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Chapter 2
Care of the Child with
Medical/Surgical Needs
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
Key Terms
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Adventitious
Case manager
Contaminated
Critical pathways
Disinfected
Dramatic play
Hospice
• Hypnosis
• Pediatric nurse
practitioner (PNP)
• Reconciled
• Standard precautions
• Therapeutic holding
• Triage
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Health Care Delivery Settings
Clinics and Offices
• Outpatient facilities and/or community clinics
– Run by a larger hospital
– A collaborating group of physicians, or a private
physician’s office
• Both general and specialty clinics exist
– Cardiac, orthopedic, respiratory, etc
• Elective surgery for uncomplicated conditions is
routinely done in outpatient clinics
– Parents/caretakers must be taught to meet all of a child’s
recovery needs at home for a same-day discharge
procedure
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Health Care Delivery Settings
Clinics and Offices
• Triage
– In most offices/clinics, nurses triage
(prioritize) and respond to telephone inquiries
• Pediatric Nurse Practitioner (PNP)
– Provide in-clinic patient care, including routine
physical exams in collaboration with the
physician
– Often they are the primary contact person for
children in the health care system
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Health Care Delivery Settings
Home Care
• Increasingly popular due to technical improvements
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Ongoing IV therapy home care
Phototherapy home care for jaundice
Lower cost
Increased patient satisfaction
• Case Manager
– Plays a vital role in home care arrangements by managing
complete medical care for the patient
– Facilitates linking home care families into a wide variety of
network services
• Hospice
– A team of hospice nurses and caregivers assist the
families in providing home care for terminally ill children
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Health Care Delivery Settings
Other Settings
• Support groups
– Geared toward family support and learning
– Group therapy aids in the prevention of mental health
problems for children who have undergone stressful situations
• Camps
– Many exist in the U.S. for children with chronic illnesses
– Camp nurses ensure children receive proper care
• Parish nurses
– Promote health within the context of a faith community
• Long-term care facilities
– May be necessary for children with severe mental retardation,
multiple disabilities or medical fragility
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The Hospital Setting
• Pediatric units differ from adult units
– A more cheerful, casual atmosphere in keeping with the
child’s emotional and physical needs
• Most pediatric departments include a playroom with
toys for various age groups run by a child life
specialist
– Nurses provide age-appropriate toys to children who
can’t leave their rooms
• A flexible routine is typically maintained in regards to
eating, play, and rest
• Most hospitals provide beds and encourage parents
to stay with their children
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The Child’s Reaction to Hospitalization
• Factors
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Age
Previous illness-related experiences
Support of family and health professionals
Emotional status
• Stressors
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Separation anxiety
Loss of control
Bodily injury
Pain
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Question 2.1
Which of the following is true pertaining to a
child in isolation?
A. The child may visit play areas with other
children, as long as careful sanitation
procedures are followed
B. The child shouldn’t be allowed any toys
because his/her disease is very contagious
and could spread easily through toys
C. The nurse may provide age-appropriate toys
to the child in his/her room
D. Both A & C
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The Child’s Reaction to Hospitalization
Infants and Toddlers
• Separation anxiety
– The major stressor of hospitalization for toddlers
– Occurs in the following stages
• Grief
– Protesting loudly and crying for their mothers until falling
asleep from exhaustion
• Despair
– Depression, lethargy, refusal to eat
• Denial
– Deny the need for mother by appearing detached and
uninterested in her visits
– A disguise to prevent further emotional pain
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The Child’s Reaction to Hospitalization
Infants and Toddlers
• Loss of control
• Regression
– Toddlers will abandon recently acquired skills and
demand assistance with tasks previously
mastered
– Nurses should remind parents that this is normal
behavior when toddlers are hospitalized
• Fear of injury
– Minimizing fear of injury stressors
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The Child’s Reaction to Hospitalization
Infants and Toddlers
• Dealing with the stressors of hospitalization
– Toddlers achieve control through choices
– Forewarn children about any unpleasant or new
experience immediately beforehand
– Be honest about procedures, etc., that may hurt
– Explain procedures step-by-step as they occur
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The Child’s Reaction to Hospitalization
Infants and Toddlers
• Dealing with the stressors of hospitalization
– Encourage play with safe equipment; i.e.,
stethoscopes under supervision
– Administer treatments in a room other than the
child’s room
– Allow toddlers out of the crib whenever possible
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Child’s Reaction to Hospitalization
Preschoolers
• Separation anxiety
• Uncooperative; frequently ask for parent
• Loss of control
– Many preschoolers perceive hospitalization as
punishment
• Regression
– E.g.: bedwetting
• Fantasy
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Pre-logical thinking; fantasy
Fear of hospital machinery
Nightmares
Fear of bodily harm during procedures
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The Child’s Reaction to Hospitalization
Preschoolers
• Communication between nurse and patient
– Use understandable language when describing
procedures
– Communicate time as a series of events, not
hours and minutes
– Be aware of verbal and nonverbal cues
– Participate in fantasies in a positive way, giving
the child control over imagined situations
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The Child’s Reaction to Hospitalization
Preschoolers
• Dealing with the stressors of hospitalization
– Dramatic play
• Children act out situations that are a part of their
hospital experience
• Allows children to “work through” emotions
• Make a doll with a dressing or an IV so the child can
act out the care they receive in order to displace their
fears.
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Child’s Reaction to Hospitalization
School-Age Children
• Separation anxiety
• Miss parents but miss friends more
• Loss of control
– Children in this age group are learning to control
their feelings and actions
– Independence is limited
– They may have changes in vital signs due to
stress when hospitalized, even if making efforts to
seem calm
• Fear of pain, bodily harm, permanent
disability, body disfigurement or death
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The Child’s Reaction to Hospitalization
School-Age Children
• Dealing with the stressors of hospitalization
– Bring items from home for familiarity and control
– Drawing
– Board games with involved adults
– Maintain the child’s privacy
– Continue education; connect to the outside world
– Encourage classmate correspondence; Oh, the
cell phones!!!
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The Child’s Reaction to Hospitalization
Adolescents
• May be hesitant to have visitors
– May be embarrassed by appearance
– Fear that illness or procedures will change them
• Compliance may be a problem with a chronic disease
– Probably afraid and stressed, even if they seem calm
• Dealing with the stressors of hospitalization
– Fear of the unknown; explain everything in an
age-appropriate manner
– Offer choices to maintain control and
independence
– Clear limits and expectations so adolescents feel
less confused
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Question 2.2
A mother is distraught to find her toddler uninterested in
her presence as she visits him in the hospital. She
begins reprimanding him. What action should the nurse
take?
A. None; a nurse shouldn’t come between a mother and
her child.
B. Explain that the child must be in a bad mood today,
and the mother should visit tomorrow.
C. Explain that his behavior is normal and encourage
continued frequent parental visits.
D. Discourage subsequent visits until the child is
discharged for his own mental health. Assure her that
he is in good hands.
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Hospitalized Child
The Family’s Reaction to Hospitalization
• Parents may initially feel guilty, helpless, and
anxious
• Developing a trusting relationship with
parents is often the key to helping the child
• Hospitalization may cause financial problems
for the family
• The nurse assesses the family’s needs and
develops interventions to meet these needs
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Hospitalized Child
The Family’s Reaction to Hospitalization
• Nursing Interventions
– Assist parents in obtaining written and verbal
information concerning the condition of the child and
the treatment plan
– Orient the family to the hospital
– Explain all procedures
– Refer the parents as needed to social services
– Listen to parents’ concerns and clarify information
– Involve parents in the care of the child
– Provide for rooming-in
– Reinforce positive parenting
– Provide educational resources as necessary
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Nurse’s Role
Admission Process
• Provide a tour for the parents and child before admission, if
possible to decrease fear of the unknown
• Focus on pleasant and positive aspects—but not to the
point where hospitalization seems to involve no discomforts
• Security objects from home reduce anxiety in an unfamiliar
setting
• In addition to explaining certain procedures, listen to
patients and encourage questions
• After essential admission information is documented, the
nurse performs a systems review and physical examination
of the child
• All medications are reconciled upon admission, transfer,
and discharge
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Nurse’s Role
Health History
• Statistical information (name, address, phone
number)
• Patient profile (eating and sleeping habits,
educational level, developmental level, etc.)
• Health history (birth history, illnesses,
immunizations, previous hospitalizations, allergies,
etc.)
• Family history (information concerning the health
status of the immediate family)
• Lifestyle and life patterns (social, psychological,
physical, and cultural environment)
• Review of systems
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The Nurse’s Role
Systems Review
• When examining the child, generally proceed
in a head-to-toe manner while collecting vital
signs
• Note the facial expression and the general
appearance of the child
• Always talk to the parents about how they
think their child is doing, because they know
their child best
• Be sure to document and report any unusual
or abnormal findings
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Nurse’s Role
Systems Review
• Pulse
– The pulse rate varies considerably in different
children of the same age and size
– An apical pulse is recommended for infants
and small children
– The normal pulse and respiratory rates of the
newborn infant are high
– Both pulse and respiratory rates gradually
decrease with age until adult values are
reached
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The Nurse’s Role
Systems Review
• Respirations
– Counted by observing the movement of the
abdominal wall because respirations are
primarily abdominal at this time
– After about age 7 years, the child’s
respirations are measured in the same way as
the adult’s
– Lungs should be clear to auscultation with no
adventitious or abnormal breath sounds
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Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Nurse’s Role
Cultural and Religious Preferences
• Cultural beliefs affect how a family perceives
health and illness
• Some practices raise concerns of abuse
– E.g.: Coining; cupping
• Inform families that strict disciplinary
practices may place them in jeopardy with
child protective services
• Respect any rites, dietary restrictions, etc.,
associated with a family’s religion, as long as
it does not interfere with the child’s well-being
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Nurse’s Role
Care Plans and Critical Pathways
• Most hospitals use nursing care plans
– Written expression of the nursing process
• Critical pathways
– Convert expected medical, nursing, social,
and emotional outcomes for a particular
problem into actions necessary to achieve the
outcomes within a specified time frame
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The Nurse’s Role
Discharge Planning
• Preparation for discharge begins on admission
• Directions for home treatment should be given to
parents gradually throughout their child’s
hospitalization
• Charting includes time of departure, person with
whom the child departs, patient’s behavior,
instructions/medications given to the patient or
parents, and weight/vital signs upon discharge
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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The Nurse’s Role
Discharge Planning
• Prepare parents for potential post-hospitalization behavior
problems
– Clinging, regression in bowel and bladder control, aggression, fears,
nightmares, negativism
– Return former family responsibilities within the limits of the child’s
present abilities as soon as possible
– Avoid making the child a center of attention because of illness. Praise
accomplishments unrelated to illness
– Be kind, firm, and consistent if the child misbehaves
– Be truthful to maintain trust
– Provide suitable play materials: Clay, paints, doctor/nurse kits. Allow free
play
– Listen to the child, clear up misconceptions about the illness
– Don’t leave child alone for a long period or overnight until a sense of
security is regained
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Safety
Transporting, Positioning, and Restraining the Child
• Means of transportation varies with a child’s age
• Ensure that a patient’s identification band is secure
before leaving the unit
• Holding a baby
– Head and back support is necessary for young infants
– Random movements of small children necessitate secure
holding
• Restraints should rarely be used
– Detailed documentation is required
– Restraints must be removed at least every 2 hours to
avoid impairing circulation
• Therapeutic holding
– Holding a child in a secure, comfortable manner
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Safety
Transporting, Positioning, and Restraining the Child
Do
• Check wheelchairs and stretchers before placing patients in
them
• Use safety straps with children when they are in a highchair,
swing, infant seat, stroller, and so on
• Apply restraints correctly to prevent constriction of a part.
Check institutional policy on frequency of releasing restraints
and providing range of motion
• Handle infants and small children carefully. Use elevators
rather than stairs. Walk at the child’s pace
• Place a hand on the infant or child’s back or abdomen when
you turn your back to the child
• Always look for small objects which can become choking
hazards
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Safety
Transporting, Positioning, and Restraining the Child
Do
• Protect children from entering the treatment room, elevator,
utility rooms, and stairwells
• Keep crib sides up at all times when the patient is unattended
in bed. Use enclosed (bubble top) cribs for older infants and
toddlers to keep them from falling or climbing out of the crib
• Turn an infant perpendicular to the side of the bed when rails
are down. This helps ensure that the infant will not roll off
when side rails are down
• Place cribs so that children cannot reach electrical outlets and
appliances
• Check hospital policy for children who are alone (for instance,
policy may recommend that the door be kept open)
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ADAPTED CRIB FOR SAFETY
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Safety
Transporting, Positioning, and Restraining the Child
Don’t
• Don’t force-feed small children. There is a danger of choking, which
may cause lung disease or sudden death
• Don’t allow ambulatory patients to use wheelchairs or stretchers as
toys
• Don’t leave a child unattended in a highchair, infant seat, swing or
stroller
• Don’t leave a child unattended on an examination table
– Always keep your hand on the child
• Don’t leave a child unattended in an infant seat if it is placed on any
area above the floor
• Don’t leave small children unattended out of their cribs in their
rooms
• Don’t leave a child unattended in the bathtub
• Do not tie balloons to the crib rails
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Safety
Medical Asepsis
• Contaminated
– A person/object that has come into contact with an infected patient
• Disinfected
– Killing microorganisms physically or chemically
Do
• Wash your hands before and after caring for each patient
• Properly disinfect any item brought out of an isolation room
Don’t
– Don’t cause cross-infection
• Diapers, toys, and materials that belong in one patient’s storage unit
should not be borrowed for another patient’s use
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Safety
Preventing the Transmission of Infection
• Standard precautions—Followed because a
history and physical exam cannot identify all
patients infected with HIV or other blood-borne
pathogens
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Handwashing
Gloves
Masks
Gowns
Protective eyewear
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Safety
General Safety Guidelines
Do
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Inspect toys for sharp edges and removable parts
Identify the patient properly before giving medications
Keep medications and solutions out of reach of the child
Keep the medication room locked when not in use
Keep lotions, tissues, disposable pads and diapers, and safety
pins out of infant’s reach
Locate fire exits and extinguishers on the unit and learn how to
use them properly. Become familiar with the facility's fire manual
Supervise playroom activity
Take proper precautions when oxygen is in use
Use electrical outlet safety plugs on the unit
Continually assess the patient setting for safety issues
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Safety
General Safety Guidelines
Don’t
• Don’t leave medications at the bedside
• Don’t leave any medication administration materials in
the child’s bed or infant’s crib
• Be aware of wear you place the caps from the pediatric
oral syringes. Do not leave in the bed!
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Safety
Education of the Family
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Importance of immunizing children
Proper food handling
Handwashing
Primary modes of infectious disease spread and
how to avoid them
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Implications of Pediatric Surgery
Patient Preparation
• The nurse should give simple information about the
system that will be affected
– Stress that this is the only area of the body that will be
involved
• Children need to know what to expect on the day of
surgery
• Children are particularly fearful of surgery and need
both physical and psychological preparation
• The child should be able to easily understand
explanations and information given in simple terms
• It is important to always be truthful; this establishes
trust
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The Child in Pain
Definition and Challenges
• Children of all ages experience pain and
are entitled to appropriate pain
management
• Pain is an individual, subjective
experience, and health care providers
need to identify and treat pain adequately
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The Child in Pain
Evaluation
• Always ask the child and/or the parents about past
pain experiences and known coping mechanisms
• When evaluating the child, include precipitating
factors, location, onset, duration, quality, intensity,
and characteristics of the pain
• Pain scales
– 1 to 10
– FLACC
• Infants and young children
– Oucher Scale
• 2- to 7-year-olds
– Wong-Baker FACES Pain Rating Scale
• Preschool and young school-age
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Wong and Baker Faces scale
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FLACC pain scale
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The Child in Pain
Intervention
• Oral administration is generally used for mild to moderate pain
• When the child needs immediate pain relief for more intense pain,
intravenous administration is indicated
• For moderate to severe pain that is expected to persist, continuous
dosing or around-the-clock dosing at fixed intervals is recommended
• Pain medication may also be administered rectally, by intramuscular
(IM) injection, transdermally, or topically (EMLA, LMX)
• Nonopioid analgesics are most effective for mild to moderate pain
and have antipyretic effects as well
• Opioids are used to manage most forms of moderate to severe
acute and chronic pain
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The Child in Pain
Intervention
• Nonpharmacologic interventions
– Used in conjunction with pharmacologic
interventions or by themselves
– Complementary or alternative medicine
(CAM)
• Hypnosis
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– Altered state of consciousness. Suggestions
can lead to changes in behavior or physical
sensations
TENS unit
Acupuncture
Chiropractors
Massage therapy
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