; fear of an unknown environment; potential for pain, bodily injury, or mutilation; and loss of control. > Family-centered care and atraumatic care are philosophies that pay special attention to the concerns of the family and child during hospitalization. < Providing support to hospitalized children and their families is critical for minimizing stress. > Due to their age and developmental level, children may be vulnerable to harm, and the nurse must use appropriate safety measures in caring for children (e.g., identification of children, use of restraints and transportation, basic hygiene measures). These measures need to address developmental risks, such as that the infants, toddlers, and preschoolers require close supervision and the nurse must avoid leaving small objects within reach.

Introduction to Caring for Special Needs Child

> The Maternal Child Health Bureau defines children with special health care needs as "those who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally" > Children who have a terminal illness, or are otherwise dying, also require additional care.

Nursing Assessment in the Home Setting

> The focus of home health nursing is on meeting the child's physical and psychological needs while involving the family. > Assessment in the home is similar to that in the acute care setting but involves obtaining first-hand data about the family and the way it functions. > Assess the child's growth and development and thoroughly assess the home environment > Assess resources available to the family. This includes necessary equipment such as a hospital bed and oxygen, suitable physical and emotional surroundings (are the family members able to deal with the stress of the situation?), ability to contact emergency services, power backup if needed, and ease of evacuation of the child in case of a fire. > During the assessment phase, the nurse identifies the person who is the primary caregiver; this may be the mother, father, grandparent, or older sibling. It is essential to include this person when developing the plan of care, as he or she is the expert on the child and family.

Medically Fragile Child

> The numbers of children with chronic illness (a long-lasting or recurrent illness) are increasing > Increasing numbers of children are being diagnosed with physical and mental disorders and larger numbers of children are living with the assistance of high-tech treatments and equipment.

Nursing Management in the Home Setting

> The nurse has a great deal of independence since there are no other nurses, supervisors, or physicians on site. > When complex care is provided in the home, the nurse may need to adjust procedures to fit the setting. > For example, feeding schedules may be adjusted to fit a child's school schedule or equipment may be adjusted to allow a child to receive feedings continuously while at school

Factors Influencing Family Reactions

> The parenting style and the family-child relationship can influence the hospital experience as well as the family members' coping skills. > Families already in crisis or without support systems have a more difficult time dealing with the added stress of hospitalization

Other Community Settings

> The primary focus of nursing in other community settings continues to be on promoting health, preventing disease and injury, and ensuring a safe environment. > Nurses play important roles in child care centers, camps, health department clinics, and shelters. > In child care centers, nurses help address infection control issues and assess for a safe environment. They provide education and training to staff members. > A camp nurse ensures a safe environment for all campers and provides first-aid and acute illness care as needed > Camps for children with special needs exist, staffed by specially trained nurses. These camps cater to children with complex health care needs, such as diabetes, cancer, head injuries, and physical disabilities, and allow the children the opportunity to experience camp life while providing a safe environment and necessary medical care.

Rehabilitation Units/Facilities

> The rehabilitation unit/facility provides care for children beyond the initial period of illness or injury. The care involves an interdisciplinary approach that assists the child to reach his or her potential and achieve developmental skills. > The facilities often resemble a home environment, with special services to help children to relearn activities of daily living and to help them deal with the physical or mental challenges associated with the original illness or injury > Typically, families are encouraged to participate and are given support for their child's eventual return home. There is a balance of nurturing and firm discipline while the child reclaims independence.

Infants Response to Illness/Hospitalization

> They are dependent on others for nurturance and protection. > They gain a sense of trust in the world through rhythmic and reciprocal patterns of contact and feeding, resulting in bonding to the primary caregiver. > Unfortunately, during illness and hospitalization, these critical patterns of feeding, contact, comfort, sleeping, elimination, and stimulation are disrupted, resulting in fear, separation anxiety, and loss of control. > By 5 to 6 months of age, infants have developed an awareness of self as separate from mother. As a result, infants of this age are acutely aware of the absence of their primary caregiver and become fearful of unfamiliar persons

Loss of Control

> This loss of control (hospitalization) increases the perception of threat and affects their coping skills. > They lose control over routine self-care and their usual tasks and play as well as decisions related to the care of their own bodies. In the hospital, the child's usual routine is disrupted. He or she cannot choose what to do and at what time. The child can no longer accomplish simple tasks independently as he or she does at home or school. > Confinement to the bed or crib worsens this loss of control. > Hospitalization also affects the child's control over decisions related to his or her own body. Many of the procedures and treatments that occur in the hospital are invasive or are at least disturbing to children, and much of the time they do not have the option to refuse to undergo them > children often feel powerless when in the hospital, not having their feelings and wishes respected and having minimal control over events.

Play as Part of Nursing Care

> To increase range of motion in a school-age child who is hospitalized for traction due to a fracture, have the child throw a soft sponge ball or beanbag ball into a hoop, and compete against the child. > To increase deep breathing, encourage the child to blow bubbles or blow a whistle. > To increase intake of fluids, help the child create a graph to chart the number of glasses of fluids he or she drinks over a period of time. > Award the child a sticker, baseball card, special pencil, or other small item if he or she reaches a certain level.

Toddlers Response to Illness/Hospitalization

> Toddlers are more aware of self and can communicate their desires. > Toddlers are often fearful of strangers and can recall traumatic events. Simply walking toward the room where a traumatic procedure previously occurred may upset the toddler > a resurgence in separation anxiety occurs during the toddler years. When the toddler is separated from his or her parents or caregivers in an unfamiliar environment, separation anxiety is compounded. > In response to this anxiety, toddlers may demonstrate behaviors such as pleading for the parents to stay, physically trying to go after the parents, throwing temper tantrums, and refusing to comply with usual routines. > Restrictions related to mobility and new skill acquisition result in loss of control. > Disruption in usual routines also contributes to loss of control, and the toddler feels insecure. > As a result, regression in toilet training and refusal to eat are common reactions in toddlers.

Transport of the Child

> Various methods to transport children include carrying the infant and using strollers, wagons, or rolling beds > the parents should accompany the child to offer support and comfort. > When carrying an infant, good support of the back and head is vital. Rails should be up on all beds and wagons. Use safety belts with strollers and wheelchairs. > Never leave a child unattended during transport. Keep the child visible at all times during the transport.

Reactions of Parents to Illness and Hospitalization

> Watching a child in pain is difficult, especially when the parent is assisting with the procedure by holding the child. > The parent may feel guilty for not seeking care sooner. Parents may also exhibit other feelings such as denial, anger, depression, and confusion. > Parents may deny that the child is ill. > They may express anger, especially directed at the nursing staff, another family member, or a higher power, because of their loss of control in caring for the child.

Effects of Special Needs on the Child

> When a child is medically fragile or has special needs, the child's coping ability is affected. In addition, the child's ability to cope is significantly affected by the family's response to stressors, which are often numerous in this population. > Infants may fail to develop a sense of trust or attach appropriately with the parents because of frequent hospitalizations, often with multiple caregivers involved; lack of consistency in nurturing; or parental detachment or grieving over the child's condition > The infant's ability to learn through sensorimotor exploration may be impaired due to lack of appropriate stimulation, confinement to a crib, or increased contact with painful experiences > The toddler may experience difficulty developing autonomy because of increased dependency on the parent or overinvolvement by the parent. > Motor and language skill development may be delayed if the toddler is not given adequate opportunities to test his or her limits and abilities > Limited opportunity also reduces the preschooler's development of a sense of initiative. The preschooler may experience limited opportunities for socialization, causing him or her to withdraw or to feel criticized. In preschoolers, magical thinking may lead to feelings of guilt for having caused their own disease or condition > The school-age child may have limited opportunities to achieve a sense of industry because of school absence and inability to participate in activities or competitive events. Lack of socialization limits the school-age child's ability to form peer relationships. > Adolescents may feel as though they are different from their peers because of their lack of skills/abilities or their appearance. This may hinder the teen's ability to form a sense of personal identity. > Since the teen with special health care needs often requires significant amounts of support from the parents, it may be difficult for the adolescent to achieve independence. > The child with special health care needs may be able to focus on the positive experiences in his or her life as a method of coping, leading to as much independence as possible. > Other children may always feel different from their peers (in a negative sense) and withdraw. Irritability and acting out may also occur.

Restraining Children to Maintain Safety

> When deciding whether it is necessary to restrain a child, consider the child's age, developmental level, mental status, and threat to others and self. > If it is determined that a restraint is needed, select the most appropriate, least restrictive type of restraint > For example, if the child has an intravenous catheter in the antecubital space that stops flowing when the child bends the arm, an elbow restraint or armboard, rather than a soft wrist restraint or four-point extremity restraint, would be appropriate. > Explain why the child should not touch the intravenous site or should maintain a certain position so that he or she has a basic understanding of what is necessary. This may be all that is necessary for an older child. > One-to-one supervision and behavior modification techniques may be other alternatives to the use of restraints. > Therapeutic hugging should be used for procedures and treatments such as intravenous line insertion for which the child needs to remain still.

Preparing Children and Families for Hospitalization

> When preparing children for hospitalization, be aware of the situations that may create distress in a child and try to minimize or eliminate them. > new experiences, unfamiliar sights and sounds, disruption of sleep patterns, and pain associated with procedures and treatments are major causes of stress for the hospitalized child and family. > Reduce the child's fears and increase his or her ability to cope with the hospital experience through good preparation. Preparation should include exploring the child's perceptions, reviewing previous experiences, and identifying coping strategies. > The goal should be to decrease fear and anxiety by allowing the child to better understand what is happening. > Identify what role the child will play in the situation: it is always helpful for children to have something to do, since it shows them that they are included > The child and family may be able to take a tour of the hospital unit or the surgical facility. Videos or DVDs, photographs, and books on hospitalization and surgery can serve as resources for the family and child. > During the tour, opportunities are provided for role-playing, and during stops along the way the child can see, touch, and feel the equipment that may be used

Caring for Hospitalized Preschoolers

> When working with preschoolers, remember that they use magical thinking and fantasy. > Be honest and specific, providing information just prior to the intervention to allay the child's fears. > Allow the preschooler to make simple decisions such as which color bandage to use or whether to take medicine from a cup or syringe.

Introduction to Caring for Children in Diverse Settings

> Within each setting, the nurse incorporates basic nursing care with specific strategies to help promote positive outcomes for the child, family, and community as a whole. > Community health nursing refers to nursing care that strives to improve the health of a specific community as a whole

Providing Preoperative Teaching

> adapt the teaching to the child's developmental level. For example, when teaching a toddler or preschooler about breathing exercises, have the child blow a pinwheel or cotton balls across the table through a straw. The child will enjoy the activity while also reaping the respiratory benefits of the activity. > In preparation for surgery, use items such as stuffed animals or dolls to help children understand what is going to happen to them (role play) > Shadow Buddies: The dolls were developed to help children cope with their illness or disease and send the message that it is OK to be different. (Dolls designed to simulate surgical experiences have been developed. For example, Shadow Buddies are custom-made dolls that have the same illness or surgery as the child; the doll may have an ostomy, a scar, or a catheter) > Using a stuffed animal to explain a surgical procedure to the child.

Physician's Office or Clinic, Health Departments, and Urgent Care Centers

> children and families are discouraged from using urgent care centers or the emergency department for routine care, since it is difficult to provide coordinated, comprehensive family-centered care consistent with a "medical home" concept > The nurse's role in these settings includes preparing clients, collecting pertinent health information, performing assessments, assisting the physician with diagnostic testing and procedures, administering injections and medications, changing wound dressings, assisting with minor surgery, helping to maintain records, and educating the child and family about home care and when to call the physician or nurse practitioner or return to be seen.

Illness and Hospitalization in Childhood

> fewer children may actually be admitted to a hospital unit, and those who are hospitalized are generally acutely ill. > trend has changed t community health settings

Outpatient Facilities

> health care provided to individuals who do not require care in an acute setting. > These settings allow for increased independence and permit children to return to their normal routine as quickly as possible. > Outpatient units are used to keep hospital stays short and decrease the cost of hospitalization > The advantages of this environment include minimal separation of the child from the family, minimal disruption of the family pattern, decreased risk of infection, and decreased cost. > Disadvantages include lack of equipment for overnight stays, so if there are complications, the child will need to be transported to the hospital. > The roles of the nurse in the outpatient or ambulatory setting include admission and assessment, preoperative teaching and preparation, client assessment and support, postoperative monitoring, case management, discharge planning, and teaching. > Before the procedure, the nurse reviews with the family the routine to be followed and any special instructions (such as NPO orders), and familiarizes the child with the setting to help alleviate fears. > Once the child's condition is stable and he or she meets the discharge criteria of the facility, the nurse reviews with the parent postoperative instructions, including pain management; care of the incision if appropriate; diet; activity, including return to school; necessary follow-up; and when to call the physician or nurse practitioner. > Encourage the parent to bring one of the child's favorite toys, blankets, or games to make the child feel more comfortable.

Admitting the Child to the Facility

> involves preparing him or her for admission and introducing the child to the unit where he or she will be staying. > In today's health care environment, the admission process occurs quickly, with little time for extensive preparation; this is why preparation before admission is so important. > Begins with developing rapport and trusting relationship > Smile, introduce yourself, and give your title. > With a younger child, start with the family first so the child can see that the family trusts you.

Use of Restraints in Children

> may be needed to ensure the child's safety, allow a therapeutic or diagnostic procedure to be done, immobilize a body part or limit movement, or prevent disruption of prescribed therapy. > However, restraints can be overused and are not without risks to the child's safety and should be used as a last resort

Medically Fragile Day Care Centers

> medically fragile child (child with medical complexity) = a child with substantial health care needs, one or more chronic conditions, functional limitations often associated with technology assistance, and health care use" > The number of medically fragile children is growing. > Reasons include improvements in the treatment and care of complex medical conditions and increased sophistication of medical technology which has led to infants and children surviving and thriving with previously fatal conditions such as extreme prematurity > For many years, these children lived in hospitals their entire lives. Due to concerns about the high cost of long-term hospitalization and the diminished quality of life for these children, alternative care settings in the community, such as medically fragile day care centers, are being developed. > Medically fragile day care centers are specifically designed to meet the needs of these children. > Most centers accept children who have complicated medical needs or are dependent on technology. Examples include children with multiple congenital anomalies, children who are ventilator dependent, children with respiratory conditions, children with cardiac conditions, and children with cancer. > parents or caregivers can drop the child off in the morning and pick the child up in the afternoon. > Health professionals are present at these centers to provide for the children's medical, emotional, and developmental needs. Nurses trained in pediatric and neonatal care, physical therapists, occupational therapists, speech therapists, child life specialists (CLSs), and social workers staff the centers > Children can receive all prescribed therapies while at the center > Most centers are located in the community to help ease transportation issues. > Advantages of community-based services over hospitalization or home care include decreased cost, social isolation, family stress, and rehospitalization rate

Therapeutic Play

> nondirected and focuses on helping the child cope with feelings and fears. > Supervised play with medical equipment in the hospital environment can help children work through their feelings about what has happened to them. In a large hospital or a children's hospital, the CLS typically coordinates these activities. > Goals include maintaining normal living patterns, minimizing psychological trauma, and promoting optimal development of the child. > Drawing is a way for the child to express his or her thoughts and feelings

Separation Anxiety

> typically begins once a child has developed object permanence (an understanding that things exist even when they are out of sight) which is usually around 4 to 8 months > three stages that the infant and child go through during separation anxiety: protest, despair, detachment 1. Protest 2. Despair 3. Detachment

Recent Stresses and Changes and Individual Coping Skills

A lack of sensory stimulation in the hospital environment can lead to listlessness, indifference, unhappiness, and even appetite changes. > When the child's motor activity is restricted, anger and hyperactivity may result. > Play, recreation, and educational opportunities can provide an outlet to distract the child from the illness, provide pleasant experiences, and help the child understand his or her condition. > The child's ability to work through a situation will also affect his or her responses to illness and hospitalization.

Caring for Hospitalized School-Agers

Involve the child in making simple decisions and planning the schedule as appropriate to give him or her a sense of control.

Caring for Hospitalized Adolescents

Respect the teen's need for privacy. Encourage visits from the adolescent's friends to minimize anxiety related to separation. Prepare a mutually agreeable schedule with the teen, as appropriate, that includes the teen's preferences while incorporating the required nursing care.

(T/F) Appropriate safety interventions that are age and developmentally appropriate and would be used outside of the health care setting to protect an infant, toddler, or preschool child such as stroller, swing, highchair safety belts, and crib rails, crib covers, and enclosed or domed cribs, and raised padded side rails used for seizure precautions are not considered restraints

True

(T/F) Avoid using the term "playroom" when caring for older school-age children and adolescents. Instead, call it the "activity room" or "social room." Doing so promotes a greater feeling of maturity and makes it more likely that they will use the area.

True

(T/F) In the acute setting, the nurse is in control of the environment; in the home setting, the nurse is a guest in the home.

True

(T/F) Keep the bed or crib and playroom as "safe" places. Perform invasive procedures such as venipunctures in the treatment room if possible. Never perform any nursing interventions in the playroom, no matter how nonthreatening they may appear to the nurse.

True

(T/F) Nurses have a unique opportunity to give back to their community by volunteering their services in various settings, such as shelters and clinics in medically underserved areas.

True

(T/F) Parents often can pick up on subtle problems in their children. They may not be able to accurately describe signs and symptoms, but they know that their child "isn't acting right." Nurses must listen to parents and act on their concerns.

True

(T/F) Research supports the need to provide support and information to the siblings to decrease their stress, anxiety, and worry and to promote psychosocial adjustment.

True

(T/F) When a child is admitted to a general unit, take extra time to orient and explain the routines and procedures to the child and family. Emphasize that the parents can stay with the child (if institutional policy permits). If possible, place the child in a room close to the nurses' station and order food appropriate for the child's age and developmental level.

True

(T/F) When advocating for a child, make sure to include the child's voice. Do not assume what his or her wishes may be; ask about them directly.

True

Community

a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging

Separation Anxiety

distress related to removal from family and familiar surroundings

Regression

return to a previous stage of development

Nursing Interventions for Families of Children with Special Health Care Needs

• Develop written health plans. • Provide care coordination and collaboration with specialists in other disciplines, early intervention, schools, and public agencies. • Address needs for prior authorization for treatments, medications, or specialist referrals; retain copies in the child's chart of authorization forms and approvals. • Modify office routines to promote family and child comfort. • Assist parents with child care decisions. • Know community resources available to children with special health care needs. • When the child is hospitalized, encourage high levels of parental participation. • Provide care coordination across multiple health settings. • Educate child care providers on child health needs. • Help parents get involved with parent support networks.

Tips to Establishing a Trusting Relationship in Homecare

• Include the child in the conversation and make him or her feel a part of the interaction. • Address caregivers formally unless otherwise instructed. • Be friendly. Use a soft, calm voice. • Be interested in the child's activities. • Have the primary caregiver present at the initial visit. • Listen to and show respect to the child and the family.

Preparing Child for Hospitalization (Parents)

• Read stories about experiences with hospitals or surgery. • Talk about going to the hospital and what it will be like coming home. • Be honest and encourage the child to ask questions. • Visit the hospital and go through the preadmission tour if time permits. • Provide support to the child via your presence, telephone calls, and special items brought from home. • Encourage the child to draw pictures to express how he or she is feeling. • Include siblings in the preparation.