Hospitalization of Sick Child PDF

**UNIT VI: HOSPITALIZATION OF SICK CHILD** **INTRODUCTION:** Admission to the hospital can be a positive psychological experience for children, if prepared properly. It helps in developing confidence in dealing with stressful situation in future. Consistent support to the children and their parents...

**UNIT VI: HOSPITALIZATION OF SICK CHILD** **INTRODUCTION:** Admission to the hospital can be a positive psychological experience for children, if prepared properly. It helps in developing confidence in dealing with stressful situation in future. Consistent support to the children and their parents can only bring this positive outcome. The following concepts help to minimize the emotional trauma to the children and their parents for better adjustment during hospital stay. These are: - Family integrity and the child's relationship should be maintained. - The sick child be supported and guided to learn to handle new experiences and feelings by family participation to provide love and security - Needs of each child are different based on individual differences, family background, level of growth and development and degree of illness - The peadiatric nurse seeks to promote, maintain and restore health in both children and their parents by health counseling and teaching about the needs - Hospitalized child should be cared by professional nurses following scientific principles of disease process and nursing process with appropriate therapeutic and nursing interventions - Family participation for planning, implementation and evaluating plan of care is essential for optimal outcome by continuity of care - Within a safe environment, the sick child needs expert physical care, emotional support, expression of feelings (through play) and continuation of school education to promote continued growth - Parents should have trusting relationship with nurses and health team members and permission for expression of feelings and emotions in the hospital environment - Family members and their child must be supported emotionally - Hospitalization is the break in the unity of the family. The emotional effects should be considered and not just the physical care given to the sick child. **CHILD'S REACTION TO ILLNESS AND HOSPITALIZATION** **Effects of illness and hospitalization on children and families:** Illness threatens both the physical and psychological development of children. Sickness causes pain, restraint of movement, long sleepless periods, restriction of feeds, separation from parents and home environment which may result into emotional trauma. Hospitalization and prolonged illness can retard growth and development and cause adverse reactions in the child, based on stage of development. **NEONATES:** This interrupt in the early stages of development of a healthy mother-child relationship and family integration. Impairment of bonding and trusting relationship, inability of the parents to love and care for the baby and inability of the baby to respond to parents and family members are common reactions of the neonates. **INFANT:** by about 6 months of age, infants have developed an awareness of themselves as separate from their parents. They are able to identify primary caretakers and to feel anxious when in contact with strangers. Hospitalization can be a traumatic time for an infant, particularly if the parents are not staying with the child. They can sense the anxiety their parents are experiencing during hospitalization. Three phases of separation anxiety were first identified in young children who were separated from their parents for long periods or permanently and lacked a close relationship with one caretaker after separation. **Stages of separation anxiety in young children** **Protest:** screaming, crying, clinging to parents, withdrawal from other adults **Despair:** sadness, depression, withdrawal or compliant behaviour, crying when parents appear **Denial:** lack of protest when parents leave, appearance of being happy and content with everyone, close relationships not established, developmental delay possible. The protest phase is viewed as a healthy response to separation from loved ones and as an indication that the infant has a meaningful and close relationship. Parents should be encouraged to remain with and provide care to hospitalized infant, and to visit as often as possible if they cannot remain with the young child. **TODDLER AND PRESCHOOLER:** Toddlers and preschoolers are beginning to understand illness but not its cause. Separation from parents remains the major stressor for the child. When a parent cannot be present, reminders (objects belonging to the parent) can be left with the child. However, the nurse should encourage the parents to present as much as possible for important rituals such as toileting. **SCHOOL-AGE CHILD:** older children have a more realistic understanding of the reasons for illness and are able to comprehend explanations. They benefit from use of models and pictures to understand explanations. Teaching should be geared to the child's level of understanding. Concepts of time are well formed, and parents should be encouraged to tell the child when they will return. Stressful procedures can lead to regression or other behavioral changes. The child relies on parents and others for support and understanding during these events. **ADOLESCENTS**: after 11 years of age, adolescents become increasingly aware of the physiologic, psychologic and behavioural causes of illness and injury. Adolescents are concerned with appearance and perceive an illness or injury in terms of its effect on their body image. Privacy and modesty are their major concerns. Nurse should respect their feelings. Adolescents are in the process of becoming independent of their parents' influence, so control over aspects of their care is important. The peer group is a major influence in their lives, and having recreation facilities available are among their major recommendations. Separation from peers, home and school are cited as major stressors of hospitalization by adolescents. **Effects of hospitalization on the family of the child:** Parents whose children have been admitted to the hospital feel not only separation from their children but also they may have feeling of inadequacy as others provide care for their children. They feel anxiety, anger, fear, disappointment, self-blame and possible guilt feeling due to lack of confidence and competence for caring the child in illness and wellness. The specific causes of parental anxiety related to hospitalization of their children are the fear of the followings: - Strange environment in the hospital - Separation from the child - Unknown events and outcome - Spread of infections to other members of the family - Unbearable financial obligations incurred through the illness - Society will look upon the illness as a reflection of something wrong with the parents **Role of nurse to help cope with stress of illness and hospitalization of children** 1. Provide family centred care with different approach to specific age group. 2. In neonates: provide continual contact between baby and parents with active involvement by rooming-in and sensory-motor stimulation as appropriate. 3. In infants: encourage mother to balance her responsibilities and minimize separation with confidence and competence. Basic needs of the infant should be fulfilled promptly with attention and appropriate handling from a limited number of personnel. Mother can be allowed during procedure. Tension and loneliness can be relieved by toys. 4. In toddlers: provide rooming-in and unlimited visiting hours to express child's feeling. No punishment to the child. Home routine can be continued especially regarding sleeping, eating, bathing, etc. familiar toys and articles can reinforce the child's sense of security. Parents should provide love and understanding to help the child to restore trusting and relationship. Hostility and withdrawal of love can cause the child's loss of trust, self-esteem and independence. 5. In preschool children: minimize stress of separation by providing parental presence and participation in care. Plan to shorten the hospital stay. Help the child to accept the stressful situation by love and concern. Set limits for the child and provide opportunity to verbalize the feelings. Careful preparation for all procedures by privacy and explanation according to level of understanding. Encourage the child to participate in self-care and hygiene as appropriate. Remove fears by adequate explanation. Discourage parents from reinforcing negative feelings to the child. 6. In school children: help the parent to prepare the child for elective hospitalization. Respect the child's need for privacy and modesty during examination. Thorough nursing history should be obtained to plan the care. Help the child to identify problems and to ask the questions. Explain the procedure and its purpose with reassurance. Encourage the child in self-care, play and continue school work when the condition permits. Encourage parental participation in child care and consistent visiting pattern especially with peers and siblings. Parents may be introduced to other parents of the same unit. 7. In adolescents: help parents to prepare the adolescent for planned hospital admission. Assess the impact of illness and hospitalization and presence of misconceptions. Respect the need for privacy, recreation, personal preferences on self-care and food habit. Involve the adolescent patients in planning of care and help them to accept restrictions and health teaching. Explain all procedures and reassure to accept the plan of care and to cooperate. Provide opportunities for recreation, peer relationships, interaction with other adolescent patients to deal effectively, adolescent's response related to stress of illness and hospitalization. Nurse guide the hospitalized child in health promotion and restoration activities. **NURSING INTERVENTIONS AND ADAPTATIONS IN NURSING CARE OF SICK CHILD** The nursing interventions involve doing something for, doing something with or doing something that allows the child or family to take actions that resolves the problems or needs. These are actions taken to help the patient and /or family to move from their present state to a condition described as a projected goal or outcome. The types of intervention depend on the nursing diagnosis and projected goals. **Adaptation in nursing care of the sick child** The sources of stress during illness and admission in the hospital include the following five categories: - Psychological stress: due to separation from home, parents, other family members and friends, change in role, anxiety, fear and pain. - Physiologic stress: due to loss of sleep, diagnostic and treatment procedures, trauma, surgery, immobilization and physical restraint. - Environmental stress: due to loss of daily routine, unfamiliar noise, strange odour and stimuli and various gadgets. - Biological stress: due to pathological organisms and cross infections - Chemical stress: due to drugs, toxic substances, reactions to blood transfusions, anaesthesia, etc. Strategies for adaptation in nursing care 1. Welcome the child and parents heartily during each nursing interventions 2. Call by name and touch the child gently with love 3. Explain the interventions in simple sentence according to the level of understanding 4. Ask for cooperation and its benefit 5. Encourage to express the feelings, allow to verbalize and answer questions 6. Demonstrate the interest and empathy to the child and family members 7. Explain and reason out any unpleasant experience of the past which will reduce anxiety level and help to obtain cooperation 8. Discuss about cultural and religious belief of the family, never ignore those belief. 9. Allow parent or significant other during any treatment or nursing procedures or ask to wait nearby. 10. Maintain privacy, minimize exposure and gentle handling of the child nursing care 11. Provide physical comfort by appropriate positioning, warmth, before and during the interventions 12. Maintain eye level contact during conversation 13. Divert the child's attention by toys or telling story or simply talking with him/her. Show the articles used in procedure and allow the child to manipulate it, if possible. 14. Restraints should be used only if there is no alternative. 15. Protect the child from physical injury and infections. 16. Assure about confidentiality of the information whenever required. 17. Patience, tenderness and emotional strength are essential. 18. Never tell lie or negative statement to the child 19. Praise the child for co-operation, never threaten the child for noncooperation. 20. Establishment of rapport and friendly approach are the points to gain cooperation and trust. **ASSESSMENT OF CHILD IN HEALTH FACILITY** **Paediatric nursing history:** The purposes of health history of a child are to obtain data to help in diagnosis and treatment and to formulate individualized plan for care. It helps to establish relationship with the child and family and to assess understanding of the family members about their child's health. It helps to correct misconceptions and misinformation of the family regarding the child rearing practices based on the cultural and socioeconomic patterns. The following information to be collected and recorded include: 1. Identifying information: child's name, age, sex, address, name of informant and relation with the child, date and time of history collection. 2. Chief complaints: reasons for hospitalization or seeking medical care along with duration of complaints and any treatment taken prior to hospital visit 3. History of present illness: quality, quantity and severity of complaints, time sequence, aggravating and alleviating factors, associated symptoms. 4. Past history of illness: medical illness and surgical illness other than the present illness, accidents and injuries, operations, medications, blood transfusion, allergy and diagnostic screening procedures. 5. Birth history: details of prenatal, intranatal, perinatal, neonatal/postnatal periods. 6. History of growth and development: previous weights, height, dentition, important developmental milestones, toilet training, social behaviour, language, motor skills and sexual development. 7. Immunization history: complete or incomplete schedule, defaulter. 8. Dietary history: duration of breastfeeding, weaning, feeding problems, dietary pattern, weight gain, food preferences, allergies. 9. Personal history: hygiene, sleep, eliminations, habit, exercise and rest, play,hobbies, special talents, relationship with others(siblings and parent), expressions of emotions(temper tantrum), behavioral problems(thumb sucking, nail biting, pica) and schooling. 10. Family history of illness: any history of illness sin the family members, presence of hereditary diseases and congenital abnormalities. 11. Socioeconomic history: residence, housing, water supply, waste disposal, communication facilities, financial condition with family income, source of income, total number of family members, cultural belief regarding child care. **Technique of physical examination of children** - Vital signs: obtain T, P, R, B/P based on child's condition. - Anthropometry: record anthropometric measurements, i.e. weight, height, head and chest circumferences, skin-fold thickness etc. - General appearance: observe general appearance like- body position, pain, crying, hygiene, nutritional status, mental alertness, restlessness, presence of developmental abnormalities or any abnormal features. - Skin: examine skin for colour, pigmentation, lesions, jaundice. Scar, moisture, oedema, birthmarks, tenderness, rash, etc. - Lymph nodes: observe and palpate for enlarged lymph nodes i.e. neck, axilla, inguinal region. - Hair: observe colour and distribution of hair on the hair, back. - Head and neck: examine head for shape, and size, fontanelle, sutures, hair colour, presence of infection or lice, movement of head, head holding, webbing of the neck, enlarged thyroid or neck swelling. - Face: examine face for expression, asymmetry, paralysis, etc. - Eyes: observe eyes for infection, oedema, photophobia, distance between the eyes, distribution of eyebrows, exopthalmos, cataract, squint and vision. - Ears: examine ears for shape, size, position, deformities, discharge, tenderness and hearing abilities. - Nose: examine nose for patency, discharge, bleeding, deviated septum, depressed nasal bridge, nasal polyp, foreign body, flaring nostrils, etc. - Mouth and throat: examine the color of lips, lesions at the corner of the mouth, cleft lip or palate, number of teeth, dental caries, staining on the teeth, extra or missing teeth, gum bleeding, swelling of the tongue and pharynx, tonsillitis, tongue tie, etc. - Chest: observe the size, shape and symmetry, retractions, funnel chest, condition of breast and nipples, breath sounds, heart sounds, etc. - Abdomen: examine abdomen for size and shape, distension, infection or scar, cleanliness, condition of umbilical cord in neonate, congenital abnormalities or hernias. - Limbs: limbs to be examined for any deformity, asymmetry, bow legs, knock-knees, oedema, any swelling or limitation of movements of the joints, paralysis, clubbing of fingers, number of fingers and toes, creases on the palms and soles, deformity of the feet (talipes, flat feet) ,any infections, general cleanliness, etc. - Spine and back: note the signs of abnormal spinal curvature (kyphosis, lordosis, scoliosis), dimples, tufts of hair, spina bifida, meningocele or meningomyelocele, dislocation of hip, neck stiffness. - Genitalia: male genitalia to be examined for urethral opening and its abnormalities, hypospadias, epispadias, phimosis, hydorcele, hernia, undescended testes, size of penis and ambiguous genitalia. Female genitalia to be observed for hypertrophy of clitoris, labia majora and minora, vaginal and urethral openings, any vaginal discharge, cleanliness, infections, swell of Bartholin's glands in adolescents. - Anus and rectum: observe for patency of anus, presence of fistula, rectal prolapsed, perinatal erythema, etc. - Neurological examination: note characteristics of cry, posture of head, neck and extremities, neurological reflexes, motor co-ordination, muscle tone, sense of touch or pain, etc. - Behavioural pattern: note the behaviour of the child (irritable, depressed, nervous, apathetic, excited, aggressive and disobedient), ability to respond, attitude towards health team members, habit disorders, emotional problems and mental status. - Abnormal signs and symptoms: examine for presence of cough and cold, bleeding from any site, vomitus, loose motion, lack of hygiene, convulsions, oliguria, full bladder, anemia, oedema, wound, ulcer, etc. **Preparing of child for diagnostic tests** For the psychological preparation of parents and children the following guidelines can assist the nurse: \- emphasis on positive outcome of the procedure, its importance and purposes \- timing of the preparation sould be settled Verbal preparation to be done with the use of specific words to explain the procedure. Explaantion should be given according to the level of maturity and understanding and past experience with medical care and discomfort. Anxiety -producing information should be given at the end of the preparation. \- use of visual aids is important to make the verbal explanation more concrete. \- role playing of the procedure to be done in which the child will take an active the part. \- evaluation of the preparation can be done through the verbal expalnations of parents and children or the use of teaching aids. The knowlwdge of parents and child concerning the procedure to be evaluated. The process may stimulate further questions that the nurse can then answer. The physical preparation of the child vary from one procedure to others. The major aspects are positioning, privacy, asepsis, restraint, should be done accordingly. **Basic care of children undergoing surgery** **Preoperative nursing management of children:** these include psychological preparation, physical preparation, protective measures and preoperative teaching. Details nursing history and physical asssessment are done as for other peadiatric admissions to the hospital. Necessary laboratory and radiological investigations should be performed as required. **Psychological preparation:** during preoperative period the nurse should develop trusting relationship with the child and parents. Parents must be present during stressful experience of the child. The nurse should assess the level of understanding and anxiety of the child and parents and their coping abilities. The following nursing interventions help to promote co-operationand reduce fear, anxiety and negative emotional reactions of the child and parents. These include: 1. Discuss about the type of surgery 2. Explain about the preoperative medication which can cause discomfort 3. Discuss about anaesthesia and operating room set up 4. Explain about the limitation of diet, nothing per mouth at least 4 to 6 hours prior surgery 5. Demonstrate the equipment to be used postoperatively, such as, oxygen mask, IV fluid set, urinary catheter etc. 6. Describe the postoperative discomfort and pain which may be rekieved by medications 7. Explain about rrecovery room care and set up 8. Demonstrate the procedures to prevent postoperative complications such as deep breathing and coughing exercise 9. Do not remove favourite toys or other objects to prevent loss of security 10. Assure the child that the parent will be nearby and waiting for him or her. **Physical preparation** 1. Monitor temperature, pulse, respiration, blood pressure, body weight, skin rash or any other abnormalities. Record the findings and report to the appropriate authority. 2. Give nothing by mouth for the period prescribed prior to surgery, take the child away from the area where other children are taking food. 3. Maintain good hydration 4. Make certain that all other precribed preoperative procedures have been completed 5. Check for any loose teeth 6. Ask the child to empty the bladder to prevent bladder distension or incontinence 7. Administer prescribed preoperative medications 8. Transfer the child to the operating theatre(OT) and handover to the OT nurse. **Protective measures** 1. Obtain an informed written consent for anaesthesia and surgical intervention as a legal protection 2. Check tha all laboratoryreports, X-ray and any other tests are included in the case note 3. Record completeinformation regarding premedication, preoperative procedures, child's emotional and physical state 4. Make sure that the identification band for the child is attached securely 5. Allow one familiar person to stay with the child to provide a sense of security and emotional preotection. **Postoperative nursing management of children** **Immediate postoperative care** 1. Receive the child with details information about the operation performed 2. Check vital signs 3. Maintain patent airway by placing the child on side or abdoment to allow secretions to drain and to prevent tongue from obstructing pharynx 4. Suction any secretions present 5. Restrain the child to prevent dislodging of IV channel and dressing 6. Monitor vital signs, bleeding, vomiting, dehydration, signs of shock, level of consciousness, restlessness, skin colour, cyanosis and other complications 7. Administer prescribed medications and record 8. Monitor IV infusion flow rate as directed 9. Give the child nothing per mouth till complete awake from anaesthesia and begin feeding with sips of water when directed 10. Maintain intake and output chart accurately 11. Explain to the parent about the treatment plan 12. Maintain warmth and cleanliness. **Care after recovery from anaesthesia** 1. Continue to make frequent observations in regard to vital signs, behaviour, hydration, urination, dressing, bowel sound, crying, pain etc. 2. Change the position frequently to minimize discomfort and complications 3. Administer prescribed medications and record effects 4. Continue I.V. infusion, NG aspiration and other drainage as required 5. Provide diet as prrescribed 6. Maintain adequate restperiods and sleep 7. Prevent infections by aseptic measures 8. Provide good general hygiene with emphasis on mouth care, skin care, care of bladder and bowel 9. Provide emotional support, reassurance, recreation and diversion 10. Plan for removal of stitches if required 11. Teach the parents regarding continuation of care at home.