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.

FIGURE 2-2 A home care nurse helps the child attain an optimal level of functioning within the home setting.

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.

FIGURE 2-3 A child-friendly atmosphere on the pediatric unit may help children feel less anxious when hospitalized.

Communication

Always meet and speak with children at their eye level. Figures that tower over them can be frightening.

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.

Community Considerations

Child life specialists apply knowledge of child development, therapeutic play, treatment of stress, and other psychosocial principles in working with children and their families to help them cope effectively with potential stressful situations, primarily in hospitals, but also in a variety of other settings (www.childlife.org).

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.

Box 2-1 Nursing Interventions for Stressors of Hospitalization

Explain all procedures with honesty.

Include parents in the care of the child.

Encourage parents to stay with the child.

Maintain the routines and rituals of home.

Encourage parents to bring familiar objects from home (e.g., stuffed animal, blanket, doll).

If the parents cannot stay with the child, encourage them to call, leave photographs, and visit when possible.

Perform all invasive procedures in the treatment room to keep the child’s room a safe place for the child.

Provide for a consistent caretaker when possible.

Comfort the child after traumatic procedures if the parent is not present to care for the child.

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.

Communication

Using a stuffed animal, doll, or puppet decreases fear and helps the toddler to communicate. The nurse can use the inanimate object to assist in gaining the child’s cooperation. For instance, pretending to “count the heart rate” on a stuffed animal prior to the child will often elicit cooperation.

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.

FIGURE 2-4 To facilitate autonomy, young toddlers should be allowed outside of their cribs whenever possible.

Preschoolers

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.

Communication

Preschool children do not have a concept of time as it relates to the clock. If the child asks a question regarding time, the nurse might reply, “We will do that after cartoons” or “Mommy will come back after you eat your lunch.”

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.

Communication

Use of the first person can help a child express feelings. The nurse might say, “Sometimes when I am in a new place, I feel afraid.” The child can either agree, disagree, or remain silent. Silence might indicate that the child agrees but is still unable to express feelings.

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.

FIGURE 2-5 A child life specialist engaged in play therapy.

Nursing Brief

In addition to toys appropriate for the child’s age group, everyday hospital supplies such as tongue depressors and bandages may become works of art.

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).

FIGURE 2-6 While gifts can brighten a child’s hospital experience, objects from home provide comfort and familiarity.

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.

Communication