Stressors of Hospitalization: Protest Stages

Stressors of Hospitalization

• Separation anxiety is a key stressor
• Protest phase involves crying, screaming, and clinging to parents
• Despair phase includes the cessation of crying and evidence of depression via withdrawal and regression
• Detachment (denial) phase shows resignation without contentment and may affect parental attachment
• Separation from family, loss of control, bodily injury, and pain are major stressors
• Developmental age influences a child's reaction
• Previous experiences with illness, separation, or hospitalization impact the child
• Coping skills determine reactions
• Diagnosis seriousness also changes the response
• Available support impacts reaction
• Ages 6-30 months commonly experience major stress

Stages of Protest

• Children show outward unhappiness when seeing parents during the protest stage
• Symptoms during later infancy: cries, screams, searches for parents, clings to parents, avoids/rejects strangers, verbally attacks strangers, and physical attempts to keep parents present
• Behaviors during protest last from hours to days
• Crying may persist continuously until exhaustion due to protesting

Despair Stage

• Children may reject their parents
• Inactivity occurs, and the child withdraws
• Depression, sadness, and loss of interest happen
• The child is uncommunicative and regresses to earlier behaviors
• The despair lasts for variable lengths of time
• The child's physical condition may worsen if they refuse to eat, drink or move

Detachment Stage

• Children respond no differently to their parents than anyone else
• Shows increased interest in surroundings
• Interacts with familiar caregivers or strangers
• Forms superficial connections
• Appears happy
• Detachment usually is seen after prolonged separation from parents, it is rare in hospitalized children
• Behaviors signify superficial loss adjustment

Loss of Control in Infants

• Infants need trust, consistent caregivers, and daily routines

Loss of Control in Toddlers

• Toddlers require autonomy plus daily routines and rituals
• Loss of control contributes to regression, negativity, and temper tantrums

Loss of Control in Preschoolers

• Preschoolers show egocentric and magical thinking
• Illness/hospitalization may be viewed as punishment
• Display preoperational thought

Loss of Control in School-Age Children

• School-age children strive for independence and productivity
• School-age children fear death, abandonment, and permanent injury
• School-age children experience boredom

Loss of Control in Adolescents

• Adolescents need independence, liberation and struggle for it
• They experience separation from the peer group
• Adolescents may respond with anger and frustration
• Adolescents need information about their condition

Effects of Hospitalization on the Child

• Effects may be evident before admission, during, or after
• A child's concept of illness is more important than intellectual maturity, when predicting anxiety

Risk Factors for Increased Vulnerability

• "Difficult" temperament
• Lack of fit between a child and a parent
• Age, especially 6 months to 5 years of age
• Male gender
• Below-average intelligence
• Multiple and continuing stressors, such as frequent hospitalizations

Beneficial Effects of Hospitalization

• Recovery from illness happens
• Increased coping skills
• Mastering stress and understanding capability to cope
• New socialization experiences

Parental Responses to Stressors

• Parents can feel disbelief, anger, and guilt
• Illness with a sudden onset amplifies negative emotions
• Fear and anxiety are typical
• Child's pain and illness severity related to parental distress
• Frustration occurs
• Need for information worsens the parental situation
• Depression ensues
• Other adverse reactions include loneliness, fear, worry, anger, resentment, jealousy + guilt

Altered Family Roles

• Anger and jealousy can exist between siblings
• An ill child is obligated to play their role
• Parents maintain overprotective and indulgent attention

Preventing or Minimizing Separation

• Is a primary nursing goal
• Important for children under 5 years of age
• Family-centered care: Parents are not "visitors" and familiar items from home are included

Minimizing Loss of Control

• Promote freedom of movement
• Maintain children's routines
• Encourage independence
• Promote understanding

Normalizing the Hospital Environment

• Maintain child's routine, if possible
• Time structuring
• Age-appropriate self-care promoted
• Schoolwork continues
• Friends and visitors

Fears of Bodily Injury and Pain

• Common childhood fears
• Fears may persist into adulthood resulting in the avoidance of needed care

Play Opportunities

• Play helps distance themselves from illness
• Play creates a sense of control
• Play may not always look enthusiastic
• Includes diversional activities
• Includes toys, expressive activities, and creative expression

Nursing Care of the Family

• Includes family assessment
• Discharge assessment and planning
• Encouraging parent participation in planning and care
• Information
• Preparing for discharge and home care

Skin Infections

• Can be bacterial, viral, or fungal
• Examples of bacterial infections include: Methicillin-resistant Staphylococcus aureus (MRSA), impetigo contagiosa, pyoderma, and cellulitis
• Nursing management involves preventing spread, complications, and reoccurrence

Viral Infections Characteristics and Management

• Characterized by a characteristic rash
• Examples include: verruca (warts), herpes simplex I and II, varicella-zoster, + molluscum contagiosum
• Nursing management is based on the cause and is mostly comfort-driven

Fungal Infections

• Fungal infections are caused by dermatophytes
• Examples are tinea capitis, tinea corporis, tinea pedis, and candidiasis (oral, diaper, vaginal)
• Nursing management: prevent spread, provide medication education plus using 2% ketoconazole and 1% selenium shampoos, and Griseofulvin

Contact Dermatitis

• Contact dermatitis is an inflammatory reaction of the skin due to chemical, natural, or synthetic substances causing hypersensitivity or irritation
• Poison Ivy, Oak & Sumac: Localized streaked or spotty oozing and painful impetiginous lesions heal spontaneously, itching lasts 10-14 days, flush area immediately, remove clothing, prevent scratching, and treat symptoms

Skin Disorders: Bites and Stings

• Spiders (Brown Recluse and Black Widow)
• Scorpion
• Bee and Wasp sting
• Dog/Cat/Human bites
• Spider/scorpion bites: Cool compress + medical attention
• Bee and Wasp Sting: Remove stinger + anaphylaxis protocol
• Dog/Cat/Human bites: Cleanse area, antibiotics + prevention

Scabies

• Scabies are caused by scabies mites
• Female mites deposit eggs and feces into the epidermis
• Inflammation occurs 30-60 days later
• Focus nursing on prevention of spread and medication education, use Permethrin 5%

Pediculosis Capitis (Head Lice)

• Very common, especially in school-age children
• Scalp itching is the most common symptom
• Females lay eggs (nits) at the base of the hair shaft which hatch in 7-10 days
• Focus nursing management on surveillance, education, prevention, and recurrence

Diaper Dermatitis

• Common in infants
• Caused by prolonged and repetitive contact with an irritant
• Usually, occurs on surface or in folds
• Detergents/chemicals in disposable wipes can cause dermatitis
• Diaper rash appearing to have small circular satellite pustules is Candida albicans

Diaper Dermatitis Treatment

• Treatment requires changing diapers as soon as they are wet or soiled
• Diapers should be changed often and the perineal area should be allowed to air dry
• Use superabsorbent disposable paper diapers

Atopic Dermatitis (Eczema)

• Chronic relapsing inflammatory skin disorder
• Results in itching and lesions
• Clinical manifestation is age-based
• 2-6 months of age for infants, which often resolves at 3 years
• Childhood occurs at 2-3 years
• Preadolescent and adolescent: 12 years and on

Diagnostic Evaluation of Dermatitis

• Requires a history and exam findings

Therapeutic Management of Dermatitis

• Hydrate the skin with treatment
• Relieve pruritus
• Reduce flare-ups or inflammation
• Prevent and control secondary infection

Nursing Care Management for Dermatitis

• Nursing care requires hygiene, symptom relief, prevention of itching, and family support

Seborrheic Dermatitis

• Is a chronic, recurrent, inflammatory reaction of skin
• Manifestations include scalp (cradle cap), eyelids (blepharitis), external ear canal (otitis externa), nasolabial folds, and inguinal region

Nursing Care Management for Seborrheic Dermatitis

• Nursing care requires hygiene and supportive treatment

Burns

• Heat-related scalds, flames, and contact
• Cold-related
• Chemical-related
• Electrical-related
• Radiation-related

Burn Complications:

• Inhalation injuries
• Shock
• Wound sepsis

Minor Burn Treatment

• Stop burn process
• Remove clothing
• Apply cool water
• Cleanse skin and protect w/clean dressing

Major Burn Treatment:

• Stop the burn process by removing clothing and covering the burn with a clean cloth
• Ensure to keep the victim warm
• ABC's