The Hospitalized Child

The Healthy Family The capacity for clear boundaries (able to establish rules and guidelines) The ability to operate mainly in the present (and not in the past, because they wont be able to deal with today) A respect for individual choice and autonomy (respectful attitude and if they dont, they that environment can show/lead to abuse) Skills in negotiating The ability to share positive feelings (children need positive environment) [Entire] Family Reactions to Hospitalization Parents Reactions o Disbelief (OMG) o Anger /& guilt (Why me? Why werent you watching them?!) o Fear, anxiety, frustration (outcome is unknown, get angry in ED) Sibling Reactions o Loneliness (with brother/sister), fears (will this happen to me?), and worry o Anger, resentment, jealous, guilt (this is because the parents and focus/taking care of the hospitalized child) Factors that Influence Developmental cognitive level (level of understanding of child) (a 10 year old have different coping skills than a 2 year old) Previous experience (has an effect on a childs response to hospitalization anxiety/fear) Culture (take their culture into consideration!!) Spirituality (promote and enhance it! This encourages and quickens healing) Age appropriate intervention/language (eg. If a 10 year old has a cognitive level of a 5 yo, then treat them like a 5 year old) Concept of Illness Preoperational (2-7 yo) Piaget o Perceives external, unrelated, concrete phenomenon as cause of illness (cant see casue and effect) o Perceives cause of illness as proximity between two events occurs by magic Concrete Operational (7-10+ years) *Sees cause as a person, object, or action external as bad *Illness has external cause that located inside Formal Operational (13+ years) *Sees cause as malfunction or nonfunctioning organ or process (can understand dz process) *Can explain illness in sequence of events *Realizes that psychologic actions and attitudes affect health and illness (feel better to get better)

The Hospitalized Child Separation Anxiety *Major stress from middle infancy thru preschool *Stages 1. Protest 2. Despair 3. Detachment (True separation happens from 2 to 3 yo) Protest Later Infancy: *Cries, screams, searches for parent with eyes (will look at them thru crib), clings to parent, avoids and rejects contact with strangers (7 to 9 months, stranger danger) Toddler: *Also cries and screams-NO!, verbally attacks strangers, physically attacks strangers, attempts to escape to find parent, attempts to physically force parent to stay (cling) *Behaviors last hours to days (may cry themselves to sleep) *May be continuous ceasing with exhaustion Despair *Inactive *Withdraws from others *Depressed, sad *Uninterested in environment *Uncommunicative (turn back on you, wont talk) *Regresses to earlier behavior (thumb sucking, takes bottles, wet bed) *Physical condition may deteriorate (get sicker) *Wont play Detachment *Shows increased interest in surroundings (watch tv) *Interacts with strangers (RNs and other parents) *Forms new, superficial relationships *Appears happy *Occurs after prolonged separation (Child will love RN and ignore parents to get back at them) Loss of Control *Lack of control increases the perception of threat (big threat) *Can affect childs coping skills *Additional stimuli (sight, sounds, smell) may be overwhelming *Major areas: physical restriction, (to only room, IV pole), altered routines (these are screwed up; messes with childs eating, napping, sleeping time, etc) or rituals, dependency (on people-lose dependency and dont like it!)

Interventions Infant *Minimize use of restraints, hep lock IV, use crib with canopy (or bed with plastic verses metal bars, visually appears less constrictive), alter environment with infant seat, stroller, etc (to provide stimulation), provide toys (to decrease isolation and sense of loss of control) Toddler *Promote home rituals *Promote dietary practices (room service choose diet and eat at whatever time they want) *Give choices when possible (toys, games) [RN may ask do you want your meds?, NO, instead, ask Do you want your meds with juice or water?] *Take to playroom *Provide opportunity for medical play (stuff animal to show med intervention to reduce anxiety) *Educate parents about regression (if child is potty trained, they may regress to bed wetting and be sure to tell parent that is normal and it is ok and will go away) Pre-Schooler *Encourage autonomy *Take to playroom *Urge to participate in therapeutic play (explain med txmt thru play) *BE TRUTHFUL!! School Age *Provide opportunities to discuss medical dx *Encourage child to discuss feelings and understanding of condition (give feedback have them explain stuff back) * Allow child to help with tasks * Promote choices in care *Reward system Adolescent *Develop plan of care with adolescent input *Respect need for independence, let them wear normal clothing *Offer choices in routines *Allow for privacy (start at school age (9 years old body image concerns kick in) and privacy necessity) *Be open about medical condition (schedule time in privacy)

*Check ID bands* *Check IV rate on teens pump *Be sure to sign out of bedside computer, they will chart if given chance Nursing Diagnosis -Anxiety/fear R/T separation from routine -Anxiety/fear R/T distressing procedures -Pain **Huge issue fear/loss of control -Risk for poisoning or injury from medications R/T sensitivity, dose, etc -Diversional activity deficit -Powerlessness -Risk for injury or trauma R/T environment, equipment, therapies (**Safety HUGE factor, always double check dose, safe dosage, right flush, right dose, have extra line and extra tape on PICC, etc) Standard of Care *Issues R/T care of minors *Consent for procedures -parent or legal guardian, mature minor doctrine, emancipated minor, custodial parent, judicial system, no parental consent needed