I.

Factors affecting reactions to hospitalization: c) Denial – represses all feelings for-

● age and stage of maturity the mother, does not cry when she
● nature and degree of illness leaves, more attached to the nurse.
● past experience
● meaning of illness to him - Tool for intervention
● quality of care received o rooming-in, encouraging the
primary caregiver to stay,
II. Common Reactions of the child to illness o promoting parent substitute
1. Anxiety – not, only in the openly terrified o diversional play
child but also in the child who is good and o consistency in nursing personnel
who makes no protest The latter faces a and approach to care
greater psychological emergency.
B. PRESCHOOL CHILD
2. Guilt – especially who goes to the hospital - Concerns:
because of something wrong they have o separation anxiety continues
done, also among children who are always o concerned about medical
threatened so they behave or obey. manipulation
o fear of body mutilation (wounds,
3. Regression – going back to an earlier form surgery, injections)
or stage of development manifested most
commonly by almost everyone. - Reactions
o prone to develop fantasies
4. Covering up for pain or discomfort – associated with illness.
especially for those children who have a
desire to go home already. - Tools for nursing intervention
a) play therapy, e.g. role playing and
5. Extremes of aggression or passivity – puppetry
resisting all procedures or accepting it b) avoid use of the word “cut”,
without reactions; could be an indication of “remove” when explaining
a problem, ie. child abuse procedures.
c) cover injection site with tape
III. The reactions and concerns of the hospitalized d) all interventions used for infants
child are greatly influenced by his stage of growth and toddlers
and development.
C. SCHOOL CHILD
A. INFANTS AND TODDLERS - Concerns:
- Concerns: o questions regarding effects of
o stranger anxiety illness to his body, additional
o separation anxiety concerns of helplessness and
o strong need for continuity of care defenselessness, of being excluded
and affection. in school activities, of displeasing
teachers for being absent.
- Reactions, they may experience stages of:
a) Protest – urgent desire to find his - Reactions
mother, expects that she will o tends to be phobic; fears includes
answer her cries so be cries fear of the dark, of doctors, of. the
frequently, shakes the crib, rejects hospital, unrealistic fears attached
the nurse's attention to needles, procedures ,etc.
b) Despair – feels increasingly
hopeless, becomes apathetic and - Tools for Intervention
may begin to accept nurse's o honesty in all explanations
attention o group play if possible
o sharing in some ward. activities if
possible like bed making
 o continuation of lecturing education 7. The nurse should show team work with the
especially in chronic illness with other members of the health team.
tutorial services or distance
modular education, home Selection of Toys
schooling. - The selection of toys should be based on the
special interest of the child, the age of the
D. ADOLESCENT child, the level of activity allowed and the
- Concerns: capability of the parents to provide.
o interferes with his struggle for - Toys for handicapped palsied or "special
independence children' should not be classified by
o illness is a major threat to his ego chronological age group but should be
o threatened by helplessness selected in terms of the capacity of the
o illness is punishment for feelings, child and the developmental and
not mastered or for breaking rules therapeutic purpose served.
imposed by adults. - Generally speaking a toy that encourages
imagination and allows the child to become
- Reactions: involved in the activity is more desirable
a) denial than a mechanical toy that plays for the
b) withdrawal child. Safety is of primary importance.
c) disappointment
d) anger and hostility For the Bedridden Child
- Quiet or moderate activity may include
- Tools for nursing intervention picture books., drawing books, clay,
o introduce patient to hospital/ward weaving, sewing kits, puppets, miniature
staff and regular routines autos, radio for the older client. Consider
o provide opportunity for asking the therapeutic value of the toy.
questions
o allow independence for caring for Therapeutic Values of Selected Toys/ Activities
his personal needs. 1. Encouraging Fluids – hold a tea party or
o provide privacy juice drinking party, play Simon says, play
o permit socialization and games where the loser drinks as penalty.
continuation of peer relationship Use colorful child-size cups or glasses
o meals should reflect own preference with surprise at the bottom of the glass, use
if possible colorful straw
o allow freedom in clothing 2. Deep Breathing Exercises – blowing rubber
o allow continuation of education gloves., soap or water bubble, playing with
musical instruments-clarinet, trumpet,
Principles in Establishing Relationship with whistle, blowing paper toys, pipes,
Parents and Child pinwheels , Simon Says, use of incentive
1. The nurse plans to build. a working spirometer for older patients
relationship with the parents and-the 3. Muscle Strengthening Exercises – squeeze
child at first contact. toys, modeling clay , kicking balloons
2. The nurse understands that all behaviors suspended at the foot of the bed, Simon
are meaningful. Says, push-pull toys if allowed.
3. The nurse accepts the child and the 4. Health teachings and other instructions –
parents as they are. use puppets as teachers.
4. The nurse should have empathy for the
parents and the child. PRINCIPLES OF ESTABLISHING RELATIONS WITH
5. The nurse should acknowledge the PARENTS AND CHILD:
parent’s right to their own decision about 1. The nurse begins to build a working
their child. relationship with the child and the parents
6. The nurse should speak in an at first contact.
understandable language. 2. The nurse understands that all behaviors
are meaningful.
 3. The nurse accepts the child and parents as
they are.
4. The nurse should have empathy for parents
and children.
5. The nurse should acknowledge the parents’
right to their own decision concerning their
child.
6. The nurse should ask questions which are
limited to a single idea or references.
7. The nurse should speak in understandable
language.
8. The nurse should show teamwork with
other medical and para-medical personnel.
PRINCIPLES OF ADMISSION
1. The child has no idea of what is happening
and the parent's ignorance is nearly as
profound.
- Notice and listen to them.
2. Protect the child from hearing what be
cannot understand.
3. Know some facts about the child as an
individual.
4. The child needs his mother's support while
admitted and adjusting to the new
environment..
5. Cooperation between the mother and the
nurse increases the child’s feeling of
security..
6. The hospital routine must be flexible
enough to allow for changes when needed-
7. The child. needs opportunity to become
familiar. with his environment.
8. The child needs help in adjusting to the
hospital routine.
9. Inability to play productively is a symptom
of acute anxiety.
PRINCIPLES IN PREPARING THE CHILD FOR
DIAGNOSTIC PROCEDURES
1. The nurse should. not allow her natural
compassion to blind hex from subjecting
the child to the procedure.
2. Maintain the sense of trust of the child on
the nurse and the doctor.
3. In older children, explain the procedure
simply and clearly.
4. Let the child participate, if possible.
5. Let the child express himself before the
procedure.
6. Child must be forewarned of any
discomfort or pain because it would be
harder to bear it if it comes as a shock.
Guidelines for Communicating with Children
1. Allow the child to feel comfortable with the
nurse
2. Avoid sudden or rapid advances, broad
smiles or extended eye contact or other
gestures which may be threatening,
3. Talk to the parents first if the child is
initially shy.
4. Communicate through transition objects
such as dolls, puppets, or stuffed animals
before questioning the child directly,
5. Give older children the opportunity to talk
without the parent's presence.
6. Assume a position that is at eye contact
with the child.
7. Speak in a quiet unhurried and confident
tone of voice.
8. Speak clearly, be specific, use simple words
and sentences.
9. State directions and suggestions positively
10. Offer a choke when one exists.
11. Be honest with the child.
12. Allow them to express their concerns and
fears.
13. Use a variety of communication
techniques– verbal and non-verbal
TECHNIQUES IN ILL CHILD CARE
Taking Vital Signs in Children
TEMPERATURE
- Could be taken from several sites- oral,
rectal, axilla using traditional mercury,
tympanic route using tympanic membrane
sensor, and skin using plastic strip
thermometer.
Methods of Taking:
a) Digital Thermometer
o Oral – under the tongue in the R or
L sublingual pocket not in front of
the tongue
o Axillary – under the arm with the
tip at the center of the axilla close to
the skin.
Indication for axillary method:
→ bigger children who cannot
hold thermo in the mouth (5
y/o below)
→ unconscious child
 → those with neurological
problems like seizure
→ dyspneic children
→ babies with diarrhea and other
rectal problem
→ bigger children with problems
of the oral cavity
o Rectal – well lubricated (insert 2.5
cm / 1 inch) into the rectum.
Sometimes still taken in some
hospitals where better and safer
temperature taking device is not
available otherwise, not
recommended because core
temperature is not obtained unless
thermometer is inserted to depth 5
cm/2 inches (rectal perforation is
the risk, colon of children curves at
3 cm)
Indications for rectal method:
→ neonates and younger babies (1
y/o below)
b) Electronic Thermometer
o Contains thermistor at the tip of the
tip of the plastic end connected to
stainless steel probe.
o This device changes its resistance
with changes in temperature. A
computer or other circuit measures
the resistance and converts it to a
temperatureIdeal for children
because the mouth can remain open
while temperature is being taken.
c) Infrared Tympanic Membrane Sensor/
Thermo Scanner
o a clinical thermometer
o Inserted into the external acoustic
meatus to determine the body
temperature by measuring the
infrared radiation emanating from
the tympanic membrane.
o It has been suggested that tympanic
thermometers give a more accurate
representation of actual body
temperature because the tympanic
membrane lies close to the
temperature regulation centre in
the hypothalamus and shares the
same artery
d) Temporal Artery Thermometer
o The scanner measures the
temperature of the room as well as
the temperature of the skin over the
temporal artery about 1000 times a
second as you sweep the scanner
across the forehead.
o Why the temporal artery? It's the
artery which carries blood directly
from the heart and is closest to the
heart so it provides the most
accurate results
e) Plastic Strip Thermometer
o The forehead thermometer is a
disposable strip of plastic with
liquid crystals embedded into the
strip.
o To take a person's temperature, one
places the strip against the person's
forehead.
o The liquid crystals react with the
temperature of the skin.
o After waiting anywhere from a few
seconds to a few minutes,
depending on the brand, the crystals
will change color.
o The thermometers have a number
line that shows the temperature
based on the color displayed.
PULSE/ CARDIAC RATE
1. Taken radially on children over 2 years old.
(Apically if below 2 y/o)
- place stethoscope between the left
nipple and sternum
- take heart rate for 1 full minute.
2. With older children, PR may be obtained at
the radial, temple, or neck locations
3. Take PR prior to taking temperature
because a child may cry when temperature
is being taken, thereby increasing the PR
and making it more difficult to hear the
apical rate.
RESPIRATION
1. Taken first before the other vitals signs
because non invasive. (Once child is
touched, they might cry) May be normally
irregular and with periods of normal apnea
(less that 20 seconds) among neonates
2. Count respiration on an infant for 1 full
minute
 3. Observe chest movements and abdominal
movements
4. record and report any change in respiratory
characteristics.
BLOOD PRESSURE
- Not routinely taken in children below 3
years-old unless there is an indication
(bleeding disorders, renal problem, cardiac
problem)
- Cuff should cover 75% of upper arm
Estimate of expected BP:
a. there is a gradual rise of sstolic
pressure during growth
b. diastolic pressure rises only
between the ages of 6-18 yrs.
c. significant increases in BP occur
during adolescence with many
temporary variations.
2. Variability of BP among children of
approximately the same age and body build
is normal
3. The pressure in the legs with the cuff
technique is ordinarily 20 mm Hg than that
in the arms.

Systolic 1 to 7 y/o: age in years + 90 APPROXIMATE VITAL SIGNS GUIDE FOR

8 to 18 y/o: age in years x 2 + 83 CHILDREN AT VARIOUS LEVELS

Diastolic 1 to 5 y/o: age in years + 56 AGE PR RR BP

6 to 18 y/o: age in years + 52 NEONATES 140 40 70/50
6 MONTHS OLD 110 30 90/60
1. Generally, the technique observed in taking 1 YEAR OLD 100 28 90/60
the BP of the child is the same. 3 TO 4 YEARS OLD 95 25 100/70
2. The following principles are important 5 TO 10 YEARS OLD 90 24 105/70
when dealing with the pediatric patient: 11- 15 YEARS OLD 85 20 110/70
- the cuff must cover two-thirds of the OVER 15 YEARS OLD 75-80 16-18 120/80
length of the upper arm of the leg.
Even small variations in cuff size may MEDICATION ADMINISTRATION
produce significant inaccuracies in BP
readings: Identifying the Patient
a) A narrow cuff will produce an - Ask their name
apparent increase in BP - Check their bracelet
b) A wide cuff will produce an - Ask their parents or companion
apparent decrease
- If the child is excited, uncomfortable ORAL
or distrusts the person taking the BP, - Usually prepared in child form like syrup,
systolic pressure may arise as much as suspension, chewable tablets or if
50 mm Hg above the usual level pulverized adult tablets, camouflaged with
a) BP must be taken when the child small amounts of sweet tasting substances
is at rest and in a consistent like, juice, syrup, sugar, jam, ice cream.
position - ***a small amount of expressed breast
b) Explains the procedure to the milk is allowed.
older child before it is done, that - ***if not breastfeeding, small amount of
it will not hurt him, allow him to formula in a small cup, not into the feeding
handle the equipment or pup the bottle
cuff, etc. or he may be allowed to
use it on his parents, the nurse Method of Administration of Liquid Meds
or a doll in order to overcome - calibrated cups, syringe dropper, empty
his fears and understand its use. nipple, teaspoon
- Note: Never mix meds into the feeding
bottle . It will destroy the child’s trust on
PRINCIPLES RELATED TO PEDIATRIC BLOOD
the feeding bottle which is used in taking
PRESSURE VALUES:
his milk which may still be his staple food
1. The BP varies with the age of the child and is
especially if younger than 6 months: also,
closely related with his height and weight
 and the child may not consume all the milk
so he will be underdosed.
- If big enough to participate, let him be the
one to put the meds into his mount.
To ensure acceptance of the oral meds:
- Give a flavored ice pop or small ice cubes to
suck to numb the tongue
- For toddlers and older children, give them
choice of what “chaser” they want after
taking the meds (they like to participate in
their treatment)
- Be generous in giving them praise for
participation
Technique
- Prevent aspiration (Never in supine
position with their nose occluded to force
their mouth to open)
- Put dropper at the side of the mouth
allowing swallowing in between (blow a
small puff of air on the face to elicit
swallowing reflex)
- Allow them to suck on the dropper. If
resisting, determine why and explain that it
is for their own good and not a punishment.
- Don’t pour into the mouth while crying, he
might aspirate.
- ***Use restraint properly as necessary.
- ***If all efforts fail in making the child
take the drug, refer to MD for change of
route of administration.
PARENTERAL
a) Intramuscular
o Syringe used for volume less than 1
ml. tuberculin syringe
o Needle gauge- g 23-25
o Determining the site: Non-walking
children - vastus lateralis / rectus
femoris
o Walking children (for at least 1 year)
and gluteal muscles (more
developed by then, sciatic nerve is
more protected)
Administration Technique:
- Restrain PRN
- Lying or sitting position (never standing!)
- Decrease pain perception by: distracting
conversation, giving something in which to
concentrate like squeezing hand, humming,
singing)
- Inject quickly using dartlike action.
- Cover with band aid or tape afterwards
(especially for preschoolers with strong fear
of body mutilation. They are afraid that their
body’s content will leak out of the puncture
created)
- Give praise generously afterwards.
b) Intraosseous
o It is the process of injecting directly
into the marrow of a bone to provide
a non-collapsible entry point into
the systemic venous system.
o This technique is used in emergency
situations to provide fluids and
medication when intravenous
access is not available or not
feasible.
o A comparison of intravenous (IV),
intramuscular (IM), and
intraosseous (IO) routes of
administration concluded that the
intraosseous route is superior to
intramuscular and comparable to
intravenous administration
EYE INSTILLATION
- Position in supine or sitting with head
extended.
- Child looks up.
- Hand of the nurse holding the dropper rests
on the forehead of the child for better
anchorage.
- For infants with eyes closed: Place drop on
the nasal corner where the lids meet. Let
meds pool in the area. When an infant opens
the eyes, meds will flow into the
conjunctival sac.
NASAL INSTILLATION
- Position in supine or sitting also with head
hyperextended or leaning back against the
nurses’ arms.
- Hold in that position 1-3 minutes After
instilling solution.
- For infants and young toddler, be ready with
the nasal aspirator to be used after.
EAR INSTILLATION
- Child in supine position on the unaffected
side.
- Below 3 years old: pull pinna downward and
back
 - Above 3 years old: pull pinna upwards and
back
- Massage area anterior to the ears after to
facilitate entry of the drug into the ear canal.
Protective Measures To Limit Movement
(Restraints)
- Purpose:
1. To maintain the child's safety and
protect him from injury.
2. To facilitate examination and minimize
the child's discomfort during special
tests, procedures and specimen
collections.
PRINCIPLES
1. Protective devices should be used only when
necessary and never as a substitute for careful
observation of the child.
2. The reason for using the device should be
explained to the child and the parents to
prevent misinterpretation and to ensure their
cooperation for the procedure.
3. Any protective device should be checked
frequently to make sure that it is effective. It
should be removed periodically to prevent skin
irritations or circulation impairment.
4. The device should always be applied in a
manner which maintains proper body
alignment and ensures the child’s comfort.
5. Any protective device which requires
attachment to the bed should be secured to the
bedsprings or frame, never the mattress or side
rails. This allows the side to be adjusted
without removing the restraint or injuring the
child’s extremity.
6. Any knots which are required should be tied in
a manner which permits their quick release.
This is a safety precaution.
4. Each child manifests his uniqueness at
medicine time just as he does at every other
time.
5. The child's threshold for pain and fear is
lower in illness than in normal conditions.
6. Restraints must be applied only when
necessary for his own protection.
IMPORTANCE OF MAINTAINING FLUIDS AND
ELECTROLYTES IN INFANTS AND CHILDREN
1. The daily requirement per unit of body weight
in infants, small children is greater than adults
— 75-
—young children need double this amount.
2. The ratio of skin area to cubic contents of body
is greater because the smaller he is, the greater
is the proportional quantity of water in his
body and the more rapid rate it is used.
Children have 83% water while adults, 56%.
3. Renal function is still immature. Expect at least
1-1.5 ml/kbwt/hour urine output.
4. Infections tend to be more frequent and violent
than in adults.
5. Child cannot recognize his need for water.
6. Child cannot express adequately his need for
fluids.

PRINCIPLES OF DRUG ADMINISTRATION TO

CHILDREN
1. The nurses' approach to the child determines
his capacity for cooperation—help him know
that the drug must be taken.
1. Poise, expectancy of cooperation and faith in
the child's ability to learn, supports the
strength within his personality.
2. A good relationship between the nurse and the
patient solves problems of drug
administration.
3. Force in giving medicines communicates
hostility instead of helpfulness.