Hockenberry: Wong’s Essentials of Pediatric Nursing, 11th

Edition

Chapter 19: Family-Centered Care of the Child During Illness and

Hospitalization

Key Point Summaries

• • Children are particularly vulnerable to the stressors of illness and

hospitalization. Stress represents a change from the usual state of health
and routine, and children possess limited coping mechanisms for dealing
with this stress.
• • The major stress from middle infancy throughout the preschool years,
especially for children ages 6 to 30 months, is separation anxiety. The
three phases of separation anxiety are protest, despair, and detachment
(also called denial).
• • One of the factors influencing the amount of stress imposed by
hospitalization is the amount of control that persons perceive themselves
as having. Feelings of loss of control are caused by unfamiliar
environmental stimuli, physical restriction, altered routine, and
dependency.
• • Because of their separation from significant people in their lives,
children who are hospitalized may lack the opportunity to form new
attachments in the strange environment of the hospital and exhibit
negative behaviors after discharge. Common responses include
regression, separation anxiety, apathy, fears, and sleeping disturbances,
especially for children younger than 7 years old.
• • Nursing care of the child in the hospital is aimed at preventing or
minimizing separation, decreasing loss of control, minimizing fear of
bodily injury, using play or expressive activities to lessen stress, and
maximizing the potential benefits of hospitalization.
• • Children and families require individualized care to minimize the
potential negative effects of hospitalization. The nurse can maximize
potential benefits of hospitalization by fostering parent-child relations,
providing educational opportunities, promoting self-mastery, and
encouraging socialization.
• • Family reactions to hospitalization are influenced by many things,
including the seriousness of the illness, experience with illness or
hospitalization, experience with diagnostic or therapeutic procedures,
available support systems, personal ego strengths, coping abilities,
presence of additional stressors, cultural and religious beliefs, and family
communication patterns.
• • Hospitalization can have deleterious effects on siblings. Factors that
contribute to these negative effects can include fear of contracting illness,
their younger age, a close relationship with the ill sibling, substitute child
 care, minimal explanation of the illness, and perceived changes in
parenting.
• • Nursing care of the family involves listening to parents’ verbal and
nonverbal messages; providing clergy support; accepting cultural,
socioeconomic, and ethnic values; giving information to families and
siblings; and preparing for discharge and home care.
• • A primary nursing goal is to prevent separation, particularly in
children younger than 5 years of age. Changes in hospitals’ policies over
recent years reflect a changed attitude toward parents. Many hospitals
have developed a system of family-centered care. They no longer
consider parents “visitors” and welcome their presence at all times
throughout the child’s hospitalization.
• • Parents may display different needs regarding involvement in their
child’s care. Not all parents feel comfortable assuming responsibility, and
they may be under such great emotional stress that they need a
temporary reprieve from caregiving activities. Others may feel insecure in
participating in specialized care. On the other hand, some parents may
wish to control their child’s care and to be involved in every way possible.
Individual assessment of each parent’s preferred involvement is
necessary to prevent the effects of separation while supporting parents’
needs.
• • The dependent role of being hospitalized imposes feelings of loss on
older children. Principal interventions should focus on respect for
individuality and the opportunity for decision making. Although these
sound simple, their efficacy depends on nurses who are flexible and
tolerant. It is also important to empower the patient and not be
threatened by a sense of lessened control.
• • A primary goal of nursing care for the child who is hospitalized is to
minimize threats to the child’s development. Many strategies (e.g.,
minimizing separation) have been discussed and may be all that the
short-term patient requires. However, children who experience prolonged
or repeated hospitalization are at greater risk for developmental delay or
regression. The nurse who provides opportunities for the child to
participate in developmentally appropriate activities further normalizes
the child’s environment and helps reduce interference with the child’s
ongoing development.
• • Play is one of the most important aspects of a child’s life and one of
the most effective tools for managing stress. Play and other expressive
activities provide some of the best opportunities for encouraging
emotional expression, including the safe release of anger and hostility.
Nondirective play that allows children freedom for expression can be
tremendously therapeutic.
• • Although hospitalization generally represents a stressful time for
children and families, it also represents an opportunity for facilitating
positive change within the child and among family members. For some
families, the stress of a child’s illness, hospitalization, or both can lead to
 strengthening of family coping behaviors and the emergence of new
coping strategies.
• • Although preparation for hospitalization is a common practice, no
universal standard or program is advocated in both general and children’s
hospitals. Some hospital admission programs focus on group preparation
before actual admission, whereas others prepare each child either before
or on the day of admission. The preparation process may include tours,
puppet shows, or therapeutic play with toy or real medical equipment.
• • Admission to an outpatient setting, emergency department, isolation
room, or intensive care unit requires additional intervention strategies to
meet the child’s and family’s needs.
• • One of the most traumatic hospital experiences for the child and
parents is an emergency admission. A sudden illness or injury leaves little
time for preparation and explanation. Sometimes the emergency
admission is compounded by admission to an intensive care unit (ICU) or
the need for immediate surgery.
• • Admission to an ICU can be traumatic for both the child and parents.
The nature and severity of the illness, the circumstances surrounding the
admission, and the highly technologic, unfamiliar environment are major
factors, especially for parents. Parents experience significantly more
stress when the admission is unexpected rather than expected.
• • Most hospitalizations necessitate some type of discharge planning.
Often this involves education of the family for continued care and follow-
up in the home. Depending on the diagnosis, this may be relatively simple
or complex.