Care of the Child with Medical/Surgical Needs

Care of the Child with Medical/Surgical Needs

Health Care Delivery Settings

Although children are hospitalized when illnesses or injuries warrant, in general, they are most often cared for in a variety of other settings. These include, but are not limited to, community and school clinics, pediatrician and family practice offices, home care, children’s camps, and pediatric long-term care facilities.

Clinics and Offices

Most large hospitals today have well-organized outpatient facilities and satellite or community clinics for preventive medicine and care of the child who is ill. Although substantial socioeconomic disparities are still involved in the procurement of routine preventive services, Medicaid and other similar programs have made these services available to more low-income families. In many institutions, information is distributed and education is offered on childhood immunizations, injury prevention, and parenting skills. Specialty clinics such as cardiac, orthopedic, respiratory, and so forth exist to facilitate ongoing care on an outpatient basis.

In many cities, groups of pediatricians practice in office settings or clinic settings removed from the hospital. Such services aid in the distribution of health services and often provide evening and weekend health coverage. In most offices or clinics, nurses constantly triage (prioritize) and respond to telephone inquiries.

The pediatric nurse practitioner (PNP) may care for children in the pediatric or family practice office, give routine physical examinations at the clinic, and otherwise collaborate with the physician so that a higher quality of individual care may be attained. This nurse frequently is the primary contact person for children in the health care system. The PNP may also work in school-based clinics or health centers along with school nurses and other health care providers. School-based health centers are often an ideal location to provide primary health care for children and adolescents. (Access to quality health care for all is the number-one focus area for Healthy People 2010.) The role of the school nurse has expanded at the same time that school-based health centers have increased in number (Figure 2-1). Most school-based health centers provide the basics of primary health care. Health assessments, anticipatory guidance, screenings, immunizations, acute illness care, lab services, dental care, sexually transmitted disease precautions, pregnancy testing, and family planning may be incorporated into these centers. School nurses provide health counseling and education and act as advocates for students with disabilities. School nurses and nurse practitioners also partner with community physicians and community organizations and may collaborate with state programs, such as SCHIP (State Children’s Health Insurance Program).

Elective surgery for children with uncomplicated conditions, such as tonsillectomy or hernia repair, is also routinely done in outpatient settings. Advantages of same-day surgery include a reduction in cross-infection and hospital costs. Outpatient clinics also eliminate the need to separate the child from the family, making it less stressful for the child. In this type of setting, careful preparation and teaching must be done, and the child’s home environment must be adequate to meet the child’s recovery needs.

As more and more medical care occurs in outpatient settings, there is an even greater reduction in the number of children who need hospitalization. It is expected that, for many children, the only exposure to medical personnel will be through brief clinic appointments. The nurse’s responsibility is to make these encounters positive for children and their families.

Home Care

Because hospitalizations are now briefer for most children, home care may be an acceptable alternative to a prolonged hospital stay (Figure 2-2). Technical improvements and research in specific disease entities have helped to advance the movement in home care. The result is often lower cost, increased patient satisfaction, and overall general well-being. Ongoing intravenous therapy is often maintained through home care, as is phototherapy for the newborn with jaundice. Home care, however, is not merely a matter of supplying equipment, appliances, and nursing care; it requires assessment of the total needs of children and their families. Families need to be linked to a wide variety of network services. These services are often established by a case manager, who plays a vital role in home care arrangements. Case managers oversee a continuum of care for the child by managing medical care.

For families who are facing the loss of a child, hospice is a service that offers unique help. Hospice is a program offered to children who are terminally ill, usually those with only 4 to 6 months left to live. Parents, with the help of hospice nurses and caregivers, often provide the care for their dying child at home. See Chapter 22 for further discussion on hospice.

Other Settings

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 available. Many different types of organized camps exist in the United States. Examples include camps for children with asthma or children with cancer. Many of these camps are held in the summer months. Camp nurses perform assessments, dispense medications, provide first aid, triage health problems, and may also provide training to other staff.

Parish nurses provide specialized practice of professional nursing that focuses on the promotion of health within the context of the values, beliefs, and practices of a faith community. Parish nursing focuses on the health care needs of all ages and provides health promotion, health maintenance, and illness prevention programs, as well as community resources and support groups. Children and adults can benefit from the services provided.

Group therapy for children who have undergone stressful situations is important in prevention of mental health problems. Children coping with depression or suicidal tendencies often need the support of group therapy. Many children also need group support if their parents are divorced, abusive, or abusing substances. Group support programs not only have the potential for improving life for the child and family but may also help reduce the high cost of medical care.

Long-term care facilities may be necessary for children with severe or profound mental retardation or for those with multiple disabilities. Placing a child in a long-term care facility is a difficult decision for any family to make. A thorough assessment of the facility, with the needs of the child kept in mind, is essential not only for the child’s well-being but for the family’s peace of mind as well.

The Hospital Setting

Children are usually hospitalized in a pediatric hospital. They may also be hospitalized in a community hospital. Regardless of where the child is hospitalized, the pediatric setting differs in many respects from an adult setting. The pediatric unit or hospital is designed to meet the needs of children and their parents. A cheerful, casual atmosphere helps bridge the gap between home and hospital and is in keeping with the child’s emotional and physical needs. Children may wear their own clothing while they are hospitalized, and nurses wear colorful scrubs or pastel uniforms. The physical structure of a pediatric unit includes furniture of the proper height for the child, colorful furnishings, and child-friendly décor (Figure 2-3). Even transportation is suited to the child; wagons are often used to take younger children to and from procedures in the hospital setting.

Most pediatric departments include a playroom in the structural plan. This room is generally equipped with toys for various age groups. Some playrooms are equipped with a fish aquarium or blossoming plants because most children love living things. Computers are also often available for use by the child. The playroom may be under the supervision of a play therapist or a child life specialist. Parents usually enjoy taking their children to the playroom and observing the various activities. The nurse should allow each child freedom to develop independently and should make observations about the child’s play. See Chapter 8 for further discussion on the value of play to the child.

Some children are not able to be taken to the playroom because of their physical condition. In such cases, the nurse should provide age-appropriate toys for the child in his or her room. If the child is in isolation, the toys generally stay in the room until the child goes home. The nurse ensures that cleaning procedures are followed once the child is discharged.

The daily routine in the pediatric setting also differs widely for obvious reasons. Although rigid schedules are not encouraged, children do benefit from a certain amount of routine. Meals, rest, and play are carried out at approximately the same time each day. Such questions about the child’s routine are asked on admission. Children should have choices in food selection, and the same protocols are followed for children at mealtimes as for adults: No urinals should be in view, the tray table should be clean, and so on. For the school-age child, time needs to be included in the daily routine for school work. Observe the time the child is with a teacher, and keep interaction to a minimum. It is important for children to carry on school work while in the hospital.

Nursing care is often delivered by consistent caregivers, which provides comfort to the child in the hospital. Oftentimes nurses and children form bonds, especially if the child returns frequently to the same unit in the hospital. Visiting hours on the pediatric unit are usually liberal and depend on the child’s condition. Parents are encouraged to stay with their child whenever possible, and most hospitals provide beds for parents.

The Child’s Reaction to Hospitalization

How a child reacts to hospitalization depends on the child’s age, preparation, previous illness-related experiences, support of family and health professionals, and the child’s emotional status. The major stressors of hospitalization include separation, loss of control, and bodily injury and pain (Hockenberry and Wilson, 2009).

Infants and Toddlers

For infants and toddlers, separation anxiety is the major stressor during hospitalization. Unless toddlers are extremely ill, their grief and sense of abandonment are obvious. They protest loudly, watch and listen for their mother, and cry continuously until they fall asleep from sheer exhaustion. The second stage occurs as anger turns to despair. The children look sad and lonely and may refuse to eat. They may become depressed and move about less than usual. In the third stage—denial—children may try to deny the need for their mother or father by appearing detached and uninterested during visits. On the surface, children may seem to have settled in, but this is only a disguise to prevent further emotional pain. The nurse who comprehends the various separation stages sees parental visits as essential, even though the process of separation and reunion is painful. Education of the parents helps promote their continued visits and decreases feelings of inadequacy.

Toddlers also react to the loss of control they experience while hospitalized. According to Erikson, these children are involved in the task of autonomy. (See Chapter 4 for further discussion.) Activity limits, decreased opportunities for choices, and interrupted rituals contribute to a feeling of powerlessness. It is not unusual for toddlers to respond to this feeling with regression. They abandon recently acquired skills and may demand assistance with tasks that they have previously mastered. Without preparation for this, parents often do not understand the child’s behavior. They need to be reminded that in this situation, this is normal behavior. Parents, however, do need to reinforce appropriate behavior, and the nurse needs to maintain a sense of sameness whenever possible.

Toddlers also are often affected by fear of injury and remember previous painful experiences. A brief explanation of the procedure followed by comfort after the procedure is often the best way to deal with this stressor.

Box 2-1 lists interventions for dealing with the stressors of hospitalization. In addition, toddlers need to be allowed choices, within reason, which helps them to achieve control. However, questions such as, “Do you want to take your nap now?” could lead to answers such as, “I don’t want to take a nap.” Thus, questions such as, “Do you want to take your nap now or after a story?” are better. Sometimes limits on behavior are necessary, especially if the behavior is intolerable. Parents are encouraged to support the child and use sensible limit setting if necessary.

Children should be forewarned, in keeping with their level of understanding, about any unpleasant or new experience that they may have to undergo while in the hospital. Be truthful about procedures that may hurt; this prevents a child from feeling betrayed and losing trust. Preparation and explanation should be done immediately before a procedure so that the child does not worry needlessly for an extended period of time. During the procedure, explain what is happening step by step. Children should be allowed to discuss how they feel after the procedure. It is better not to put preconceived ideas in the child’s mind, such as suggesting how something might feel. The child should be allowed to describe the experience after the procedure is over. Reassure the child that it is all right to cry or say “ouch.” Allow toddlers to master the threatening experience through the use of play and fantasy.

Toddlers are encouraged to play with safe equipment used in their care, for example, tongue blades and stethoscopes. Provide other toys that are appropriate to the developmental level, such as blocks, stacking toys, balls, and wooden puzzles. Whenever possible, toddlers should also be allowed out of the crib because being confined is frustrating for little ones who have just begun to enjoy walking (Figure 2-4). Supervised playroom activity contributes to intellectual, social, and motor development. Whenever possible, treatments should be done in the treatment room. The child’s room should remain a “safe place,” and the playroom should never be used for anything but play.


Preschoolers exhibit separation anxiety, although not as obviously as the toddler. Preschoolers may act uncooperatively and ask frequently for their parents. Preschoolers are, however, significantly affected by loss of control. Not only have their schedules changed, but they are physically restricted. Children at this age are pre-logical in their thinking and have a difficult time distinguishing between fantasy and reality. They believe they are all-powerful and control the world around them and, in fact, may believe that their illness was caused by something they did or thought. They may feel guilty, particularly if an accident happened because of some mischief on their part, as in the case of a burn or a fall. It is important to help hospitalized preschoolers realize that hospitalization is not a punishment for something they have done wrong. Preschoolers also need choices so that they can regain some sense of control.

One of the major ways preschoolers cope with their environment is by fantasizing. Unfortunately, when in an unfamiliar environment, preschoolers’ use of fantasy also contributes to their fears. Hospitalized preschoolers often have nightmares and are afraid of the dark or of unfamiliar sights and sounds. Preschoolers may also worry that inanimate objects are alive; for this reason, they may fear hospital machinery and equipment. This causes them to feel powerless. See Chapter 8 for further discussion on the preschooler.

Preschoolers fear mutilation during hospitalization and do not understand body integrity. They are afraid of bodily harm, particularly by invasive procedures and procedures that involve the genital area. Because they still have limited understanding of the inside of the body, preschool children often imagine that bodies are filled with air and will collapse when punctured or that bodies are filled with blood, which could all leak out through any artificial opening. This is why bandages (Band-Aids, for example) are so important to cover any injury, real or imagined.

Preschoolers tend to attach literal meanings to words such as dye, draw blood, take, or test. These words can have more than one meaning for the child and can be confusing. Avoid these words when describing procedures to children, and try to rephrase information in terms that are clear and understandable.

In addition to the interventions listed in Box 2-1, nurses should use their communication skills to assist the child in dealing with feelings of separation or fear. For example, the nurse might say, “Some boys and girls feel afraid in the hospital. Do you feel that way?” This assists the child in expressing fears. Nurses and parents should not tell a child that they will return unless they definitely intend to do so.

The nurse must be aware of verbal and nonverbal cues from children this age. The child may withdraw or act in an aggressive manner. Parents may tell their children to “be brave” or to “act like a grown-up.” This can prevent the child from verbalizing fears and discomfort.

The preschool child relieves tension through magical thinking, fantasy, and role playing. Nurses should participate readily in the child’s fantasy if the fantasy is positive and appears to be helping the child achieve control. For example, if the child views the cardiac monitor as threatening because it is so loud, help the child write or draw a sign telling it to “talk softly” or “be quiet.” Many children this age have imaginary friends with whom they converse and behave as though the friends were really present in the room. Participation in this form of imagination is acceptable because displacing fears and feelings onto an imaginary friend helps a child feel more powerful.

Play is important to help the child adjust to hospitalization (Figure 2-5). Through dramatic play, children can act out situations that are part of their hospital experience. Dramatic play through the use of hospital equipment enables children to “work through” emotions they may be dealing with. Giving a “shot” to a doll is an example of dramatic play. Puppets also help young children work through feelings. Nurses can encourage children to communicate through puppets; dolls and puppets may also be an avenue to play out situations with children.

Preschool children may regress in their behavior when they are ill. An example of this regression would be bedwetting after the child has not had an “accident” for some time. Children may also be irritable and demanding when they are hospitalized. The parent should be assured that these behavior changes are temporary and the child will soon return to his or her “old self.”

School-Age Children

School-age children may show some signs of parental separation anxiety, especially when they are ill. Even more so, these children miss their friends. They may fear that their peers will forget them while they are away from school. On the other hand, their more sophisticated concept of time generally allows them to be patient and wait for a parent’s return or a peer’s visit.

School-age children are in the process of developing confidence in their abilities to control their feelings and actions. Hospitalization places them in the position of feeling out of control because it interrupts their routine and limits their independence. They may demonstrate resistive behaviors and have changes in vital signs in response to stress. Anger, boredom, frustration, and disinterest are other common manifestations of loss of control in the school-age child. These children appreciate the familiarity of objects from home and should be encouraged to bring such items to the hospital (Figure 2-6).

The school-age child fears pain and bodily harm. These children are more concerned with permanent disability or body disfigurement than are younger children. The older school-age child may also fear death.

In addition to the interventions listed in Box 2-1, school-age children can benefit from drawing and talking about drawings. This activity allows them to get in touch with their feelings because they may not have the ability or vocabulary to express their fears, worries, and concerns verbally. The use of drawings allows a child to express his or her feelings in an abstract manner, and the nurse can then discuss these drawings with the child.

Encourage the hospitalized school-age child to be as independent as possible. Most school-age children are capable of complete self-care and can perform most daily activities independently within the limitations of their illness. Maintaining a school-age child’s privacy is extremely important.

The education of the school-age child must continue throughout any illness. This gives the child a sense of continuity with the outside world, provides periods of socialization, and may reinforce weak academic areas. Some pediatric hospitals have areas designated for school-learning activities. The local school district may provide teachers to do on-site teaching. If this service is not available, family or friends may bring in school work from the child’s regular teacher. This will ensure that the child does not fall behind in his or her studies. Education involves the parents, who may act as liaisons between the school and hospital. The teacher needs to be informed of the child’s physical and emotional health to deal effectively with him or her. The nurse provides the children with opportunities to study undisturbed so that they are prepared for their classes. Whenever possible, diagnostic tests and treatments should be scheduled around established school routines.

Teachers should be notified if a child will be out of school for any length of time, and classmates should be encouraged to send cards, draw pictures, call, and visit if appropriate. The nurse should assist the child in displaying the cards and pictures. If possible, care should be planned around the visit of classmates and friends. Children need to maintain as much control as possible while in the hospital.


Adolescents may still want their parents present when they are hospitalized. They too miss their friends. However, some are hesitant to have friends visit because they are not sure how their friends will handle their illness or injury. They do not want to appear different or act differently, so compliance may be a problem if the child lives with a chronic disease. Even though adolescents may give the impression that they are not afraid, they actually may be terrified of being in the hospital. The whole process of why they are there and having to undergo different procedures may be very frightening to them. They may feel that they will no longer “fit in” with their friends. Encouraging adolescents to express their fears helps alleviate these stressors and allows them to work toward maintaining or reestablishing their identity. Offer choices; this helps them maintain control and independence.

In general, fear of the unknown affects all hospitalized children. The nurse must explain in an age-appropriate manner what the child can expect, whether it pertains to unit routines or to procedures that need to be performed.

Unclear limits and expectations can best be minimized by explaining the rules and the expectations to the child. Once children understand what is expected of them, they feel less threatened and confused.

The Family’s Reaction to Hospitalization

When a child is hospitalized, the whole family is affected. If the caregiver stays with the child in the hospital, then normal duties at home are neglected. Parents may be concerned about small children who are being cared for by relatives or friends. If the parents are unable to stay at the hospital, they may feel guilty about leaving the child. They may also attempt to rearrange their schedules to spend as much time as possible with the hospitalized child. Whatever the situation, the parents’ needs should be identified by the nurse, and efforts should be made to decrease the anxiety the parents experience.

Parents may initially feel guilty, helpless, and anxious. They often blame themselves for the child’s illness because they did not recognize early symptoms of a disease, may have delayed treatment, or were behind in preventive care. However, parents seldom are the direct cause of a child’s hospital admission. Even in cases of child abuse, nothing is gained by blaming the parents. The nurse must realize that developing a trusting relationship with parents is often at the center of helping the child. This can be done only if the nurse remains objective and empathetic. The nurse should listen, acknowledge feelings, and support the family.

Parents may also fear the unknown. They may be unfamiliar with the hospital setting, procedures, treatments, and the disease itself. Explaining the rules and protocol of the hospital unit will reduce anxiety. Discussing procedures ahead of time and educating the parents on the disease process will also help to allay anxious feelings. Many children’s hospitals now have educational areas designed for parents. Hospital librarians or other resource persons help parents to be empowered in the care of their child.

Hospitalization may cause financial problems for the family. This is especially true in the case of long-term illnesses and treatment. In addition to the obvious expense of the hospital and physician, families often have the added costs of travel, lodging, food, and missed work. The nurse must be aware of these needs and make the appropriate referrals to social services as necessary.

As with the child, the nurse assesses the family’s needs and develops interventions to meet these needs. Some of these interventions include the following:

Siblings are also affected when a family member is hospitalized. They may experience anger, resentment, jealousy, and guilt. Suddenly attention is focused on the sick family member, and siblings may feel neglected. When routines are changed and members are separated, the needs of the siblings may not receive attention. Siblings may feel resentment. This can lead them to feel guilty about their ill family member. The nurse can assist the parents in identifying and meeting the needs of siblings in the following ways:

The Nurse’s Role

Admission Process

A child must be prepared for outpatient procedures or hospitalization. If a planned, nonemergency hospitalization is required, the nurse should provide a tour of the pediatric unit to the parents and the child before admission. This is advisable and enables the parents to meet the people who will be caring for their child. Children and their families are often overwhelmed by the size of an institution and fear becoming lost.

Beginning as early as age 6 months, the child is worried about being separated from the parents. Increased stress can lead to increased separation anxiety. After age 3 years, children may become more fearful about what is going to happen to them. Parents should try to be as matter-of-fact about this new experience as possible. Unless they have been hospitalized before, children can only try to imagine what will happen to them. Much detail is not provided because giving information beyond a child’s understanding may create unnecessary fears. It is better to focus on the more pleasant and positive aspects—but not to the point where hospitalization seems to involve no discomforts. For example, one might mention that meals are served on a tray, that baths are taken from a basin at the bedside, and that the child will be with other children. The fact that there is a buzzer to call the nurse if necessary may add to the child’s sense of security. The parents may also plan with the child what favorite toy or book to bring to the hospital. Security objects from home will help reduce anxiety in an unfamiliar setting.

In addition to explaining certain procedures, it is important to listen to children and encourage questions. Parents should prepare children a few days, not weeks, in advance of a hospital admission. They should never lure children to the hospital under the pretense that they are actually going someplace else. In emergency situations, however, there may be little time for any preparation. In such cases, the entire medical team must try to give added emotional support to the child.

The nurse prepares the child’s room for the admission (including equipment needed for determining weight, length, vital signs, and so forth) well in advance. This saves time and frustration. Once the technical details are attended to, the nurse should concentrate on the approach to the child and the family. The initial greeting should show warmth and friendliness. Smile and introduce yourself to the family and the child. When addressing the child, position yourself at eye level. If the child is shy, talk to the parents first. Children may need time to feel comfortable. Speak in a quiet and unhurried manner. When the child and parents are taken to the child’s room, parents should be seated comfortably. Explain the admission procedure carefully. Avoid discussing information in front of the child that he or she will not understand. The parents are encouraged to do as much for their child as possible, such as removing the child’s clothes. This is also true throughout the hospital stay. Be prepared to meet the family’s emotional needs because many parents are stressed when their child is hospitalized.

The admission form asks about the child’s statistical information, health history, family history, lifestyle, and home routine. This includes questions about nutrition, elimination, sleep, activity, previous hospitalization, terminology used by the child, and so on. The questions are generally directed to the parent; the child can help answer if old enough. The nurse also inquires about the use of medications at home, including complementary medicine. Complementary and Alternative Medicine (CAM) is often used by parents with conventional treatments; the nurse needs to document the use of any alternative medicine products including herbs because of potential drug interactions or surgical complications (Box 2-2 and Table 2-1).

Box 2-2   Complementary and Alternative Medicine

• Complementary therapy refers to nontraditional therapy that is used with traditional or conventional therapy.

• Alternative therapy replaces traditional or conventional therapy.

• In 2005, the American Academy of Pediatrics reaffirmed its position statement on CAM for children with chronic illnesses or disabilities. The AAP recommends that physicians provide balanced advice about therapeutic options, guard against bias, and establish a trusting relationship with families. Physicians need to be informed and be willing to actively listen to the family and child with a chronic illness, realizing that many families may want to provide CAM as a treatment option.

• Often, a perception exists that CAM is more “natural” and “does no harm.” Some parents do not realize that herbal remedies can actually cause health problems for their children. The concept of “natural” may also disillusion parents.

• Consumers have no guarantee of quality because the Food and Drug Administration (FDA) does not require testing of herbal remedies for therapeutic or adverse effects.

Dec 22, 2016 | Posted by in NURSING | Comments Off on Care of the Child with Medical/Surgical Needs
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