Variations and the Hospitalized Child

Question 1

one of the things we need to pay attention to the most is the stress that this has on the child this is one of the most important aspects of pediatric nursing is how we can relieve some of that stress so in order to release the stress we have to figure out what is causing some of the stress
Loss of control= no sense of control
Increases perception of threat
Impacts coping skills
Overwhelming stimuli
Separation
children are very intuitive they can very easily read the room so when you’re having conversation with the parents that child is probably listening and even if they can’t understand or can’t hear what you say they can read that room so that’s another thing if you can have a parent step outside of the room for a quick second if it’s something you don’t want the children hearing from you

Answer 1

Stressors

Question 2

the child feels that they have no control over their environment and we can kind of break this down into each kind of subgroup think about the toddler the toddler doesn’t want to be restrained they want to be able to run around and explore everything but if we’re in the hospital they are confined to a room and they don’t have that freedom that they want to the school age child they want to be making friends they want to be playing sports doing activities and they want to be in school learning

Answer 2

Loss of control= no sense of control

Question 3

when the first things you do when you go to the hospital is you get an IV that hurts hey so there is this threat that is always there we also have the impact of coping skills kids use physical activity to help cope that’s how they bring down a lot of that anxiety But again in the hospital setting we’re taking that away from them they’re also overly stressed and this is making them blind to some of their actions kids are going to act out in the hospital this is normal you cannot expect a toddler to not have a tantrum within the hospital we have to be able to predict some of these we have to be able to work with the parents the more we understand the kids normal routine

Answer 3

Increases perception of threat

Question 4

Lights, noise, smell
No sense of personal space
there’s no sense of personal space so if we have a child that’s going to be in the hospital for a long amount of time if we can make that room more like home or bring something from home that make it feel a little more homey

Answer 4

Overwhelming stimuli

Question 5

fear of not having that parent with you while you’re sick I always think about that you know preteen the things they’re cool and they want to be on their own and they don’t want to be around their parent 24/7 well this changes when a preteen is sick
We know all of the ages before this they want their parents there
do still want their parents with them so we do try and encourage that
can we call you can we FaceTime you what kinds of things can we do to help maintain that balance and that relationship and that’s a big thing esp younger age

Answer 5

Separation

Question 6

being separated from one’s parents can be the most stressful aspect of any hospitalization
some of the reactions that give kids have when they are separated
we have three different phases here and they do typically go in order the first one is very common and it’s something we expect this is the protest phase
Protest phase
Despair phase
Detachment phase

Answer 6

Separation anxiety

Question 7

Common; want see
Crying and screaming, clinging to parent
this typically begins around 4 to 8 months and they do eventually grow out of it however I will say for the hospitalized child they go through this protest phase for a lot longer it goes throughout that childhood and even some preschoolers are going to protest when a parent has to leave so when I say protest this means that they this is typical
this is a good sign and this means that that child has a good attachment to the parent

Answer 7

Protest phase

Question 8

Get parent back
not super common this is not something that every child goes through typically we just have that protest phase
is for kiddos that have been separated from their parents for a lot longer the length of that is different in any child for a long time they can start kind of slipping into this despair face
I think this is very similar to the depression the kids aren’t really wanting to be involved in activities they’re not very hungry they’re kind of turning away they’re not being very talkative to the nurses as a nurse if we see this happening we need to call our parents and have them come back
Happens with long periods of separation
Cessation of crying; evidence of depression

Answer 8

Despair phase

Question 9

Social work involved; see why parent no able come visit child
The last phase that we can go through is this Detachment phase and this is even more rare than the despair phase but it can happen if that parent is not reunited during that despair phase if we go into this Detachment phase then they are detaching from the parent or the primary caregiver the staff
the child starts attaching to us and they view us as the parent so if we go to lunch or we leave at the end of our shift they start to protest when we leave that’s an inappropriate relationship
we need to get those parents back here if that’s something that’s not happening which in a case like this typically there are some social issues going on then
important that they have that consistent person there
Denial; resignation but not contentment
Possible serious effects on attachment to parent after separation

Answer 9

Detachment phase

Question 10

“Difficult” temperament
Age
Gender
Below-average intelligence
Multiple and continuing stresses (e.g., frequent hospitalizations)

Answer 10

Risk factors that increase vulnerability to stressors

Question 11

That increase vulnerability to stressors in the Pediatric population first if a child has a difficult temperament they’re going to have increased stress in the hospital and what this means is that the child gets thrown off very easily

Answer 11

“Difficult” temperament

Question 12

So kids that are between around 6 months it’s when we start to get that separation anxiety to about 5 years they struggle the most within the hospital; esp toddlers

Answer 12

Age

Question 13

the male gender does struggle more than the female gender

Answer 13

Gender

Question 14

if a child is hospitalized over and over again those hospitalizations become more stressful oh they’ve done this before they know what’s coming
If there’s something going on at home so if there’s a marriage difficulties If the parents are separated or divorced that causes more stress for the kids as well

Answer 14

Multiple and continuing stresses (e.g., frequent hospitalizations)

Question 15

When you have a pediatric patient you have to remember that you’re not just caring for that patient you are caring for that family it is a unit and parents have big emotions as we expect and we need to know as nurses what are some of these reactions they are going to have and how we can help them how we can help those parents
Parental reactions

Answer 15

Stressors and reaction of the fam of the child who is hospitalized

Question 16

Overall sense of helplessness
Questioning the skills of staff
Accepting the reality of hospitalization
Dealing with fear
Coping with uncertainty
Seeking reassurance
To this and learn what their preferences are it’s very important that we are using that multiplicationary team get that therapist involved Child Life specialist the chaplain if that’s an if that’s something that the family would benefit from

Answer 16

Parental reactions

Question 17

they question the skills of the staff
explain what you’re doing and why the more you explain the rationale to parents the less they question you and the quicker they go they turn to trust you

Answer 17

Questioning the skills of staff

Question 18

eventually some of them start to accept the reality that hospitalization

Answer 18

Accepting the reality of hospitalization

Question 19

that’s also going to have to do with you know how sick that child is parents may also seek reassurance during this time they’re definitely things that impact parents reactions more or less there’s certain events that will change How Deeply a parent reacts you
the things that kind of impact these reactions depend on the seriousness of the disease previous experience with this parent has had a lot of trauma

Answer 19

Coping with uncertainty

Question 20

our main goal is to prevent traumatic care
Preparation for hospitalization
Nursing interventions

Answer 20

Nurse’s role

Question 21

help that child prep for the hospitalization we’re going to help them through the admission we’re going to prevent any separation is possible we are going to encourage that moment nowadays
Preparing child for admission
Preventing or minimizing separation
Preventing or minimizing parental absence
Minimizing loss of control

Answer 21

Preparation for hospitalization

Question 22

promote them allow them to maintain that routine especially with our toddlers
we also want to provide opportunities for play and expressive activities distracting younger kiddos playing with them that therapeutic play remember it’s the job of the child to play so the more we can encourage that even throughout the hospitalization the better their stay will be
Promoting freedom of movement
Maintaining child’s routine
Encouraging independence and industry

Answer 22

Minimizing loss of control

Question 23

Providing developmentally appropriate activities
Providing opportunities for play and expressive activities
Diversional activities
Toys
Expressive activities
Creative expression
Dramatic play

Answer 23

Nursing interventions

Question 24

Child life specialists are pediatric health care professionals who work with children and families in hospitals and other settings to help them cope with the challenges of hospitalization, illness, and disability.
On staff at children’s hospitals
Important member of the interdisciplinary team
Services provided:

Answer 24

Child life specialists

Question 25

Therapeutic play
Specialist that role goes beyond just taking care of the patient and extends to the family in the siblings the main goal of having a child life specialist is to help provide a traumatic care for our children
Activities to support normal G&D
Sibling support
Advocacy
Grief/bereavement support
Tours and information programs
Outpatient consultations

Answer 25

Services provided: - Child life specialists

Question 26

when we are giving a very potent drug or an adult drug to a child and we need a very specific amount of the drug base for example chemotherapy
figure out how much of the drug we need to give
Weight:50 in
Height: 80lbs
BSA?

Answer 26

Body surface area (BSA) calculation

Question 27

So unfortunately in Pediatrics we do have to restrain our kids a lot and this just has to do is because they don’t cooperate think
try and think of alternative methods - can we have the parents participate
Typically I will say this can kind of change depending on the hospital and the state you’re in but typically they are reordered every hour if we have an order for restraint is reordered every hour and we have to assess the child every 15 minutes
Alternative methods: Consider first
Use least restrictive
Orders
Physical vs. Chemical restraints
Reordered every hour and child must be assessed every 15 minutes

Answer 27

Restraining methods

Question 28

Diversional activities
Parental participation
Therapeutic holding

Answer 28

Alternative methods: Consider first

Question 29

As we discuss legal and ethical aspects related to the Pediatric population there’s a lot of gray areas this is definitely one of those areas where it’s not black and white I’m going to give you several outlines kind of what we expect but I’m going to say there’s always a caveat I’m going to kind of stick with the basics of Missouri in Kansas
But again it depends on every state so let’s start with
Informed consent
Emancipation
Ethical committees

Answer 29

Legal and ethical aspects

Question 30

informed consent this isn’t something the nurse gets this is something that Doctor gets this is then providing the risk the benefits of the alternatives to the procedure and then we get the signature of the patient the difference
That is under 18 then the parents are the one that give the consent for the treatment again that’s the only change there’s if they’re under 18 the parents signs it gives the consent unless they’re what we called emancipated

Answer 30

Informed consent

Question 31

When we say emancipated this means that the child that is under 18 is separated from the parents and they have the right to make their own decisions typically you have to be at least 16 to be considered emancipated and there’s a couple ways you can do this first of all if you are in the military you’re considered emancipated if you have graduated high school and Most states at least you’re considered a emancipated military so let’s say you’re 17 and you want emancipation and your parents say that’s fine then they give up those parental rights that’s another way the other way is if you’re 17 and your parents say no we’re not giving the rights then you can go to court the court will provide you what’s called a guardian of item and that’s a third party someone is not involved in the situation and they will work with you talk with you and make sure that you are competent make sure that you are competent to make those decisions typically again this has to you have to be at least 16 to be considered for this so now
And talk about Reproductive Rights mental health rights drug substance abuse and addiction so as I said if you are under 18 your parents are the ones that consent for you unless it falls under one of these three categories
Reproductive rights
Mental health
Drug/substance abuse/addiction

Answer 31

Emancipation

Question 32

let’s say a 16 year old The Reproductive Rights so let’s say a 16-year-old becomes pregnant okay let’s say she wants the baby the parents don’t or it’s the opposite or way around the parents do and the child doesn’t that becomes that child that is pregnant Choice even though she is under 18 she is the right to choose what happens with that child same with birth control a 16 year old can ask for birth control and be can be prescribed birth control while still under control of her parents so she’s not emancipated she can make that decision and the provider can write her that prescription without getting in trouble

Answer 32

Reproductive rights

Question 33

That they need something like an antidepressant or they need inpatient therapy they can go above their parents and they can get this again without being legally emancipated

Answer 33

Mental health

Question 34

with drug and substance abuse we can seek treatments without the approval of our parents

Answer 34

Drug/substance abuse/addiction

Question 35

And any hospital that cares for minors actually all hospitals they have ethical committees but definitely even More so within the hospital setting because this comes up even more it is often that children will make or want different decisions than their parents especially with kids that have chronic illnesses they may choose things that their parents may want another one I often talk about is transfusions there are certain religions however the ethical committees go above the parents when it comes to that and they make the final decision so if it is going to cause life or death in a child whether or not they get a blood transfusion and their parents are saying no majority of times the hospital those ethical committees will go above the parents and they will still give the transfusion like I said a lot of these things also very from state to state if you are going to be working with the Pediatric population aware of rules in state

Answer 35

Ethical committees

Question 36

decrease anxiety, promote cooperation, support coping skills, help facilitate mastery (esp younger kids) in potentially stressful event

Answer 36

Properly prepare:

Question 37

should not be done in patient’s room; room should be safe space for them; allow them have safe space in hospital room

Answer 37

Doing procedures -

Question 38

Parental involvement
Development of sense of trust - Erikson; learning trust environment; want them always involved because trust parents - learn trust caregiver if parents comfy and trust us
Eyes/Mouth
Stranger Anxiety around 6 months
What would be the most effective way to communicate and assess this child?
Medication Administration:
Safety concerns within the hospital setting?
Preparation for procedures?

Answer 38

The infant

Question 39

Let’s go ahead and discuss the infant so when we are preparing an infant for a procedure or we are preparing them to be assessed we want the parent or the legal guardian as involved as possible this means if you are doing an assessment let the parent hold the child if it’s appropriate

Answer 39

Parental involvement - The infant

Question 40

Sneak down real quick that eyes and mouth were that Piaget sensory motor phase they put everything in their mouth so if they can put a nipple in their mouth or they can put a pacifier in their mouth that’s going to help them soothe additionally when it comes to our eyes and mouth they’re going to put everything in their mouth has something we have to be aware when they are in the hospital - not leaving things around

Answer 40

Eyes/Mouth - The infant

Question 41

Starts around 4 months
Pay attention to when assessing
May be more leery of us; parents involved very helpful
Protest
Despair
Detachment
Imp for long term hospitalizations when are separated

Answer 41

3 stages of separation anxiety? - The infant

Question 42

Keeping parents involved; younger they involved; older to year and toddler - harder becomes fight us and not want listen to us; aware where parents are in situations; address slowly and move towards them slowly; eye contact; games with them help warm up

Answer 42

What would be the most effective way to communicate and assess this child? - The infant

Question 43

Topical - try to limit in first 6 months because skin so thin that absorb things and not always predictable; do use sometimes; aware of how quickly absorbs and how sensitive skin is
IM - good; better than IV; smaller muscles; given in leg (vastus lateralis); <0.5 mL; antibiotic and greater volume divide into 2 separate shots and given into both legs
IV - do if needed; veins can be harder to get into and blow easier; older child, going to try to pull it out; not ideal because will try to pull it out
Oral - first choice always; another hard one because may not want to take it; not mix into bunch of food: not take entire amount food - not know how much taken
Rectal - try to avoid it in first month - same with temps; worry about rupturing; not as often; good if sore throat in first month or not want anything PO

Answer 43

Medication Administration: - The infant

Question 44

Leave small things in bed - put things in mouth; throwing all away
Pull on cords - wrap around neck; careful on what have access to - someone at bedside - infants may need one-on-one depending on how active
Falling - crib - bedside up; infant: incubator - closed

Answer 44

Safety concerns within the hospital setting? - The infant

Question 45

No prepping them or education; prep the parents; not understand what is going; not educating the infant; education for the parents

Answer 45

Preparation for procedures? - The infant

Question 46

Parental Involvement
Development of autonomy - want do everything themself
Be clear and concise; what do you need THEM to do. (but give them one direction at a time) - cannot process more than that; clear and concise; give them choices; more choices give them more in control they feel
It is all about them (aka egocentric). - do not understand your view or what their doing impacts you; not understand a world about them
Do not share the scary equipment - hide it
What is our best tool with a toddler?
What would be the most effective way to communicate and assess this child?
Medication Administration:
Safety concerns within the hospital setting?
Preparation for procedures?

Answer 46

The toddler

Question 47

Parent involved as much as possible
holding/sitting by toddler
Most cooperation as muscle

Answer 47

Parental Involvement - The toddler

Question 48

Distraction
How can we distract toddler while assess toddler/on procedure

Answer 48

What is our best tool with a toddler? - The toddler

Question 49

Initiate convo with parents; toddlers visualize us and see that parents trusting of us and slowly focus on child
Toddler - ask questions and start slow; play games, ask about doll, clap hands, do little things to warm them up to us
Do least invasive to most invasive when assessment

Answer 49

What would be the most effective way to communicate and assess this child? - The toddler

Question 50

Topical - good at this age
IM - hate these; quick and done fairly fast; vastus lateralis
IV - sometimes needed; not ideal for this age group because try to take them out
Oral - wonderful; encourage this; in little bit of food is helpful
Rectal - if sore throat great way give med

Answer 50

Medication Administration: - The toddler

Question 51

Into everything
Watched closely
If sick not as active and not crawling around
Feeling okay watching can be hard
Not put small objects in mouth
Careful with cords and IV tubing
Falling - still concern; still working and rolling - fall off and out of things

Answer 51

Safety concerns within the hospital setting? - The toddler

Question 52

Can be hard
Early toddlerhood - not much prep and if any kind of prep right before surgery; not bunch of warning
As older in toddler yrs closer to 2-3 yrs can show some equipment - stethoscope - helps them less scared of it - know not hurtful; let them play with the equipment; if prepping for something - may have to sedate them; still explain to them in relation to 5 senses
Animism - objects have life-like features - keep away scary objects because of this because think is real and hurt them
Expect negative behaviors - ignore tantrums; flexible when comes to them; still use firm, direct approach; give 1 direction at a time; limited language development - hard communicate with them and them with us; use lot holophrases - one word at a time to mean a sentence
No or very limited concept of time
If child hospitalized not do med procedures/blood draws in child room if possible - keep room a safe space

Answer 52

Preparation for procedures? - The toddler

Question 53

Big on magical thinking
Parental involvement
Development of initiative. - like being involved and want help with things: involving them as much as possible; opportunity to show initiative
Be clear and concise; show what do you need THEM to do
Concerned with body integrity? - not understand how body works but understand it is their body; body integrity: cut worried about all insides will come out; not want see blood and worried about inside coming out or losing limbs; be reassuring about things; concerned about genital mutilation - assessing here be conscious what thinking and feeling
Distraction- allow a little more time for understanding. - still good with these kids; let process and distract as about to do things
Slight control and understanding over time, play with equipment - time based on events
What would be the most effective way to communicate and assess this child?
Medication Administration:
Safety concerns within the hospital setting?
Preparation for procedures?

Answer 53

The preschooler

Question 54

Still want parents in there with child if possible
Let preschooler dictate where want parent to be

Answer 54

Parental involvement - The preschooler

Question 55

Talk through play - esp when fearful - lot fear - still have animism - objects have lifelike properties
Worried about body integrity
Way express fears is through play - play out situation - show what think might happen even if so unrealistic to us act out/draw fears and gives us a way to communicate; play great way to communicate with them
Do not use analogies and not understand them
Support cooperation - do + reinforcement
1 direction at time
They or sibling get sick/hurt feel their fault/punishment - imp give reassurance

Answer 55

What would be the most effective way to communicate and assess this child? - The preschooler

Question 56

Topical - great; absorb things more reliably; understand who do that; help take away pain if do IM/IV
IM - hates shots; try and prepare them; remind is quick and needed
IV - extremely scary; not know needle not there (body integrity) - worried insides come out through IV; give lot explanations and edu about IV; discussing fears very imp
Oral - if can do this do it
Rectal - still option; more concerned about it; some modesty; towards end preschoolerhood get modesty and more hesitant on it

Answer 56

Medication Administration: - The preschooler

Question 57

Understand things more
Not putting things in mouth as much as more
Worry about pulling out IVs
Messing with cords
Go to restrooms with them esp in younger age group - typ potty trained in toddler - can have regression in hospital; in stressful situations lose ability; reassure them that will gain skill back and not shame child for accident

Answer 57

Safety concerns within the hospital setting? - The preschooler

Question 58

Hard age group
Very fearful
Explain procedures
Still very worried about body integrity
Prep them about 1-2 hrs before procedure
When educate them 10-15 min edu - words understand; let play with equipment; ex on animals and dolls; keep scary equipment out view

Answer 58

Preparation for procedures? - The preschooler

Question 59

Parental involvement
Development of industry: harder aspects of hospitalized child; want make friends and successful in school; hard meet and reach in hospital; short-term not worried; long-term worry if friends forgetting them or not feel successful because not in school; consider bringing tutor; bringing in friends; depends on illness and why child is there - if can meet social and learning needs - child life specialist great about it
Be clear and concise; explain what is happening: want to learn; ask lot questions; can start using simple med terminology; showing pics and equipment; want to learn; magical thinking is gone; not have lot fears of preschoolers; want be involved
Want to learn, they will often watch and ask questions
Allow time for understanding, can prepare ahead of time
Good Control over time and understanding of time
What would be the most effective way to communicate and assess this child?
Medication Administration:
Safety concerns within the hospital setting?
Preparation for procedures?
Allow for some responsibility - collecting specimens (urine); not have assist to bathroom; trust to do on own

Answer 59

The school-age child

Question 60

Want parental involvement
Provide privacy for child esp if change into gown; ask parents step out - depending on age and how child acting; usually speak up; when want and show independence want support sys

Answer 60

Parental involvement - The school-age child

Question 61

Talk to them directly
Explain why doing something - benefit of it
Getting on their level
Still talk to parents but talking about the child; school-age child talk to them is most reassuring to them

Answer 61

What would be the most effective way to communicate and assess this child? - The school-age child

Question 62

Becomes fairly easy - get cause and effect; ability to rationalize and reasoning
Topical
IM
IV
Oral - can swallow meds; wider variety of meds can take
Rectal - avoid; if only option do it; private area; lot modesty now

Answer 62

Medication Administration: - The school-age child

Question 63

Not very worried
Not too many with this age group
Not into things; not worried about suicide; maybe towards end school-age (10-12) depending on child and how mental health and what going through

Answer 63

Safety concerns within the hospital setting? - The school-age child

Question 64

1-2 days of prep
Teaching sessions 20 min - showing diagrams and pics
Lots questions - answer them; even ones about fears; open and honest with them; not want to lie to them
Distraction can be felt as form lying unless agree to it

Answer 64

Preparation for procedures? - The school-age child

Question 65

Parental involvement
Development of identity: questioning who are in world; sick: worries them is if have future and if going to make an impact
Ask what they want to know with procedures; might not want to know everything; let them lead questions; guage what want to know
Teenager don’t want to be different: not want to hospital - makes them diff - concerned with how look; have a procedure: figure out if going to make them diff or have scar
Allow time for understanding, can prepare ahead of time
PRIVACY. (Do not share personal information even when obvious) - do not share unless they want to share it
What would be the most effective way to communicate and assess this child?
Medication Administration:
Safety concerns within the hospital setting?
Preparation for procedures?
Sometimes may give impression not anxious/nervous and are; may attention to subtle hints; ask if feeling anxious - not make feel bad for being anxious; not like be separated from friends - can give anxiety; worried friends forget them

Answer 65

The adolescent

Question 66

Separating from parents and not want lot do for parents; hospitalized: depends on how sick are; more comfy with parents being around
assessment/procedure may want parent out room; want close and in hospital
May be embarrassed by that - not ask parent to leave sign want them to stay there

Answer 66

Parental involvement - The adolescent

Question 67

Giving them privacy; gown for assessment
Parents present or not
Treat like adults

Answer 67

What would be the most effective way to communicate and assess this child? - The adolescent

Question 68

Topical - great
IM - do well; understand quick and painless; ask if want cream before this
IV - ask if want cream before this
Oral - swallow meds now
Rectal - try avoid at all costs; embarrassing to them; typ rather have IM injection before rectal

Answer 68

Medication Administration: - The adolescent

Question 69

Not super worried about getting into things
May attention on why there - if suicide risk - careful on what in room - one-on-one

Answer 69

Safety concerns within the hospital setting? - The adolescent

Question 70

Prep like do adults: schedule couple weeks before; charts; pics; brochures to read; teach like adults
Understand concept of time and things happening in the future
Want have time to process

Answer 70

Preparation for procedures? - The adolescent