At the end of unit 2, the students will be able to: Appreciate the differences between children and adult Describe the hospital environment for a sick child Explain the impact of hospitalization on child Discuss the grief and bereavement Outline the role of a child health nurse Explain the principles of pre- and post-operative care for children Perform pain assessment in children

1. Unit 2
Care of Hospitalized Child
Prof. (Dr.) Smriti Arora
Amity College of Nursing, Amity University Haryana
smritiamit@msn.com

2. Objectives
• At the end of unit 2, the students will be able to:
1. Appreciate the differences between children and adult
2. Describe the hospital environment for a sick child
3. Explain the impact of hospitalization on child
4. Discuss the grief and bereavement
5. Outline the role of a child health nurse
6. Explain the principles of pre- and post-operative care for children
7. Perform pain assessment in children

3. 1. Differences between children and adult
Airway: An infant is an obligatory nose breather for the first 6 months, a blocked nose can lead to respiratory
failure. Infants have very short and softer tracheas than adults. Tonsils and adenoids grow disproportionately
fast in children, making any inflammatory response more likely to compromise the movement of air.
• Infants have proportionately large heads, short necks and large tongues, which makes airway obstruction
more likely.
Breathing: A child has much small upper and lower airways which results in a great chance of respiratory
difficulties and failure.
• Infants are abdominal breathers who rely primarily on the muscles of the diaphragm. Abdominal distension
can lead to respiratory problems.
• Immature respiratory centre - neonates and young infants have irregular respirations and are at a greater
risk of apnoea.
• Children have higher RR than adults. Higher RR leads to proportionately higher minute volumes. As a result,
children may be more susceptible to agents absorbed through the pulmonary route than adults with the
same exposure.

4. Differences between children and adult
• Larger Body Surface Area- Children have a proportionately larger body surface area
(BSA) than adults. As a result, children are at greater risk of excessive loss of heat and
fluids.
• Skin- Children have thinner skin than adults. Epidermis is thin and under-keratinized, as a
result, children are at risk for increased absorption of agents that can be absorbed through
the skin.
• Immature blood brain barrier- Children have immature BBB and enhanced CNS
receptivity. Thus, children may exhibit a prevalence of neurological symptoms. Nerve
agents may produce more symptoms in pediatric patients, requiring levels of treatment for
children that are not indicated for adults with the same level of exposure.

5. Differences between children and adult
 Immature immune systems- susceptible to communicable diseases.
 Heart Rate – children have higher HR as compared to adults. The HR of
newborn is 110-160 beats/min
 Basic Metabolic Rate- Children have increased BMR, thus more susceptible to
contaminants in food or water; greater risk for increased loss of water when ill or
stressed. Medication doses must be carefully calculated based on the child's
weight and body size.
 Undeveloped hypothalamus- their ability to regulate temperature is impaired.

6. Differences between children and adult
 Rapidly dividing cells- Children's cells divide more rapidly than
adults to assist in their rapid rate of growth. Thus, children are more
susceptible to the effects of radiation than adults.
 Kidneys- Until 12-18 months of age kidneys do not concentrate urine
effectively and do not exert optimal control over electrolyte secretion
and absorption.

7. Differences between children and adult
Psychosocial Differences
• Unlike adults, children and adolescents are still in a period of social development
which involves learning the values, knowledge and skills that enable them to relate
to others.
Emotional
• Children and adolescents are still developing their ability to recognize and manage
their emotions or feelings, and this can be influenced by many social and
environmental factors. For infants and young children, their emotional bond of
attachment to their caregivers is crucial to their emotional development.
Inability to communicate
• Small children do not have the vocabulary to describe symptoms. The school age
children an describe symptoms with accuracy.

8. 2. Hospital environment for a sick child
A child friendly environment should have:
 specially trained and experienced professionals to provide high quality care
 facilities, equipment and medications tailored to fit the needs of children.
 bright colors, themed décor and plenty of areas and opportunities to play

9. Measures to make hospital environment friendly for children
 Provide good illumination
 Keep floors clear of fluid or objects that might contribute to falls
 Use nonskid surfaces in washrooms
 Familiar with the area-specific fire plan
 Secure all windows, blind and curtain cords should be out of reach of children.
 Keep plants away from immunocompromised children as they may harbor microbes.
 Electrical equipment should be in good working order and kept away from children.

10. Measures to make hospital environment friendly for children
 Furniture should be checked for safety. Do not leave infants and young children,
unattended on treatment tables, weighing scales or in treatment areas.
 Prevent fall from the beds, and cribs by raising the side rails. Electronically
controlled beds cause danger of entrapment.
 Asses the safety of toys. Toys should be appropriate to the child’s age, condition, and
treatment.
 Setting limits is essential, and children should know where they are permitted to go
and what they are supposed to do.
 Ensure safe transportation for children within or outside the unit.
 Ongoing assessment, evaluation, and documentation of restraints should be done

11. 3. Impact of hospitalization on child
• The reaction of child to hospitalization depends on :
Child’s developmental level
Presence of the mother/caregiver, preparation of the
mother
Socioeconomic status of family
Hospital environment

12. Stressors of hospitalization include
1. Separation
anxiety
2. Loss of
control
3. Bodily injury
and pain

13. Separation Anxiety
Phase of Protest Phase of Despair Phase of Detachment
• Aggressive
• cry and scream for their
parents, inconsolable.
• cling to parent when
they reach, and avoid or
reject contact with
anyone else.
• Toddlers verbally and
physically attack
strangers, attempt to
escape from the area to
find parents.
• Crying stops and depression is
evident.
• Child is less active and shows no
interest in food or play.
• looks sad, lonely, isolated and
apathetic.
• regress to earlier behavior- thumb
sucking, bed wetting, or use of a
pacifier.
• Child’s physical condition may
further deteriorate from refusal to
eat, drink or move.
• Others usually misinterpret this
phase for child’s cooperation, and
adjustment to his hospitalization.
• The child appears to
have finally adjusted
to the loss.
• Child starts showing
more interest in the
surroundings, plays
with others and
seems to form new
relationships.

14. Nursing management for a hospitalized child
Nursing Interventions
• Assess physical tolerance and abilities to perform ADL, and play activities and
restrictions imposed by the illness and medical protocol.
• Provide personal care for the infant and small child; assist child and adjust times
and methods to fit home routine.
• Anticipate child’s needs for toileting, feeding, brushing teeth, bathing and other
care if unable to manage on own; allow the child to do as much as possible.
1. Nursing diagnosis- Self-Care Deficit
Goal- Child will attain maximum self-care capability

15. Nursing interventions
• Praise the child for participation in own care according to
age, developmental level, and energy to promote self-esteem
and independence.
• Balance activities with rest as needed; place needed articles
and call light within reach if appropriate to prevent fatigue by
conserving energy
• Provide assistive aids or devices to perform ADL, allow choices
when possible.

16. 2. Nursing diagnosis- Anxiety R/T change in environment AEB crying,
restlessness
Goal- Child and family will experience reduced anxiety.
Nursing Interventions
• Assess child’s and parents’ level of anxiety, child’s developmental level,
understanding of illness, and reason for hospitalization, and responses to
this and prior hospitalizations during admission.
• Assess social and emotional history of child and family for strengths and
effective coping ability.
• Allow verbalization of feelings and concerns about condition
and procedures and listen individually to child and parents.
• Allow the child to play out feelings. Accept feelings and responses
expressed by the child.

17. Nursing Interventions
• Provide consistent same personnel in the care of child
• Provide orientation to hospital environment and room, routines,
meal and play time, introduction to staff members, forms to sign
and hospital policies.
• Interact with child in a positive manner; use child’s proper
name; avoid communicating, either verbally or nonverbally, any
rejection, judgments, or negativism.

18. Nursing Interventions
• Provide a calm, accepting environment and avoid hurrying through
interactions
and care.
• Maintain a quiet environment, control visitors, and interactions.
• Encourage involvement of child and parents in planning and interventions
of care; allow parents to remain with child; allow to hold and cuddle the
child.
• Allow child and parents to incorporate home routines as much as possible;
bring toys, tapes, photographs and favorite foods from home as
appropriate.

19. Nursing Interventions
• Assess and recognize regressive behavior as a part of the illness and
assist the child in handling dependency associated with the hospitalization.
• Provide support to child during any procedures associated with care,
including intrusive procedures, exposure of body parts, need for personal
privacy.
• Use therapeutic play to explain and prepare the child for procedures;
repeat any teaching as needed.
• Acquaint parents and child that behavior caused by anxiety and fear is
normal and expected.

20. 3. Nursing Diagnosis- Knowledge deficit
Goal- To provide adequate knowledge R/T disease condition and treatment
Nursing Interventions
• Inform and explain all procedures and plans in simple, understandable
language to child and parents based on their intellectual level and age; pace
information according to child/parental needs.
• If surgery is planned, provide information on the surgical procedure to
be done, purpose of surgery, and duration of hospitalization and preoperative
and postoperative care.

21. Care of hospitalized child includes:
Prepare for hospitalization – explain, encourage questioning
Prevent or minimize separation – Rooming in
Minimize loss of control
Prevent minimize bodily injury
Allow for regression
Provide pain management (Atraumatic care)
Provide for developmentally appropriate play activities
Focus on developmental age rather than chronological age.

22. 4. Grief and bereavement
Factors affecting grief and bereavement in children:
• age
• gender
• developmental stage
• personality
• ways they usually react to stress and emotion
• relationship with the person who has died
• earlier experiences of loss or death
• family circumstances
• how others around them are grieving
• amount of support around them

23. Infants and toddlers
Reactions Management
• looking for the person who has
died
• being irritable, crying more
• wanting to be held more; being
clingy
• being less active – quiet, less
responsive
• possible weight loss
• being jumpy, anxious, being
fretful, distressed
• keep routines and normal
activities going as much as
possible
• hold and cuddle them more
• speak calmly and gently to
them
• provide comfort items, such as
a cuddly toy, special blanket etc

24. Preschoolers
Reactions Management
• hard to understand that death is permanent.
• magical thinking- for example, thinking
someone will come alive again or thinking
somehow they made someone die.
• looking for the person who has died
• dreams, or sensing the presence of the person
who has died
• fearfulness, anxiety
• Clinginess, being fretful, distressed
• being irritable; having more tantrums
• withdrawing, being quiet, showing a lack of
response
• changes in eating, difficulty in sleeping
• toileting problems, bed wetting, regression
• explain that death is a part
of life, so they come to
understand it bit by bit.
• Give examples of plants
grow, bloom and die or
seasons change

25. Schoolage
Reaction Management
• Children understand that all body
functions stop with death. They begin
to internalize the universality and
permanence of death.
• The greatest death anxiety is in this
age group. They may be very curious
about the details of death, but begin
to hide feelings or engage in magical
thinking where they believe they are
powerful enough to cause someone’s
death by their thoughts.
• There may also be fear that death is a
punishment for bad thoughts or
actions.
• Offer constructive ways for them to
release the great energy of grief, such
as running, other sports activities, or
hitting a tennis racket on a mattress.
• Encourage a support group or writing.
• Provide reassurance and honesty.

26. Adolescents
Reaction Management
• being easily distracted, forgetful, having difficulty
concentrating at school
• overwhelmed by intense reactions, such as anger, guilt,
fear, having difficulty expressing intensity of emotions, or
conflict of emotions, blaming themselves for the death
• anxiety – increased fears about others' safety, and their
own
• having questions or concerns about death, dying,
mortality; dreams about, or sensing the presence of, the
person who has died
• wanting to be near family or friends more
• physical complaints- headaches
• being irritable, defiant, antisocial or display aggressive,
risk-taking behaviour- drinking, drugs, sex, reckless driving
• changes in eating, sleeping habits, bedwetting
• masking feelings, a sense of loneliness – isolation, a
change in self-image, lower self-esteem, possibly suicidal
thoughts, possibly moving from sadness into depression
• be honest and let them know what's
happening
• be willing to listen, and available to
talk about whatever they need to talk
about
• acknowledge the emotions they may
be feeling—fear, sadness, anger
• it can be helpful for parents, or other
adults, to share their own feelings
regarding the loss
• let them help in planning the funeral
or something to remember the loss

27. 5. Role of a child health nurse
Maintaining therapeutic and trusting relationship with the client and their family
Family advocacy and caring
Disease prevention and health promotion
Health teaching
Counseling and supporting
Restoration of health by caregiving activities
Coordination and collaboration with other professionals
Ethical decision making
Participating in Research and innovations

28. 6. Principles of pre- and post-operative care
for children
Preoperative management
• Elicit history, review previous medical records, interview the parent and child. Perform
focused preoperative assessment, do physical examination.
• Psychological preparation: pre-admission educational programmes reduce the stress of
admission for parents and children. Educate the caregiver about the surgery, encourage
questioning. Give age appropriate explanation to the child about surgery Toys and a
relaxed atmosphere are essential. Avoid separating the child from the parent.
• Recognize the need for blood transfusion.

29. Preoperative management
• Fasting guidelines: clear written instructions about the period of preoperative
fasting should be issued and the importance of compliance stressed (prevents
aspiration).
• Ensure that all the investigations are done and reports attached in the file.
• Ensure anaesthetic check up is done
• Premedication: administer anxiolytics like midazolam for the particularly anxious
child, anticholinergics and antibiotics. Topical local anaesthetic creams such as
Emla or Ametop are routinely used to enable virtually painless cannulation.

30. Postoperative management
• Ensure airway is patent. Perform oral, ET or tracheostomy suctioning as required.
• Change position 2 hourly.
• Administer oxygen. Monitor spO2 , ABG values.
• Maintain fluid and electrolyte balance, administer IV fluids at correct drop rate, maintain
intake output chart. Monitor serum electrolyte values. Notify physician if abnormal.
• Take care of drains (chest, abdominal), follow asepsis, monitor for signs of infection
• Follow standard precautions while performing any procedure to avoid infections
• Monitor and record vitals.

31. Postoperative management
• Keep the child NPO until advised which depends on the type of surgery done.
• Minimize pain by administering analgesics.
• Incorporate play while dealing with child.
• Monitor for complications- nausea, vomiting, bleeding, delayed micturition,
unsteady gait etc.
• Give postoperative health education to the caregivers related to the surgery eg
breathing exercises, advise about ambulation, colostomy care etc.
• Advise for follow up at regular intervals.

32. 7. Pain assessment in children
Self report measures Behavioural Indicators Physiologic Indicators
• valid,
• require a certain
level of
cognitive and
language
development for
the child to
understand and
give reliable
responses
• eg- NRS,
faces pain scale
• more frequently used with
neonates, infants, and younger
children where communication is
difficult
• Short attention span, irritability
• Facial expressions - grimacing, biting
or pursing lips
• Posturing (guarding a painful joint by
avoiding movement), remaining
immobile, or protecting the painful
area; Drawing up knees, massaging
affected area
• Lethargy, remaining quiet or
withdrawal , Sleep disturbances
• tachycardia
• tachypnea
• hypertension
• pupil dilation
• pallor
• increased perspiration
• increased secretion of
catecholamines and
adrenocorticoid
hormones.

33. Self report measures

34. The
Neonatal/Infant
Pain Scale (NIPS)
• Recommended for
children less than 1 year
old.
• Total pain scores range
from 0-7.
• A score greater than 3
indicates pain.
VARIABLE FINDINGS POINTS
1 Facial Expression
Relaxed muscles Restful face, neutral expression 0
Grimace Tight facial muscles; furrowed brow, chin, jaw,
(negative facial expression-nose, mouth and brow)
1
2 Cry
No cry Quiet, not crying 0
Whimper Mild moaning, intermittent 1
Vigorous Cry Loud scream; rising, shrill, continuous (Note: Silent
cry may be scored if baby is intubated as evidenced by
obvious mouth and facial movement)
2
3 Breathing Pattern
Relaxed Usual pattern for this infant 0
Change in
Breathing
In-drawing, irregular, faster than usual; gagging; breath
holding
1
4 Arms
Relaxed/Restraine
d
No muscular rigidity; occasional random movements
of arms
0
Flexed/Extended Tense, straight arms, rigid and/or rapid extension,
flexion
1
5 Legs
Relaxed/Restraine
d
No muscular rigidity; occasional random leg
movement
0
Flexed/Extended Tense, straight legs; rigid and/or rapid extension,
flexion
1
6 State of Arousal
Sleeping/Awake Quiet, peaceful sleeping or alert random leg movement 0
Fussy Alert, restless, and thrashing 1

35. Interpretation of NIPS
SCORES PAIN LEVEL INTERVENTION
0-2 Mild to no pain None
3-4 Mild to
moderate pain
Non-pharmacological intervention
with a reassessment in 30 minutes
>4 Severe pain Non-pharmacological intervention
and possibly a pharmacological
intervention with reassessment in 30
minutes

36. Faces Legs Activity Cry Consolability Revised (FLACC-R) Scale

37. Interpretation of FLACC-R
SCORES PAIN LEVEL
0 Relaxed and comfortable
1-3 Mild discomfort
4-6 Moderate pain
7-10 Severe pain or discomfort or both

38. Pain management in children
• Non Pharmacological and Pharmacological methods
• Non Pharmacological methods
distraction to shift attention away from pain- visual aids like pictures, cartoons,
mobile phones, mirrors, playing with electronic devices, watching videos; auditory
aids like music, singing, talking, or reading a book; providing toys with lots of
colour or toys that light up
reducing noise and lighting, use of soothing smells and clustering procedures to
avoid over handling
non-nutritive sucking, skin to skin contact
rocking and holding the infant, swaddling the infant
breathing exercises like blowing bubbles
age appropriate explanation to school age and adolescents

39. Pharmacological methods to manage pain
Non-opioid analgesic Opioid analgesics
1. Nonsteroidal anti-inflammatory drugs- anti-
inflammatory, analgesic, antipyretic, and
antiplatelet properties. First line
pharmacologic therapy for pain management.
acetic acids (ketorolac),
proprionic acids (ibuprofen, naproxen)
cyclooxygenase-2 selective (celecoxib)
Ketorolac- IV or intranasal
2. Acetaminophen (paracetamol) – PO,
rectally, IV; for mild to moderate pain and
antipyretic
for acute moderate to severe pain
refractory to other therapies.
Examples:
• Codeine
• Tramadol
• Hydrocodone
• Morphine
• Hydromorphone
• Fentanyl
• Methadone

40. Summary
• Children have specific needs according to their age
• It is important to understand their development pattern to give
adequate care and for early identification of problems.
• Parents need to be involved in child care
• Different age groups of children express loss, death, grief and pain
differently. Their reactions to hospitalization are different.
• For a hospitalized child with surgical condition, some common
principles need to be followed.
• Pain in children can be measured.

41. ThankYou!!!