chapter 2 care of the child with medical/surgical needs copyright © 2012 by saunders, an imprint of...

Chapter 2

Care of the Child with Medical/Surgical Needs

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

Key Terms

2-2Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

Health Care Delivery SettingsClinics 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


Health Care Delivery SettingsClinics 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


Health Care Delivery SettingsHome Care

• Increasingly popular due to technical improvements– 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


Health Care Delivery SettingsOther 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


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


The Child’s Reaction to Hospitalization

• Factors– Age– Previous illness-related experiences– Support of family and health professionals– Emotional status

• Stressors– Separation anxiety– Loss of control– Bodily injury– Pain


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 followedB.The child shouldn’t be allowed any toys because his/her disease is very contagious and could spread easily through toysC.The nurse may provide age-appropriate toys to the child in his/her roomD.Both A & C


The Child’s Reaction to HospitalizationInfants 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



• 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



• 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



• 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


The Child’s Reaction to HospitalizationPreschoolers

• Separation anxiety • Uncooperative; frequently ask for parent

• Loss of control– Many preschoolers perceive hospitalization as

punishment• Regression

– E.g.: bedwetting• Fantasy

• Pre-logical thinking; fantasy– Fear of hospital machinery– Nightmares– Fear of bodily harm during procedures



• 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



• 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.


The Child’s Reaction to HospitalizationSchool-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


The Child’s Reaction to HospitalizationSchool-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!!!


The Child’s Reaction to HospitalizationAdolescents

• 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


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.


The Hospitalized ChildThe 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


The Hospitalized ChildThe 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


The Nurse’s RoleAdmission 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


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


The Nurse’s RoleSystems 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



• 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



• 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


The Nurse’s RoleCultural 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


The Nurse’s RoleCare 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


The Nurse’s RoleDischarge 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


The Nurse’s RoleDischarge 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


SafetyTransporting, 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



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



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)



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


SafetyMedical 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


SafetyPreventing 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– Handwashing– Gloves– Masks– Gowns– Protective eyewear


SafetyGeneral Safety Guidelines

Do• 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


SafetyGeneral 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!


SafetyEducation of the Family

• Importance of immunizing children• Proper food handling• Handwashing• Primary modes of infectious disease spread and

how to avoid them


Implications of Pediatric SurgeryPatient 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


The Child in PainDefinition 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


The Child in PainEvaluation

• 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


Wong and Baker Faces scale


FLACC pain scale


The Child in PainIntervention

• 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


The Child in PainIntervention

• Nonpharmacologic interventions– Used in conjunction with pharmacologic

interventions or by themselves– Complementary or alternative medicine

(CAM)• Hypnosis

– Altered state of consciousness. Suggestions can lead to changes in behavior or physical sensations

• TENS unit • Acupuncture• Chiropractors• Massage therapy


chapter 2 care of the child with medical/surgical needs copyright © 2012 by saunders, an imprint of...

Documents

imprint of elsevier

home care families

health care system2

home care arrangements

clinic patient care

complete medical care

nurses triage

childs emotional