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Responses of Children During hospitalization, children are not able to be in their home environment or be around the usual people they encounter each day, which can negatively impact their continued progress in achieving developmental milestones. In other words, their usual routine is drastically changed. Studies have even shown that hospitalization can negatively impact children’s mental health. Stress Stress itself can have a negative influence on children. When children experience a lot of stress, especially early in their childhood, the physiological effects can lead to physical, social, and emotional complications. These effects can include anxiety, physical manifestations without illness or cause (such as stomach pain), and aggression. Hospitalization can be a stressful experience for children, and pediatric clients of every age are impacted differently. Stress experienced during hospitalization can negatively influence clients’ recoveries and health outcomes. Early Childhood (Birth to 6 years old) From birth through adolescence, children may experience increased anxiety due to the pain and discomfort associated with hospitalization. Especially scary for pediatric clients are intravenous lines (IVs), needle sticks (such as for drawing blood for laboratory tests), and medical equipment. If children have experienced hospitalization before, they may experience anxiety just anticipating the need for these interventions. PN Scope of Practice: Insertion and Care of an Intravenous Access States vary in regulations regarding intravenous insertion and administration of medications via intravenous route by PNs. Each PN must know the scope of practice for the state in which they are practicing. Hospitalization Stressors Especially for young children, medical equipment, IVs, and needle sticks can be very scary. Infants and toddlers undergoing distress may cry more than they usually do, become irritable, or cling to their parent more than usual. Infants are unable to describe how they are feeling and do not understand why they need to be hospitalized. Toddlers know their daily routine has been disrupted during hospitalization, but they do not fully understand why. Effects of Experiencing Anxiety Young children who experience anxiety may regress in their behaviors, such as having a temper tantrum, sucking their thumb, clinging more to their parent, or experiencing enuresis. enuresis
Preschoolers have an active imagination and often believe they experience pain and discomfort during hospitalization as punishment. In addition, young children can be very fearful that health care procedures and interventions can lead to permanent damage to their bodies. A nurse is caring for a 3-year-old child in the pediatric unit. Which of the following should the nurse include in the plan of care, given the client’s age and developmental stage? Select all that apply. aExplain care, especially any upcoming procedures, in simple terms. bUnderstand the child may not understand why they are in the hospital. cExpect the client to be able to explain how they are feeling. dTell the child they need to cooperate and should not cry. eEncourage the parent to stay at the bedside as much as possible. Later Childhood (6 to 12 years old) During later childhood, when children are school age, they begin to understand more about their hospitalization and may express anxiety through their emotions. For example, pediatric clients can be upset, sad, or even afraid about what they have experienced and fearful it may happen again. These clients may also regress to previously exhibited behaviors, show aggression, become withdrawn, or even be unwilling to cooperate. Adolescence (12 to 20 years old) During adolescence, hospitalization can cause distress related to changes in body image. Adolescents understand the cause and effect of health care treatments. If these interventions disrupt their sense of identity in how they look and appear to others, however, they can experience great anxiety. Stress can cause adolescents to shield their emotions. They may experience a more intense emotional response to anxiety, and they may feel as if they cannot share what they are undergoing. On the other hand, adolescents may also express their anxiety by acting out and participating in dangerous activities, such as substance use. Quick Overview of Child Development Considerations for Hospitalization Infants When their nutrition, comfort, and hygiene needs are consistently met, they learn to trust those who are caring for them. Young infants cannot express their emotions through speech but can communicate through crying and cooing. Older infants and young children can undergo separation anxiety, which can cause stress during hospitalization. Having consistent caregivers and staff for infant clients is helpful. Toddlers They become more independent with the security of their parents and environment around them. During hospitalization, offering toddlers simple choices can help
Adolescence Separation Anxiety In addition to the stress that hospitalization can cause, being separated from their home environment and support systems can be hard for children. Many pediatric clients report the desire to return home when they are in the hospital setting. Early Childhood (Birth to 6 years old) Young children do not understand why they need to be in the hospital setting, and possible separation from their parents is frequently the source of their distress. In addition, during early childhood, pediatric clients may undergo separation anxiety, which can enhance the stress of hospitalization if families cannot be at the bedside with their children. Although separation anxiety is unique for each child, if children do experience it, typically it occurs in late infancy or even early toddlerhood, but it usually does not persist past the preschool years. For more information related to separation anxiety, see Infants: 1 Month to 1 Year. During toddlerhood, many children undergo temper tantrums. Sometimes toddlers have tantrums because they are tired. Other times, tantrums happen because young children become frustrated when they cannot express what they want to say in words. Pekic/Getty Images Separation Anxiety For older infants and toddlers, being separated from their parents can be especially hard for them. Later Childhood (6 to 12 years old) For older children, peers are important and pediatric clients become more independent. Children in later childhood not only feel the separation from their home environment during hospitalization, but also from their friends, school, and activities, such as sports. Adolescence (12 to 20 years old) Adolescents can also experience stress from separation. Peer influence is even more paramount during adolescence. Similar to later childhood, adolescents also feel separation from their home environment, friends, school, and other activities when in the hospital. Which of the following underlying causes may heighten separation anxiety in young children during hospitalization? Select all that apply. aUnable to be around their peers while in the hospital. bUnable to be in school and participate in activities. cAway from home environment; active imagination/fear. dHaving to be in the hospital and unsure why. eUnable to have their parents at the bedside.
Loss of Control During hospitalization, if pediatric clients lack an understanding about what is going to happen, and especially if they are not able to be involved in the plan of care, they can feel a loss of control. In addition, some children have had many previous experiences with hospitalization. For example, pediatric clients who have chronic disorders undergo hospitalization more than children seeking acute care. These clients may recall previous negative experiences, and over time, recurring hospitalization can lead to problems with coping and stress. Early Childhood (Birth to 6 years old) For children in early childhood, hospitalization stressors are often described by them in terms of fear of pain and discomfort. Loss of control can be experienced as these clients are in new environments with unfamiliar caregivers. They may undergo too much stimulation or not enough. Their routines are disrupted, and inconsistency in care and caregivers can lead to more stress. Later Childhood (6 to 12 years old) For children in later childhood, hospitalization can spark feelings of fear of the unknown, pain, and loss of their safe environment. Pediatric clients can certainly feel at a loss of control over their usual routine. They may also feel a sense of fear about losing opportunities to practice developing skills, such as through school and physical activity. Adolescence (12 to 20 years old) For both older children and adolescents, reported stressors during hospitalization also include confusing communication, inadequate sleep and rest, and not having privacy. In addition, adolescents’ typical routines are changed, and they are separated from their peers during hospitalization. Children and adolescents may experience withdrawal, regression of behaviors, and aggression depending on their hospitalization experience. However, with effective nursing interventions, as pediatric clients adjust and become more comfortable in the health care environment, these behavior changes can lessen. It is also helpful to address adolescent clients’ concerns and be willing to be flexible about the daily schedule. A nurse is caring for an adolescent in the pediatric unit. The client’s parent is concerned that the client is not sleeping well and not telling the health care team how they feel. Which of the following responses would be the nurse’s best response to the parent? a“Adolescents undergo stress in the hospital. How can I help to make things more comfortable, like at home?” b“This is concerning. Please ask the provider about this when they come for rounds.” c“There is no need to worry. Adolescents act differently sometimes, especially in the hospital.” d“This is very concerning, and I will alert the provider immediately for further assessment.”
dAssure the parent that the client will be leaving soon and begin discharge education. Therapeutic Communication Nurses need to practice therapeutic communication whenever they work with pediatric clients and their families. Therapeutic communication involves respect, honesty, clarity, and understanding the client’s growth and developmental stage. Effective communication is at the center of holistic, quality nursing care. It enables clients to be cared for safely as well as clients and their families to better understand their care. In fact, nurses can use the AIDET communication method that enhances the health care experience for clients and families. therapeutic communication AIDET Five fundamentals for effective communication with clients/families: A – Acknowledge: welcoming the client and family. I – Introduce: making sure the client and family know your name and role. D – Duration: updating the client and family about timeframe expectations and any changes to the expected amount of time for interventions, procedures, and treatments. E – Explanation: communicating with the client and family about the plan of care, including interventions, procedures, and treatments. T – Thank you: thanking the client and family for their time and cooperation as well as allowing them to provide feedback regarding their care. Regardless of the client’s age, there are key techniques to use when practicing therapeutic communication. It is necessary to create a safe, comfortable space for the child and family. This can include a child-friendly environment, such as a playroom with age-appropriate toys or even a quiet area with dimmed lighting. Both verbal and nonverbal communication have an impact. Nurses who are approachable, smile, and involve their clients and families in the plan of care are more likely to promote a positive hospitalization experience. Other aspects of therapeutic communication include active listening, seeking clarification, and summarizing. Active listening involves verbal and nonverbal language to show engagement and interaction. Seeking clarification is related to active listening and involves the nurse asking the client and their family to further explain something while letting them know they were heard. Finally, summarizing enables the nurse to recap what was discussed and provides the client and their family the opportunity to add to or revise their statement and to ask questions. Nurses also communicate through nonverbal communication; being present and available to clients and families is important. In addition, sometimes the use of silence can be helpful. Silence can provide time for the nurse and client or family to process
what has been said and think about what needs to be covered next; this can ultimately enhance the client-family-nurse relationship as well. As a nursing student, what are some ways in which you can incorporate therapeutic communication into your clinical practice? Enter your response and submit to compare to an expert response. Minimizing Stress and Loss of Control Nurses can help decrease client and family stress by including the family in the treatment plan. Family-centered care recognizes the important role of the family in the decision-making process, promotes a more comfortable environment for hospitalization, and increases the cooperation of the client and their family. In addition, to reduce anxiety when communicating with pediatric clients and their families, nurses should explain information and instructions clearly, take time to listen, and offer opportunities for questions. It is also important to update the client and family when changes to the plan of care are anticipated. When pediatric clients undergo frequent hospitalization, having the same, consistent nurses caring for them can also be helpful for continuity in care and being familiar with the needs of the client and family. When working with pediatric clients, it is helpful to give them choices when appropriate. Not every situation during hospitalization can incorporate choices, such as the timing of certain medication administration. However, whenever possible, nurses should include the child. Allowing the client to hold a medical-safe item, such as a bandage, or listen to their own heart with a stethoscope can promote cooperation and trust. SeventyFour/Getty Images Minimizing Stress and Loss of Control A 5-year-old child and their parent are being admitted to the pediatric unit. Which of the following interventions should the nurse include? Select all that apply. aProvide a detailed explanation to the client about what to expect during the hospitalization. bAsk the parent about what the health care team should know to best care for the client. cHave the client “listen” to their teddy bear’s heart before auscultating the client’s during assessment. dWhen the client’s medication is due, allow the client to take the medicine themselves if they wish. ePromote play by allowing the client to ride in a wagon through the unit and go to the playroom.
Sort the following interventions for children being cared for in the hospital setting into therapeutic and non-therapeutic. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). Therapeutic Non-therapeutic Activities and Play When in the health care setting, it is still important to enable kids to be kids. Just because they are in the hospital does not mean pediatric clients should not be able to play and be offered fun activities to do. Play is a great way to help children cope and increase their resilience. It is also a necessity for growth and development. Research supports that medical-pretend play decreases distress in children, and when children are less stressed, their family members experience less stress as well. MoMo Productions/Getty Images Activities and Play Especially for young children who can become anxious with medical equipment, letting them see, touch, and play with the equipment before using it can help them feel more comfortable. Helpful play interventions for infants include providing music, such as lullabies, and age- appropriate toys (for example, rattles and stuffed animals) that promote infants’ involvement (moving, kicking, crawling). Transforming the hospital room into a visually stimulating environment can also help infants. For example, incorporating bright colors, mobiles, and mirrors can make the health care setting more engaging. Nurses can interact directly with older infants by playing games, such as peek-a-boo. Play options for toddlers include listening to music, stacking blocks, painting, coloring or scribbling with crayons, and bouncing, throwing, and kicking a ball. Nurses and parents can also read books to toddlers. Reading is a great way to promote neurological function by advancing vocabulary and language development. Nurses and parents can also encourage positive ways for toddlers to use their energy, such as sculpting dough or playing with hammering or pounding toys.
A nurse is caring for a young child who is experiencing separation anxiety, and their parent cannot be at the bedside with them. How should the nurse approach the client’s care? Enter your response and submit to compare to an expert response. Preschoolers can be offered the same activities as toddlers. In addition, preschoolers have active imaginations, and activities such as pretend play, dress-up, playing house, and interacting with peers are great ways to promote social engagement. Preschoolers also have more hand-eye coordination than younger children, so activities including cutting with scissors and gluing can be incorporated into arts and crafts. For school-age clients, interacting with peers is helpful, and activities such as arts and crafts and games (for example board games, card games, and video games) are therapeutic. School-age children can read books and magazines, and if there is a library within the health care setting, nurses can encourage clients and their families to use their services and possibly visit for more engagement. Journaling can also be a therapeutic way to share feelings and emotions. For adolescents, peer engagement is very important. Even if peers cannot visit in the health care setting, nurses should provide opportunities for clients to communicate with their friends, perhaps via computers and cellular phones. Adolescents may also benefit from games as well as the opportunity to journal and scrapbook. Favorite music and movies can also be helpful to make adolescent clients feel more comfortable in the health care setting. Understanding Individuality Although it is good to be aware of general information regarding play and activities for each age group, nurses should inquire about what the individual client and their family prefer and enjoy. Considering background, traditions, and culture, nurses need to be open to learning about how they can make the client’s hospitalization a better experience. Match the appropriate play intervention with the corresponding age group. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). Preschoolers School-age/adolescents Infants Toddlers
parent, discharge teaching should also incorporate the pediatric client when possible, depending on their age and developmental stage. Nurses should coordinate teaching opportunities whenever possible during the hospitalization, especially when parents can be present at the bedside. Waiting until the day of discharge to complete education, especially when parents need to complete return demonstration of skills to use at home, will not ensure the best learning environment possible. More than likely, the parents will not be able to grasp all the information to best care for their child at home. PN Scope of Practice: Teaching The registered nurse has the educational background to complete comprehensive assessments and develop plans for teaching. The practical nurse works in collaboration with the registered nurse by making recommendations to the plan and helps to reinforce teaching with child and their parents. No matter how the discharge teaching is completed, education should be clear and tailored to the health literacy and learning preferences of the pediatric client and family. Nurses should inquire ahead of time how the client and family learn best whether that be through verbal or written information. Discharge instructions are generally printed for the family, and they usually include information about the client’s hospitalization, diagnosis, medications, follow-up appointments, and reasons to call the provider. health literacy Caring for Clients and Families Who Speak Another Language Than English If clients and families speak a different language than the nurse and provider, they should be offered interpreter services when providing health care information and teaching. If an in-person interpreter is not available, phone or video interpreter services should be used. Some health care facilities offer translation services for printed or written information, and some even include audio recordings on an as-needed basis. Especially for discharge education, using interpreter services is associated with higher- quality communication between the client and their family and the provider. Nurses should use a way to check learning and make sure the client and parent understood the information presented. A common intervention in which to do this is called the teach-back method. Through the teach-back method, nurses have clients and families repeat back what they have learned in their own The Role of the Nurse and the Pediatric Assessment Health Perception/Health Management When a pediatric client is admitted to the pediatric unit, they may have come to the hospital through the emergency department, for a scheduled procedure, as a transfer from another unit or facility, or as a direct admission. Regardless of the location prior to their admission, nurses will
complete a thorough health history/overview, and they should perform an admission assessment as soon as possible. Vital signs, height, weight, head circumference (if warranted), body systems (cardiovascular, respiratory, gastrointestinal, genitourinary, neuromuscular, integumentary), and pain will all be assessed. The health history encompasses past medical information, allergies, current medications, nutritional needs, and any needs anticipated for discharge (for example, home nursing or a wheelchair). direct admission head circumference In addition, during the admission process, the nurse must assess the parent’s ability to manage care at home. Considering the increased number of pediatric clients who have chronic health care needs and many families providing care themselves, several factors need to be considered, including the education material, time, and expectations. In the health care setting, especially when caring for adolescents, sensitive topics may need to be assessed, such as alcohol and substance use. Discussing confidentiality prior to inquiring about these sensitive topics helps adolescents feel more comfortable in sharing information. Confidentiality disclosure should also include explaining to the family the importance of sometimes assessing an adolescent without parental presence; this can also promote open communication between providers and adolescents. When families are at home caring for their children’s medical needs, they can experience a different kind of stress than during hospitalization. In the hospital, the nurses, providers, and staff are ultimately in charge of the treatments provided, while still including the family. However, at home, parents may be providing treatment, especially if home nursing is not available or required. Parents can undergo constraints on time, even feeling as if they cannot leave the house because of the care they need to provide. Changes in family dynamics can happen, including effects on clients’ siblings with the shift in schedules and routines. In addition, lack of sleep is a common response from parents. It is important for parents to receive support and appropriate education before being discharged, and they should also be aware of the time and energy the care at home may require. Education may even include an in-person class at the hospital, having the parents demonstrate understanding of the care they will need to provide. Some facilities may offer additional resources for parents after discharge, including online resources and video tutorials. It is also important for nurses to assess other potential barriers to the recovery of the pediatric client following discharge. For example, some families do not follow-up with their primary health care provider as instructed because they lack transportation or money for gasoline. Other families may not have a proper car seat to provide for their child. Nurses are often the first health care personnel who discover the family’s needs. Using resources, such as social work and
Nurses will need to track their clients’ output while in the hospital. There are different ways to measure output, such as using a toilet hat, urinal, or measuring the weight of diapers. Young children may have begun toilet training before coming to the hospital. Stress of hospitalization may cause regression in toilet training progress, and toddlers may experience accidents, such as bedwetting. Clients and families should be supported during this time. Toilet training pants available through the hospital can be used instead of using diapers or expecting children to wear underwear. Also, parents should be reassured that regression due to hospitalization stress usually does not last long, and it should resolve once the client and family return home. Changing a diaper and measuring urine output of an infant A nurse is preparing to change an infant’s diaper and obtain a urine output. Which of the following actions is the nurse’s priority? aDocument the urine output in the infant’s EMR. bHave all necessary supplies within reach prior to changing the infant’s diaper. cAfter securing the new diaper, place two fingers between the diaper and the infant’s stomach. dRemove the wipes from the diaper prior to weighing. The infant has a wet diaper that weighs 132 g. The dry weight of the diaper is 48 g. What should the nurse record as the urine output in milliliters (mL) for that diaper? Calculate the urine output in milliliters (mL). Enter only the number for your response. The nurse is caring for a child who weighs 12.4 kg. The nurse changes the infant’s diaper after 2 hours. The calculated output of the wet diaper is 48 mL. Is the infant’s output within the expected range for this child? Explain your answer. Enter your response and submit to compare to an expert response. Sleep/Rest Although maintaining a sleep routine as much as possible while in a hospital setting is ideal, it can be difficult. Health care team members round on pediatric clients and families during the day, and nurses need to continue care throughout all hours of the day and night. Consistent sleep and rest can be challenging. However, nurses can help advocate for clients and families. Dim lighting can
be used during quiet hours during the day and throughout the night, and natural light can be used during the day hours. Nurses can promote as much of a consistent schedule for eating and sleeping as possible. For example, nurses can communicate with parents about when assessments and treatments are scheduled so that they can also plan around the needs of the family. Hours A Pediatric Client Should Sleep Considering growth and development, for each age group, a pediatric client should sleep the following number of hours per day. Newborns: 14 to 17 Infants: 12 to 16 (including naps) Toddlers: 11 to 14 (including naps) Preschoolers: 10 to 13 (including naps) School-age: 9 to 12 Adolescents: 8 to 10 Activity/Exercise During childhood, physical activity is important for overall growth and development. Exercise not only helps children’s bone, muscle, and joint health, but it can also impact children mentally, promoting their self-esteem, improving attention, and encouraging teamwork. In the hospital, pediatric clients may not have the same opportunities to exercise as they do at home. However, nurses can be creative in making time for play and using support staff, such as child life specialists. Some examples of activities which nurses can use to promote physical activity include games with movement, dancing to favorite music, and interactive video games. Amount of Activity Kids Need Each Day Children under 1: Activity should be promoted throughout the day through tummy time, standing while assisted, and providing a safe place to roll over, and crawl. Children 1 to 5 years old: Activity should be promoted throughout the day through play. Children 6 to 17 years old: 60 minutes or more of moderate-to-vigorous physical activity is recommended. Can be split up into activity sessions throughout the day. Most activities should be causing an increase in heart rate (for example, walking, running). Other activities, such as muscle-strengthening (for example, climbing, pushups) and bone- strengthening (for example, jumping), should be done at least three days per week. Sort each option as either therapeutic or non-therapeutic. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right).
school-age client could select which to be accomplished first. This can also promote the clients’ initiative and industry. A 12-year-old client has just been admitted to the pediatric unit. At the bedside are the client’s parents who are not proficient English speakers. Which of the following interventions should the nurse plan to include? Select all that apply. aHave the client speak for the parents when the nurse and provider are at the bedside. bStart preparing for discharge now and anticipate needs for interpreting and possibly translation. cAsk the client and family how they learn best and prefer to learn. dEncourage the client to express emotions and ask any questions they may have. eTell the parents they cannot set goals for care; the client should be able to do this. Role/Relationship In the hospital setting, it is important for the nurse-client-family relationship to be based on trust. However, this can be challenging when the hospitalization is unplanned and the relationship begins quickly, with care being started shortly after coming to the hospital. Trust can be formed and maintained through fidelity, honesty, and competence. When nurses follow through with what they say they will do, when they narrate their care and practice open communication, and when they reassure clients and families that even if they do not know something they will do their best to find out, they are promoting trust. Establishing Trust Be open and honest when caring for pediatric clients and their families. Use developmentally appropriate language. For example, when giving an injection to a young child: “This will feel like a quick pinch.” Nurses should not: Refer to medicine as candy. Make up information to answer a question if they do not know the answer. Tell the client or family everything will be okay. Tell the client that a procedure will not hurt. The hospitalization experience can bring about a bond between the client, family, and the nurse. Although this bond can be positive for a health care relationship based in trust, there still needs to be healthy boundaries. For example, clients sometimes want to connect with their nurses on social media. Nurses should use discretion when maintaining contact with clients and families after discharge and uphold client safety and privacy practices. Sexuality/Reproductive Ideally, during hospitalization, pediatric clients can be cared for by staff specifically trained in pediatrics in a children’s hospital or a children’s designated area within an adult hospital. However, this is not always the case. Sometimes pediatric clients are cared for in an adult setting by staff who are not versed in pediatrics. If this is the case, especially for adolescents, it can be
difficult. Adolescents may be undergoing puberty while in the hospital, facing the physical and emotional changes that accompany the stage of development in a new and unfamiliar setting. Nurses can help support these adolescents during this time through careful listening, showing respect, providing privacy, maintaining confidentiality, and treating adolescents as competent clients. Please refer to School-Age Children: 6 Years to 12 Years and Adolescents: 12 Years to 20 Years for more information about puberty and physical development of school-age and adolescent clients. An adolescent client has shared confidential information with the nurse and asked them not to tell anyone. What should the nurse do? Enter your response and submit to compare to an expert response. Coping, Stress Tolerance, and Values or Beliefs Families undergoing stress cope in different ways. Especially when caring for children with health care needs, families may rely heavily on their cultural and faith traditions. Religious practices are one of the most prominent coping factors for pediatric clients and families, and many report feeling calmer and more hopeful about their child’s recovery and care when they can practice their faith. Nursing Interventions Orientation to the Room When admitting a pediatric client and their family, it is important to show them around the hospital unit and their hospital room. Hospital rooms have a crib or bed for the client, and many rooms provide an area for the parents to stay, such as a pull-out couch. If parents cannot stay at the bedside, or only one parent is allowed to stay at one time, units should have access to a family lounge that parents and family members can use. Hospital rooms usually also have a private bathroom for client and family use. At each bedside is a call light, and the client and family should be educated on how to use it to contact staff for help and needs. Families should also be made aware of visiting hours, where the cafeteria is and/or how to order food, how to use the phone and television, and how to connect to the internet. Client and Family Rights Just like adult clients, pediatric clients and their families have rights while in the hospital. Information about these rights should be accessible to clients and families during their stay. Their rights include: To be told about the care being provided. To be able to help make decisions about their care. To be able to voice their opinions, even complaints. Use of Procedure Room for Invasive Interventions
