Outpatient Clinic

Many hospitals today have well-organized outpatient facilities and satellite clinics for preventive medicine and care of the child who is ill. The advent of Medicaid and other such programs has made these services available to low-income families. Within clinics, there may be specialty areas (particularly at children’s facilities) such as well-child clinics, asthma clinics, cardiac clinics, and orthopedic clinics. In some institutions, information is distributed and brief classes are held for waiting parents.

In many private medical offices the pediatricians or their nurses are available at certain hours of each day to answer telephone inquiries. The pediatric nurse practitioner may visit patients in the home, give routine physical examinations at the clinic, and otherwise work with the physician so that a higher quality of individual care may be attained. The nurse practitioner is often the primary contact person for children in the health care system.

Home

Because hospitalization is now brief for most children, the choice is not either hospital or home care but a combination of the two. They are becoming interdependent. Dramatic technical improvements and research in specific disease entities are also helping to advance the movement to home care (e.g., cry­oprecipitate for hemophiliacs, Broviac catheters for chemotherapy, heparin locks for intravenous access, glucometers for monitoring blood glucose). However, home care is broader than in years past. It is not merely a matter of supplying appliances and nursing care, but it also includes assessment of the total needs of children and their families. Families need to be linked to a wide variety of network services. This ideally involves a multidisciplinary approach spearheaded by the health care provider.

The hospice concept for children has received accolades from parents who have benefited from its service. Local and national support groups for specific problems afford opportunities for families to share and support one another and to learn from others’ successes and failures. Special groups and camps for children with chronic illnesses are also well established. Group therapy for children under stress is equally important in preventing mental health problems (e.g., groups for children whose parents are divorced, Alateen for children of alcoholics). These and other programs not only have the potential for improving life for the child and family but also may help to reduce the high cost of medical care. There have been dramatic changes in the delivery of health care to children and families. These changes affect the role and responsibilities of the nurse working both in wellness centers providing preventive care and in hospitals or homes treating illness.

Separation Anxiety

Separation anxiety occurs in infants age 6 months and older and is most pronounced at the toddler age. There are three stages of separation anxiety: protest, despair, and denial or detachment. Unless infants are extremely ill, their sense of abandonment is expressed by a loud protest. Toddlers may watch and listen for their parents. Their cry is continuous until they fall asleep in exhaustion. Toddlers may call out, “Mommy,” repeatedly, and the approach of a stranger only causes increased screaming. The crying gradually stops, and the second stage of despair sets in. Children appear sad and depressed. They move about less and withdraw from strangers who approach. They do not play actively with toys. In the third stage, denial or detachment, children appear to deny their need for the parent and become detached or disinterested in their visits. They become more interested in their surroundings, their toys, and their playmates. On the surface, it appears the child has adjusted to the separation. However, it is important for the nurse to understand that the child is using a coping mechanism to detach and reduce the emotional pain.

If the detachment stage is prolonged, an irreversible disruption of parent-infant bonding may occur. Health care workers who do not understand the stages of separation anxiety may label the crying, protesting child as “bad,” the withdrawn depressed child in despair as “adjusting,” and the child who is in the detachment phase as a “well-adjusted” child. This misinterpretation can prevent health care workers from providing desperately needed assistance and guidance to the child and family.

The nurse must understand that the child who is in despair reverts back to the protest stage when the parent arrives for a visit. Rather than showing joy, the child cries loudly when the parent appears at the door. This is good! The child who has reached the detached phase appears unmoved and uninterested in the parent’s arrival. Nursing interventions are needed in this case to preserve and heal parent-child relationships. Optimally the nurse helps the parents to understand they should not deceive the child into believing they will stay and then “sneak out” while the child is distracted. This can tear the bond of trust.

Pain

The accepted definition of pain is that “pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (American Academy of Pediatrics [AAP], 2001). This includes verbal and nonverbal expressions of pain. Freedom from pain is a basic need and right of the infant and child. To increase awareness of pain during patient assessment, pain has come to be considered a “fifth vital sign.” An assessment for pain is recorded with routine vital sign documentation.

The negative physical and psychological consequences of pain are well documented. Patients in pain secrete higher levels of cortisol, have compromised immune systems, experience more infections, and show delayed wound healing. Nurses must maintain a high level of suspicion for pain when caring for children. Infants cannot show the nurse where it hurts, and often a child’s report of pain is not given the credibility of an adult’s report. In addition, children may not realize they are supposed to report pain to the nurse.

All factors relating to pain assessment should be considered. Family members also experience emotional pain when they see their child in pain.

Nonpharmacological techniques such as drawing, distraction, imagery, relaxation, and cognitive strategies may enhance analgesia to provide necessary relief from pain symptoms. The child may draw “how the pain feels” and where it is located. Distractions such as storytelling, quiet conversation, and puppet play are effective. Imagery techniques, such as having children imagine themselves in a safe place, relieves anxiety. Slowing down breathing and listening to relaxation tapes is effective in reducing pain in adolescents. Cognitive (thinking) techniques such as “thought stopping” are also helpful in older patients. In this technique, the patient is instructed to repeat the word “stop” in response to negative thoughts and worries. A backrub or hand massage is also relaxing, depending on the child’s age and diagnosis. In newborns and infants undergoing brief painful procedures, oral sucrose may provide some analgesia. Pain medications should not be withheld from infants and children when needed.

Response to Drugs

Fear