PEDIATRIC HEALTH NURSING

UNIT IV : COMMUNICATION/ THERAPEUTIC PLAY

WHILE CARING FOR CHILDREN WITH VARIOUS
DISEASE PROCESS

MUHAMMAD SULIMAN
Post RN BSc.N

ROYAL COLLEGE OF NURSING

SWAT
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 INTRODUCTION
Communicating with children and family caregivers is a
primary source of data collection during a well-child visit or
in any health crisis situation. Communication occurs in all
settings and focuses on data collection as well as information
related to immunizations, developmental assessment,
teaching, and anticipatory guidance. Information about the
child is derived from the child, the caregivers, and the nurse’s
observations of the child and family. Understanding the
developmental level of the child and influences on the child’s
and caregiver’s communication (e.g., family, culture,
community, age, & personality) are critical for
communicating affectively.
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 PURPOSE
 Sometimes it is just about talking to and interacting
with children
 Establishing a therapeutic relationship
 Supporting children
 Eliciting and giving information
 Explaining procedures
 Listening to what they want to tell us
 Obtaining information about how they ‘are feeling’
to help with diagnosis

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 GENERAL MEASURES CONSIDERING
DURING COMMUNICATION
 Be aware of children’s inability to communicate verbally because
of disabilities, developmental delays or traumatic scenarios and
adjust your approach to meet their needs.
 Children may change their style of interaction, being passive or
active, which the nurse needs to be aware of when
communicating.
 Adopting the SOLER approach (face people Squarely; Open body
shape; Lean forward slightly; Eye contact; Relax).
 Be prepared to come down to the child’s level (e.g. sitting on the
floor) when communicating directly with them.
 Use different approaches such as play, humour or drawing to
engage with children.
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 COMMUNICATING WITH THE FAMILY
■ Encourage parents to talk openly regarding their
concerns.
■ Use open-ended questions.
■ Use careful, nonjudgmental statements.
■ Men may prefer a focus on cognitive, problem-solving
talk.
■ Females may prefer a focus on the process rather than the
outcome.
■ Be aware and considerate of generational differences.
■ Incorporate active listening skills.
■ Be aware and considerate of cultural differences.
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 Cont…
■ When communicating, use silence, empathy, respect,
genuineness, and trust as nursing interventions.
■ Communication can be tricky with non traditional
and noncustodial parents. Follow the established
policies and procedures the hospital has in place.

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 Cont…
■ Remember to observe and record nonverbal communication
factors, such as tone of voice, body language, and facial
expression. Be aware of your own nonverbal
communication factors and make sure you are not
communicating unintended messages.
■ Allow family members to voice their understanding of the
current situation.
■ Clarify or provide teaching points to decrease
misunderstandings.
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 Communicating with children
■ The majority of the communication will take
place between practitioners and parents.
However, the child cannot and should not be
excluded.
■ Make sure to incorporate active communication
strategies with the paediatric patient as well.
Incorporate an understanding of growth and
development when communicating with the
pediatric patient.
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 Cont…
■ Observe body language, facial expressions, and
other nonverbal gestures.
■ Incorporate play into nursing assessments and
interactions where appropriate.
■ Use special toys or games to assist with
assessments.

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 Methods of Communication with
Children
■ Verbal—words, face-to-face interactions; infants
cry, coo, and respond to their environment;
parents and caregiver need to learn the cues of
the infant or child
■ Be mindful of long pauses, rapid speech, and
engaging the appropriate individuals in the
communication process.
■ Gear communication to the cognitive and
developmental level of the child.

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 Methods of Communication with Children
■ Nonverbal—gestures, body language, posture, eye
contact. Be aware of cultural factors
■ Visual—can include signs, photos, and
illustrations.
■ Play—allows children to express feelings and
concerns in a nonverbal manner.
o Children base their views on the relationships and
experiences within their daily lives.
o Infants and children with altered hearing may have
delayed communication.

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 Communicating with infants
■ Newborn to 12 months
■ This is a time of rapid physical and
developmental growth. The body systems are
maturing, and skill development is taking place.
■ Social development is influenced by the infant’s
environment and the attachment developed with
their parents and caregivers.

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 Cont…
■ Infants are unable to verbalize needs, concerns, and
discomforts.
■ Nonverbal behaviors, such as smiling, promote
socialization.
■ Infants display crying and cooing.
■ Infants cry when they are hungry, when their diapers
need to be changed, when feeling pain or discomfort,
and when feeling lonely or wanting to be held.
■ Infants coo when they are content or happy.
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 Cont…
■ Infants are often quiet, observing the environment around
them.
■ Infants respond to the nonverbal behaviors of adults:
touch, sound, and tone of voice.
■ Observe parents and child caregivers’ interactions and
handling of the infant:
■ Separation anxiety
■ Fear of strangers
■ Temperament and disposition
■ If the child has attained understanding of object
permanence, he or she will know when a parent is missing

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 Quickly respond to the infant’s crying by feeding, diapering, or picking up
the infant.
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 Infants need to feel and touch the environment around them.

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 Communicating with Toddlers and
Preschoolers
■ Younger than 5 years old
■ This is a time of intense exploration of the child’s
environment. The young child learns more of his or her
environment while also exhibiting some negative
behaviors, including tantrums (emotional outburst).
■ This time can be overwhelming and challenging for
parents and caregivers but is an important period of
development for the child. Much cognitive, social,
psychosocial, and biological growth and
development is occurring.
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 A tantrum (or temper tantrum or tirade or hissy fit) is an emotional
outburst, usually associated with children or those in emotional distress,
that is typically characterized by stubbornness, crying, screaming, yelling,
shrieking
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 Cont…
■ Children of this age are typically egocentric, or
unable to think from another person’s point of
view.
■ Use statements such as “good job” instead of
“good boy/girl.”
■ Children of this age need to feel and touch the
things around them to gain knowledge of and
experiment with unknown environments

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 Cont…
■ Medical play may be useful in demonstrating how a
procedure will take place.
■ The child may practice or pretend that a doll is having a
procedure done.
■ If appropriate, allow the child to handle a stethoscope,
pulse oximeter, and blood pressure cuff and explore these
items in a nonthreatening environment.
■ Children of this age are very concrete and literal, and are
often unable to conceptualize that one word may have
more than one meaning.
■ “IV” means “intravenous” to the nurse, but may be
translated as “ivy,” a known plant, by the young patient
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 Cont…
■ “Stick” or “poke” refers to a needle insertion for the nurse,
but the young patient views a stick as a small piece of wood
found in the yard.
■ Bleeding may be perceived as a child’s “insides leaking
out.” Young children are often comforted by an adhesive
bandage used to cover an open area.
■ When having an x-ray procedure, the child may smile
when getting his or her “picture” taken.
■ Children assume that inanimate objects feel and act as
humans do. For example, they might think that something
inanimate could bite them.

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 A young child may take the expression “a little stick in the
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arm” literally. 24
 Cont…
■ The child may call an instrument “bad” if it has
caused pain or discomfort to them.
■ They are fearful of unfamiliar objects and
environments.
■ When possible, allow the child to tour a facility or
treatment room prior to the actual treatment.
■ Preschoolers begin to develop skills in fantasy and
pretend play.
■ This is a period of social, language, and behavioral
development.
■ Children of this age are developing a sense of
autonomy.

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 Developing a sense of autonomy.
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 Communicating with School-Age Children
■ Ages 6 to 12 years
■ This period of physical and psychosocial development
includes many milestones, such as entering school,
communicating independently, and beginning to
conceptualize the environment.
■ Communication directly with children of this age is equally
important as communicating with their parents.
■ School-age children are energetic and want answers to the
questions they have. They want to develop connections
and ties with information learned and ask themselves and
others why certain things occur and happen. The pediatric
nurse must be aware of this in his or her communication
with the school-age child.

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 Cont…
■ Curious
■ Used to asking questions in school when they cannot
understand
■ Want to know why or how things happen or occur
■ Gain knowledge by experience and by understanding what
is occurring
■ Enjoy having a job or task to complete
■ Eager to please, and want to complete a task
independently
■ Work well with positive feedback
■ Tell the child that he or she is part of the medical team that
will help to get him or her well.
■ Assign daily jobs, such as an exercise or a task, so that the
child can assist with care.
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 Cont…
■ Concrete
■ Unable to think abstractly
■ Examples should be given in a physical context in which the
child can see, feel, or hear a result.
■ May overreact if feeling threatened
■ Able to verbalize thoughts, feelings, or concerns
■ Encourage children to ask questions.
■ Older children may wish to journal their experiences.
■ Other children may serve as a support group.
■ Need play time
■ Playing will allow the child to communicate thoughts or
feelings in a nonthreatening environment.
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 Allow the school-age child to be an active participant in care.
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 Communicating with Adolescent Children
■ Ages 13 to 18
■ This is a time of developing independence and
maturity. The adolescent child focuses more on
social networks and friends.
■ The adolescent child may seek counsel and feedback
from sources other than parents and caregivers.
■ Sexual development, including menstruation and
emission, has already occurred.
■ Behavior may fluctuate between adult and childlike.
■ Adolescents are independent with activities of daily
living, but still require adult supervision and input
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 Adolescents are becoming more independent, but still require
adult supervision and input.
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 Nursing Care Guidelines
Communicating with children
• Allow children time to feel comfortable.
• Avoid sudden or rapid advances, broad smiles, extended eye contact, and other
gestures that may be seen as threatening.
• Talk to the parent if the child is initially shy.
• Communicate through transition objects such as dolls, puppets, and stuffed
animals before questioning a young child directly.
• Give older children the opportunity to talk without the parents present.
• Assume a position that is at eye level with the child (Fig. 6-2).
• Speak in a quiet, unhurried, and confident voice.
• Speak clearly, be specific, and use simple words and short sentences.
• State directions and suggestions positively.
• Offer a choice only when one exists.
• Be honest with children.
• Allow children to express their concerns and fears.
• Use a variety of communication techniques.
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 FIG 6-2 Nurse assumes position at child’s level.
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 CHARACTERISTICS OF COMMUNICATIVE
DEVELOPMENT IN YOUNG CHILDREN
Perlocutionary Stage (0 to 8–9 Months)
Child is reflexive to stimuli.
Child shows increasing purpose in action.
Emerging Illocutionary Stage (8–9 to 12–15 Months)
Child communicates intentionally with signals and gestures.
Conventional Illocutionary–Emerging Locutionary Stage
(12–15 to 18–24 Months)
Child communicates intentionally with gestures,
vocalizations, and verbalizations.

Modified from Hoge DR, Parette HP: Facilitating communicative

development in young children with disabilities, Transdisc J 5(2):113–130, 1995.
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 Locutionary, illocutionary,
perlocutionary
For example, my saying to you "Don't go into the
water" (a locutionary act with distinct phonetic,
syntactic and semantic features) counts as
warning you not to go into the water (an
illocutionary act), and if you heed my warning I
have thereby succeeded in persuading you not to
go into the water (a perlocutionary act). This
taxonomy of speech acts was inherited by John R.
Searle, Austin's pupil at Oxford and subsequently
an influential exponent of speech act theory.

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 Nursing Care Guidelines
Communicating with Adolescents

Build a Foundation
Spend time together.
Encourage expression of ideas and feelings.
Respect their views.
Tolerate differences.
Praise good points.
Respect their privacy.
Set a good example.

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 Cont…
Communicate Effectively
Give undivided attention.
Listen, listen, listen.
Be courteous, calm, and open minded.
Try not to overreact. If you do, take a break.
Avoid judging or criticizing.
Avoid the “third degree” of continuous questioning.
Choose important issues when taking a stand.
After taking a stand:
• Think through all options.
• Make expectations clear.

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 PLAY
Play is a universal language of children. It is one of the
most important forms of communication and can be
an effective technique in relating to them. The nurse
can often pick up on clues about physical,
intellectual, and social developmental progress from
the form and complexity of a child’s play behaviors.
Play requires minimum equipment or none at all.
Many providers use therapeutic play to reduce the
trauma of illness and hospitalization and to prepare
children for therapeutic procedures

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 CONT…
• Because their ability to perceive precedes their
ability to transmit, infants respond to activities that
register on their physical senses. Patting, stroking,
and other skin play convey messages. Repetitive
actions, such as stretching infants’ arms out to the
side while they are lying on their back and then
folding the arms across the chest or raising and
revolving the legs in a bicycling motion, will elicit
pleasurable sounds. Colorful items to catch the eye
or interesting sounds, such as a ticking clock, chimes,
bells, or singing, can be used to attract children’s
attention.
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 CONT…
Older infants respond to simple games. After this
intermittent eye contact, the nurse is no longer
viewed as a stranger but as a friend. Much of the
nursing assessment can be carried out with the use
of games and simple play equipment while the
infant remains in the safety of the parent’s arms or
lap. The nurse can capitalize on the natural
curiosity of small children by playing games such as
“Which hand do you take?” and “Guess what I have
in my hand” or by manipulating items such as a
flashlight or stethoscope.

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 Use of Play in Procedures
The use of play is an integral part of relationships with
children. Many institutions have elaborate and well-
organized play areas and programs under the direction of
child life specialists. Other institutions have limited
facilities. No matter what the institution provides for
children, nurses can include play activities as part of nursing
care. Play can be used to teach, express feelings, or achieve
a therapeutic goal. Consequently, it should be included in
preparing children for and encouraging their cooperation
during procedures. Play sessions after procedures can be
structured, such as directed toward needle play, or general,
with a wide variety of equipment available for children to
play with. Routine procedures such as measuring blood
pressure and oral administration of medication may be of
concern to children. Some suggestions for procedures are:
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 SELECTING NONTHREATENING WORDS OR PHRASES
WORDS AND PHRASES TO AVOID SUGGESTED SUBSTITUTIONS
Shot, bee sting, stick Medicine under the skin
Organ Special place in body
Test To see how (specify body part) is working
Incision, cut Special opening
Edema Puffiness
Stretcher, gurney Rolling bed, bed on wheels
Pain Hurt, discomfort, “owie,” “boo-boo,” achy,
Deaden Numb, make sleepy
Fix Make better
Take (as in “take your temperature”) See how warm you are
Take (as in “take your blood pressure”) Check your pressure; hug your arm
Put to sleep, anesthesia Special sleep so you won’t feel anything
Monitor Television screen
Electrodes Stickers
Specimen Sample
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Playing with medical objects provides children with the opportunity to play
out fears and concerns with supervision by a nurse or child life specialist.
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 Nursing Tip
Prepare a basket, toy chest, or cart to keep near the
treatment area. Items ideal for the basket include a Slinky;
a sparkling “magic” wand (sealed, acrylic tube partially
filled with liquid and suspended metallic confetti); a soft
foam ball; bubble solution; party blowers; pop-up books
with foldout, three-dimensional scenes; real medical
equipment, such as a syringe, adhesive bandages, and
alcohol packets; toy medical supplies or a toy medical kit;
marking pens; a note pad; and stickers. Have the child
choose an item to help distract and relax during the
procedure. After the procedure, allow the child to choose a
small gift, such as a sticker, or to play with items, such as
medical equipment.
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