HOSPITALIZED CHILD

1. INTRODUCTION

Based on the theory that hospitalization can be an unnecessary stress to

children, only those who cannot successfully be managed on an ambulatory

basis are now admitted to the hospital. This was not always true. For example

most children with head injuries automatically stayed overnight for observation.

Currently unless a child is unconscious or shows other signs of neurologic

injury he or she is sent to home to be observed by parents for signs of increased

ICP. This policy requires that time be spent in teaching parent skills such as

how to take a pulse or evaluate consciousness. Teaching them requires patience

because parents under stress can have difficulty comprehending instructions

however because psychological trauma as well as excessive health care costs

are prevented by allowing a child to return home it is important teaching.

Often illness and hospitalization are the first crises children must face.

Children during the early years are particularly vulnerable to the crises of illness

& hospitalization because stress represents a change from usual state of health

and environmental routine and children have a limited number of coping

mechanisms to resolve stressors, children’s reaction to these crises are

influenced by their developmental age, previous experience with illness,

separation or hospitalization, innate and acquired coping skills, the seriousness

of the diagnosis and the support system available.

MEANING OF ILLNESS AND HOSPITALIZATION TO CHILD

Infant

Charge in familiar routine and surroundings response with global reaction.

Separation from love object.

Toddler

Fear of separation, desertion, separation anxiety highest in this age group.

Relates illness to a concrete condition, circumstances or behavior

Preschool

Fear of bodily harm or mutilation, castration, intrusive procedures.

Separation anxiety less intense than toddlers but strong.

Causation same as toddler, often considers own role in causation ie, illness

as a punishment for wrong doing.

School Age

Fears physical nature of illness

Concern regarding separation from age mates and ability to maintain

position in peer group.

Perceives an external cause for illness, although located in body.

Adolescent

Anxious regarding loss independence. Control, identity concern about

privacy.

Perceives malfunctioning organ or process as cause of illness. Able to

explain illness.

B. PREPARING THE ILL CHILD AND FAMILY FOR

HOSPITALIZATION

Many childhood illness, such as febrile convulsions, appendicitis and asthma

attacks strike suddenly making advance preparation for hospital admission

impossible. However, when hospitalization is planned ahead of time, for

orthopedic second stage surgeries, preparation is possible. As a rule, parents

eagerly seek guidance from nurses or what and how much to tell their

children about an anticipated admission. The preparation a parent makes for

a child obviously varies according to the child’s age and individual

experience. No matter what the child’s age however, parents should be

encouraged to above all convey a positive attitude. The nurse can provide

further health teachings and clear up all misunderstandings.

1) Preparing the infant

As because the infant cannot understand explanations, preparation has to be

minimal.

Special items such as favorite toy, blanket, should be packed.

This objects provide care giver should spend a great deal of time with an

infant.

2) Preparing the toddler and pre-schooler

Three chief fears of the toddler and pre-schooler are fear of unknown, fear of

abandonment and separation and fear of mutilation.

These children need preparation clearly aimed at alleviating these fears.

Bringing a favorite toy can be a help.

Child could be encouraged to play hospital with dolls

3) Preparing school age and adolescent

Both school age and adolescents need factual explanations of what will

happen during hospitalization.

A hospital orientation program in which facts of hospitalization are

discussed

Interact the child with another child who had undergone through the same

condition.

4) Preparing the child of a different cultural background

Make the assurance that proper care will be provided to the child without

any differentiation.

5) Preparing disabled and chronically ill child

Help children to maintain a contact with their families and school friends

during a long hospitalization period, as they are staying in hospitals for long

term care through phone calls, letters & open visiting.

PREPARING FAMILY CARE GIVERS

Planning for hospitalization begins as soon as parents know that

hospitalization will be necessary.

Easing parental anxiety regarding illness and hospitalization is important

because infants and children can keenly sense a parent’s stress.

As a part of preparation parents should ask questions about the

hospitalization so that they become familiar with the situations. It will help

to reduce anxiety.

Advise parents to ask about the diagnostic procedures required length of

hospital stay, etc.

EFFECT OF HOSPITALIZATION ON CHILD

Children may react to the stress of hospitalization before admission, during

hospitalization and after discharge. A child’s conception of illness is even

more important than age and intellectual maturity in predicting level of

anxiety before hospitalization. This may or may not be affected by the

duration of condition or prior hospitalization. Therefore nurses should avoid

over estimating the illness concept of children with prior medical experience.

Individual risk factors

A number of risk factors make certain children more vulnerable than others

to the stress of hospitalization.

It has also been noted that rural children exhibit significantly greater degree

of psychological upset than urban children, because urban children are

familiar with hospitals.

Because separation is such an important issue of hospitalization for young

children nurses should be alert to children who passively accept all changes,

these, children need more support and care.

The stressors of hospitalization may cause young children to experience

short and long term negative out comes.

Adverse outcome may be related to the length & number of admissions,

multiple invasive procedures and the anxiety of the parents.

Common response includes regression, separation anxiety, apathy, fears,

sleeping disturbances, especially children younger than 7 years of age.

Supportive practices such as family centered care, and frequent family

visiting, may lessen the detrimental effect of such admissions.

A child’s pain experience indicates how the overall hospitalization is

experienced.

Increasing length of hospitalization because of complex medical and nursing

care, elusive diagnosis, and complicated psychosocial issues.

Without special attention, to meet child’s psychosocial developmental needs

in hospital environment the detrimental consequences of prolonged

hospitalization may be severe.

What the hospital means to pediatric patient depend upon their stage of

maturity and depend upon how accustomed they are to being left with

friends.

If they regard the separation as a punishment of wrongdoing, they will be

less able to cope with it than if they know the real reason for hospitalization.

Infants may be emotionally disturbed by hospitalization

Not only they are separated from parents but also they will have sensory

deprivation. If the nursing personal do not take the time to provide care.

If the child doesn’t have close physical contact with another human being

may result in emotional trauma.

Beneficial effects of hospitalization

The most obvious effect is the recovery from illness.

Hospitalization provides an opportunity for the children to master stress and

feel competent in their coping abilities.

Hospital environment can provide new socialization experience.

Child can broaden their inter personnel relationships.

Psychological status of child also maximized.

CHILDS REACTION TO HOSPITALIZATION AND PROLONGED

ILLNESS

Illness threatens both physiological and psychological development of

children.

Sickness causes pain, restraint of movement, long sleep less periods,

restrictions of feeds. Separation from parent home environment, which may

result emotional trauma.

Hospitalization and prolonged illness related growth and development and

cause adverse reaction in the child based on stage of development.

Reactions of neonates

Interrupts the early stages of development of a mother child relationship and

family integration.

Impairment of bonding and trusting relationship.

Inability of parents to love & care for the baby and inability of baby to

respond to parents and family members.

Reactions of infants

Infant’s reactions are mainly separation anxiety and disturbances in

development of basic trust.

Emotional withdrawal and depression are found in the infants of 4 to 8

months of age.

Interference of growth and delayed development is also found.

Older infants have limited tolerance due to separation anxiety which is found

as fear of strangers, excessive cry, clinging & over dependence on mother.

Reaction to toddler

Toddler reactions are found as protest, despair, denial and regression.

Toddle protest by frequent crying, shaking crib, rejecting nurses.

Attention, urgent desire to find mother, showing signs of distrust with anger

and fears.

In despair, toddler become hopeless, looks sad, cry continuously and use of

comfort measures like thumb sucking, fingering lip, and tightly clutching

toy.

In denial, the child reacts by accepting care without protest.

Toddlers react by regression in an attempt to control stress

Found to stop using newly acquired skills & may return to the behavior of an

infant during illness.

Reactions of pre-school child

Pre-school child adopts various defense mechanisms to adjust with stress.

They react by exhibiting regression, projection, displacement identification,

aggression, denial & fantasy.

They simply shows similar behavior of toddlers.

Reactions of school-aged

School aged children are concerned with fear, worry, mutilation, fantasies,

modesty & privacy.

They react with defense mechanism like regression, negativism, depression,

phobia, un-realistic fear or denial symptoms and conscious symptoms and

conscious attempts of mature behavior.

Reaction of adolescent

Adolescents are concerned with lack of privacy, separation from peers or

family & school interference with body image or independence or self

concept & sexuality.

They react with anxiety related to loss of control & insecurity in strange

environment.

They may show anger and demanding or un co-operative behavior

They may adopt mental mechanisms like intellectualization about disease,

rejection of treatment, depression, denial/withdrawal.

D. EFFECTS OF HOSPITALIZATION IN CHILDREN AND FAMILY

1) Stressor’s of hospitalization and children’s reaction

Major stressors of hospitalization includes, separation, loss of control, bodily

injury, and pain children’s reactions to these crisis are influenced by their

developmental age, their previous experience with illness, separation or

hospitalization their innate and acquired coping skills, the seriousness of the

diagnosis and the support system available.

a) Separation anxiety

The major stress from middle infancy throughout the pre-school years,

especially for children ages 16 to 30 months is separation anxiety, also called

anaclitic depression.

During the phase of protest children react aggressively to the separation from

the parent. They cry & scream for their parents and in-consolable by others.

During the phase of despair the crying stops and depression evident, less

active, un-interested in play

Third stage is detachment also called denial, the child is finally adjusted to

the loss, becomes interested with the surroundings and forms new

relationships.

This behavior is a sign of resignation and i9s not a sign of contentment

The child detaches from the parent in an effort to escape the emotional pain

of desiring the parent’s presence and copes by forming shallow relationship

with others being increasingly self centered, and attaching primary

importance to material objects.

Health team member understand the meaning of each stage of behavior and

should label as positive or negative.

Eg. The loud crying of the protest phase as a bad behavior during quite

withdrawn phase of behavior, health team member may think that child is

settling in.

Detachment behavior as a proof of adjustment & child is considered as ideal

patient.

Early childhood

Separation anxiety is the greatest stress imposed by hospitalization during

early childhood.

Children in the toddler stage demonstrate more goal oriented behaviors.

They may demonstrate displeasure on parent’s return or departure by temper

tantrums or regression to primitive levels of development.

Temper tantrums, bed wetting or other behaviors are expression of anger or

response to stress.

Pre-schoolers are more secure interpersonally than toddlers, they can tolerate

brief period of separation from their parents and are more inclined to develop

trust in other significant adults.

The stress of illness usually renders pre-schooler less able to cope with

separation.

They may show separation anxiety by refusing to eat, experiencing difficulty

in sleeping, crying quietly for their parents withdrawing from others.

They will express indirectly by breaking toys, hitting other children.

Later childhood and adolescence.

In school age child being away from family higher than any other fear

associated with hospitalization.

Hospitalization increase their need of parental security and guidance.

Middle and late school age children may react more due to separation from

usual activities and peer groups than to the absent of their parents.

Feelings of loneliness, boredom, isolation and depression are common.

School age children have irritability and aggression towards parents

withdrawal from hospital personnel, inability to relate to peers, rejection of

siblings, subsequent behavioral problems in school.

b) Loss of control

The major areas of loss of control in terms of physical restriction, altered

routine or rituals, and dependency.

Infants

In hospital setting, routines may be established to meet hospital staffs need

instead of infant needs.

Inconsistent care and deviation from infant’s routine may lead to mistrust

and decreased sense of control.

Toddlers

Toddlers are striving for autonomy, and this goal is evident in most of their

behaviors.

When their ego-centric pleasures meet with obstacles toddlers react with

negativism, especially temper tantrums.

Loss of control results from altered routines and rituals.

It can cause regression to toddlers.

Enforced dependency is a chief characteristic of toddler during sick role

most toddlers react negatively and aggressively to this.

Prolonged loss of autonomy may result in passively to this.

Prolonged loss of autonomy may result in passive withdrawal from

interpersonal relationships. And regression in all areas of development.

Preschoolers

Pre schoolers also suffer from loss of control caused by physical restriction,

altered routines, and enforced dependency.

Their specific cognitive abilities which make them feel omnipotent and all

powerful; also make them feel out of control.

This loss of control is a critical influencing factor in their perception of and

reaction to separation, pain, illness hospitalization.

School age

Because of their striving for independence and productivity school age

children are particularly vulnerable to events that may lessen their feeling of

control and power.

Altered family roles, physical disability, fears of death, abandonment, or

permanent injury, loss of peer acceptance, lack of productivity and inability

ot cope with stress according to perceived cultural expectation may result in

loss of control.

One of the most significant problems of this age is boredom.

When physical or enforced limitation curtails their usual abilities to care for

themselves, school age children generally respond with depression, hostility

and frustration.

Adolescents

Adolescents struggle for independence, self assertion, and liberation centers

on the quest for personal identity. Anything that interferes with this poses a

threat to their sense of identity and result in loss of control.

BODILY INJURY AND PAIN:

In caring for children nurses must have an appreciation of a child’s concerns

about bodily harm and reactions to pain at different developmental periods.

Infants

Infants may express pain by squirming, writhing, jerking and failing some

infants may cry loudly, where as others are easily calmed by gentle hug.

Older infants react intensely with physical resistance and un-co-

cooperativeness. They may refuse to lie still or try to escape with motor

activity they have achieved.

Toddlers

Toddlers reaction to pain are similar to those seen during infancy. They will

react with intense emotional upset and physical resistance to any actual or

perceived experience. Behaviors indicating pain include grimacing clenching

teeth or lips, opening their eyes wide, rocking, rubbing & acting

aggressively.

Young children become restless and overly active is a consequence of pain.

They usually able to localize the specific painful area.

Pre-schoolers

Reactions to pain tend to be similar to those seen in toddler hood

Physical and verbal aggressions are more specific.

Instead of showing total body resistance, preschoolers may push the

offending person away, try to secure the equipment and lock them

safely

some times they may verbally abuse the nurse

pre-schools can locate pain & can use appropriate pain scales.

School age

They will have a fear of illness itself, disability & death.

Fear of intrusive procedures in genital area.

School age children verbally communicate their pain in respect to location,

intensity and description.

By 9-10 years of age they show less fright or over resistance and aggression

are less likely at this age unless the adolescent is totally up prepared for a

procedure.

They are able to describe pain experience & can use any of the pain

assessment tools.

They may be reluctant to disclose their pain.

PLAY ACTIVITIES FOR ILL HOSPITILIZED CHILD

FUNCTIONS OF PLAY IN THE HOSPITAL

Provides diversion & bring about relaxation.

Helps the child feel more secure in strange environment

Helps to lessen the stress of separation & the feeling of home sickness.

Provides a mean for release of tension & expression of feelings.

Encourages interaction & development of positive attitude towards others.

Provides an expressive outlet for creative ideas or interests.

Provides a mean for accomplishing therapeutic goals.

Places child in active role & provides opportunity to make choices & be in

control.

Play in infancy

Pleasure by touch & manipulation.

5-6 months – infant repeat activities

9 months – repetitive games (pat-a-cake)

12 month - recognition & acknowledgement of other

Play in 2nd year

2 to 3 year – fascination with working part of toys talking on toy phone

involve parents

Third year – child taught to share

Conflict below parents & child.

Pre-school – competition, mastery of tasks

Genders roles (House, Doctor)

School – Foot ball, basket ball.

NURSING CARE OF HOSPITISED CHILD AND FAMILY

(PRINCIPLES AND PRACTICE)

PREVENTING OR MINIMIZING SEPARATION

Primary goal is to prevent separation particularly in children younger than 5

years of age.

Welcome the presence of parents at all time throughout the child’s

hospitalization.

Many hospitals developed a system of family centered care.

During the time of separation behavior, nu8rse provide support throught

physical presence

If behaviors of detachment are evident, the nurse maintains the child’s contact

with the parents by frequently talking about them, encouraging child to

remember them etc.

When helping parents with the fears of separation, nurses should suggest the

way of leaving and returning.

Parental visits should be frequent

If the parents can’t room-in they can leave a favorite article from home the

children gain comfort and re-assurance from them.

MINIMIZING LOSS OF CONTROL

Feelings of loss of control results from separation, physical restriction,

changed routine, enforced dependency and magical thinking.

Promoting freedom of movement during procedures can be completed by

placing child in parents lap.

Mechanical freedom can be provided by transporting child in wheel chairs, or

beds with mechanical freedom.

Maintaining child’s routine: One technique that can minimize the disruption

in child’s routine is time structuring.

It include scheduling the child’s day to include all those activities that are

important to the child and nurse such as treatment procedures, school work,

exercise, television etc. together nurse, parent and the child then plan a daily

schedule with times and activities written down.

Encouraging independence; promoting children’s control involves

maintaining independence and the concept of self-care can be most

beneficial. Self care refers to the practice of activities that individuals

personally initiates and perform on their own behalf individuals personally

initiates and perform on their own behalf in maintaining health and well

being. Self care activities are encouraged in hospitals other approaches

include jointly planning care, time structuring, making choices in food

selection & bedtime etc.

Promoting understanding- Anticipatory preparation and providing

information help greatly to lessen stress and prevent lack of understanding.

Informing children about their rights foster greater understanding any may

relieve the feelings of powerlessness.

PREVENTING OR MINIMIZING FEAR OF BODILY INJURY

Preparation of children for painful procedures decreases their fears.

Manipulating procedural techniques also minimizes fear

For children, who is fear of mutilation of body parts, the nurse repeatedly

stress the reason for a procedure and evaluate child’s understanding.

Employ pain reduction techniques.

STRATEGIES TO COPING & NORMAL DEVELOPMENT

During hospitalization care of the child focuses not only on meeting

physiologic needs, but also on meeting psychosocial and developmental

needs.

Several strategies may be used to help children adapt to the hospital

environment, promote effective loping & provide developmentally

appropriate activities.

These strategies include child life programs, rooming in, therapeutic play, and

therapeutic recreation.

a) Child life programs

If focus on the psychosocial need of hospitalized children.

Professional child life specialists, para professionals, & volunteers staff these

departments.

A child life specialist plan activities to provide age appropriate play time for

children either in playroom or child’s room.

Some of the activities are designed to assist children in working through

feeling about illness.

Eg: Playing with medical equipment

Child specialist & nurses formulate plan together to assist children with

particular needs.

b) Rooming-In

is the practice of having a parent stay in the child’s hospital room & care for

the hospitalized child.

Some hospitals provide cots, others have special built-in beds & in some

institutions parent stays in a separate room on the unit.

Parent who is rooming in may want to perform all of the child’s basic care or

help with some of the medical care.

Communication below nurse & parent is important so that the parent’s desire

for involvement is supported.

Therapeutic play

Play is an important part of the childhood.

The stress of illness & hospitalization increase the value of play.

Not only is normal development facilitated by play, but play sessions can

provide a means for the child to learn about health care, to express anxieties

to work through feelings & to achieve a sense of mastery over control over

frightening or little understood situations.

Play presents an opportunity to deal with the fears & concerns of health

experiences are called therapeutic play.

Through therapeutic play the nurse may assess the child’s knowledge of his

or her illness.

A common technique involves using body line drawing or stories & asking

the child to draw or talk about illness or injury means to him/her.

Child may be asked to draw a picture or make a story enabling the nurse to

assess fears & other emotions.

The good enough-draw-A-Person test help the nurse assess the congnitive

level of children below 3& 13 years of age.

The gillert index is another tool that help the nurse assess child’s knowledge

of the body.

The same techniques may be used in a slightly different way to teach the

child about surgery or plan activities that allow child to express fears & gain

mastery over the situation.

A variety of technique may be used to promote therapeutic play. Specific

techniques are chosen to reflect the child’s developmental stage.

Toddler, play is important for toddler. Through play the explore the

environment & learn to identify with significant people in their lives.

Play is also an acceptable way for toddlers to release tensions caused by

stress or aggressive impulses.

Toddlers should be approached slowly & the initial approach should be made

in their parent’s presence, if possible to decrease feelings of stranger anxiety.

Playing a variation of peek-a-boo or hide & seek using the curtain

surrounding the toddlers crib or bed help to promote realization of that

objects out of sight, such as parents, do return.

The use of transitional objects, such as a familiar blanket or stuffed animal,

can temporarily substitute for the security of parents.

The toddler who is restrained can be read familiar stories. Repetition of

stories promotes a sense of stability in the unfamiliar hospital environment.

A doll is familiar toy that can be used to recreate a stressful environment,

thereby providing an opportunity for the child to express & work through

feelings.

Other developmentally appropriate toys for toddlers include familiar objects

from home such as measuring cups or spoons, wooden puzzles, push & pull

toys.

Playing with safe hospital equipments (bandages, syringes without needles

etc) help toddlers to over come the anxiety associated with these items.

Pre-schooler

The nurse can intervene to reduce the stress produced by pre-schoolers fear

through the use of some kinds of play.

A simple body outline or doll can be used to address the child’s fantasies &

fears of bodily harm. Playing with safe hospital equipment may help pre-

schoolers to work through feelings such as aggression.

Pre schoolers like crayons & coloring books, puppets, felt & magnetic

boards, play dough, & recorded stories.

Both pre-schooler & school age children may enjoy play with a toy hospital.

School age child

Although play begins to lose its importance in the school age years, the nurse

can still use some techniques of therapeutic play to help the hospitalized

Child deal with stress.

School age children often regress developmentally during hospitalization,

demonstrating behaviors characteristics of an earlier state, such as separation

anxiety & fear of bodily injury.

Body outlines & occasionally dolls can be sued to illustrate the cause and

treatment of the child’s illness.

Terms for body parts that are suitable for older children should be used

drawings provide an out let for expression of fears & anger.

School age children enjoy collecting, organizing objects & often ask to keep

disposable equipment that has been used in their care. They may use these

items later to relive the experience with their friends.

Games, books, crafts, computers, provide an outlet for aggression & increase

self esteem in the school age child.

The type of play used should promote a sense of mastery & achievement.

THERAPEUTIC RECREATION

Many of the special play techniques used with younger children are not

suitable for adolescents.

Adolescents do need a planned re-creation program to assist them in meeting

developmental needs during hospitalization.

Peers are important and the isolation of hospitalization can be difficult.

Telephone contact with other teenagers & visits from friends should be

encouraged.

Interactions with other teenagers ate a pizza party or a video game or movie

night can help adolescents feel normal.

Physical activities that provide an outlet for stress are recommended. Even

adolescents on bed rest or in wheelchairs can play a modified form of basket

ball.

The independence of adolescence is interrupted by illness. Nurses can

provide choices for teenagers to assist them in regaining control.

Giving them options & letting them choose an evening recreational activity

can promote their feelings of independence.

Passes to leave the hospital for special activity may be possible.

The nurse in corporate play activities into the daily life of each pediatric patient

because play is a part of child’s total needs.

The nurse must consider, when planning activities for child, the age, interests

diagnosis & limitations imposed by illness.

An acutely ill child who is unable to play actively with toys may enjoy

listening to stories.

Telling a story rather than reading draws children into emotional involvement

with it.

The story teller can ask questions pass comments & can make the child a part

of it.

Other activities children can do are watching a plant grow, watching an

anthill or gold fish in a tank or watching supervised television programmes.

In the play area, children who are permitted out of bed should be free to

develop mental, motor & social skills and to express themselves. In a variety

of art media such as finger painting or molding with clay.

Domestic play re-assures them that their own homes are still there & that they

are missed.

Children usually select toys such as doctor, syringes with which they can

imitate the activities seen around.

Old cloth in such play can be used to restrain hands of a doll in case of

fractures to make bandages to promote healing.

Puppets are used to demonstrate procedures to children.

Such activities help children work out feelings about hospitalization.

Children also enjoy play telephone because they can pretend that they are

calling home.

They also can enjoy clay, paints, pounding boards on which they can express

their anger.

They enjoy tricycles, wagons, through the use of which they develop or

exercise their large muscles.

Children play areas cannot be kept clean & orderly as judged by adult

standars.

It the nurses are too concerned about the physical appearance of play area

during play time the children feel that the unit personnel do not approve o f

their play.

Children should be taught to take care of toys & a place must be provided to

store their toys.

Much can be learned from watching children play in a relaxed environment.

Their approaches to play & their relationship with peers, parents, adults

should be observed and recorded.

Also to be noted are the degree of their activities attention span, ability to

tolerate frustration, verbal abilities, concept formations.

In addition, nurse is able to note their comments about home, hospitalization,

general attitudes & behavior.

It will help the nurse to understand how well the child is coping with the

situations & crisis.

If the child handle it well, the experience may be of help in mastering

problem situations.

Nurse should have an opportunity to participate with children play activities.

Story telling-telling stories with themes.

Water play during bath.

Television-by instructing them about programs.

Needle play

Pre-post operative teaching

Art.