SEMINAR

ON
STRESS AND REACTIONS REALTED TO DEVELOPMENTAL
STAGES
NURSING CARE OF HOSPITALISED CHILDREN AND FAMILY

GUIDED BY
PROF SHINY MATHEW
CHILH HEALTH NURSING

PRESENTED BY
VANSANGPUII
1ST YEAR, MSC(N)
• Stress is an imbalance between environmental demand
and a person’s coping resources that disrupts the
equilibrium of the person
• Approx. 35% of American children experienced stress
due to health related problems
 STRESS
• According to endocrinology Han Selye stress refers to “the reaction and
adaptation of any organism to perceived threat “
• At the cellular level, stress is fundamental to life because it motivates
actions and behavior
 STAGES OF STRESS

FIGHT OR DAMAGE
RECOVERY
FLIGHT CONTROL

ADAPTATION BURNOUT
 BIOLOGICAL RESPONSES TO STRESS

i. Musculoskeletal system
ii. Cardiovascular system
iii. Respiratory system
iv. Endocrine system
v. Gastrointestinal system
 MUSCULOSKELETAL SYSTEM

• When body is stressed, muscles tense up

• Muscle tension is almost a reflex reaction to stress
• Tight muscles can cause headache, shoulder pain and body aches
 RESPIRATORY SYSTEM

• Stress and strong emotions can present with respiratory symptoms such as
shortness of breath , rapid breathing, etc.
• Under stress , the heart pumps faster
• Stress hormones causes the blood vessels to constrict and divert more
oxygen to the muscles , which further raises the blood pressure
 CARDIOVASCULAR SYSTEM
• Chronic stress, constant stress can contribute to long term problems for
heart and blood vessels
• Increase heart rate, elevated levels of stress hormones and of blood
pressure
• This can lead to increase risk for hypertension
 ENDOCRINE SYSTEM
• During stress, the brain initiates a cascade of events involving the
Hypothalamic Pituitary Adrenal which ultimately results in production of
• Cortisol increase the level of energy fuel available by mobilizing glucose
and fatty acid from liver
• During stressful event, an increase in cortisol can provide energy required to
deal with prolonged or extreme challenge
 GASTROINTESTINAL SYSTEM

• Stress may make swallowing difficult or increase amount of air that is

swallowed that increase burping , gases, bloating
• Stress may make pain , bloating , nausea and other stomach discomfort
• Affects digestion , affects people with chronic bowel disorders such as IBD
 BIOLOGY OF STRESS
• The endocrine interactions are relevant in translation of stress into
physiological and psychological changes
• The activity of sympathetic nervous system derives ‘fight or flight’
response
• They respond to stress which involves mydriasis, increased heart rate ,
sweating , sweating, etc.
• The parasympathetic system response ‘rest and digest’ which involves
return to maintain homeostasis
 EFFECTS OF CHRONIC STRESS

1. Acute time limited stressors result in an up regulation of natural immunity

and down regulation of specific immunity

2. Infections : increase risk for RTI, herpes ,etc.

3. Chronic disease: stress appears to play role in hypertension and other

condition associated with hypertension, may also contribute to aging,
chronic depression and metabolic disorders

4. Development: impaired developmental growth

 FAMILY STRESS THEORY
FRIEDMAN’S STRUCTURAL FUNCTIONAL THEORY
• Emphasizes the social system of the family such as organizational structure
of the family and how structures relates to the function
Key components
• Affective function
• Socialization and social placement function
• Reproductive role
• Economic function
• Health care function
VON BERTSLSNFFY GENERAL SYSTEM THEORY -1968
• Emphasize the family as a system with interdependent ,interacting parts
than endure overtime to ensure survival , continuity and growth of it’s
components
Key components
• Used to define how families interact with and influenced by the members of
their family and society
• How to analyze the interrelationship of the members and impact that change
affecting one member will have on another member
DUVALL’S DEVELOPMENTAL THEORY -1977
• Emphasizes the developmental stages that the family go through, beginning
with marriage , longitudinal career of the family .
 FAMILY STRESS THEORY (BOSS-2002)

• Address the way family respond to stress and how family copes with the
stress as a group and how each individual member copes
Key Components
• Describes elements of stress as occurring internally within the family
• Mobilization of family resources in either positive or negative response of
crisis
• Identifies the main determinant of adequate coping based on the meaning of
stressful event to the family and members
STRESSORS OF HOSPITALIZATION AND CHILDREN’S
REACTION
• Illness and hospitalization are the first crisis children face
• Stress represents a change from the unusual state of health and environmental
routine
• Children have limited number of coping mechanisms to resolve stressors
 1)SEPARATION ANXIETY

• The major stresses from middle infancy through pre school years is
separation anxiety
• During this phase of protest children react aggressively
• They cry, scream , refuse attention of anyone else , inconsolable
• During phase of despair, crying stops and depression is evident
• During detachment phase client has finally adjusted to the loss
MANIFESTATIONS OF SEPARATION ANXIETY

PHASE OF PROTEST

PHASE OF DESPAIR

PHASE OF DETACHMENT
 2)LOSS OF CONTROL
• One of the most factor influencing stress imposed by hospitalization is that
amount of control that person perceived themselves as having
• Lack of control increases perception of threat and can effect children’s coping
skills
LOSS OF CONTROL

1. Infants
• They are developing the most important attribute of healthy personality
• Trust is established through consistent loving care
• Infants attempts to control their environment through emotional expression
such as crying and suckling
• Inconsistent care and duration form infants daily routine may lead to
mistrust and decrease sense of control
2. Toddlers
• They are seeking autonomy
• If egocentric pleasure meet obstacles , toddlers react with negativism , temper
tantrums
• Any restriction or limitation of movements may led to forceful resistance and
non -compliance
• The experience of hospitalization and illness severely limits their sense of
expectation and predictability
3. Pre schoolers
• They also suffer loss of control caused by physical restriction, altered
routines and enforced dependency
• This loss of control in the context of their sense of self power is critical
influencing factors in their perception of reaction to separation, pain ,
illness ,etc.
4) School aged children
• Because of their strive to independence and productivity they are particularly
vulnerable to events that may lessen their feeling of control and power
• Altered family role, physical disability , permanent injury , lack of
productivity , inability to cope with stress may result in loss of control
5) Adolescents
• Struggle for independence , self assertion and liberation center for the quest of
personal identity
• Anything that interferes with them poses a threat to their sense of identity and
result in loss of control
3) BODILY HARM AND PAIN
• When children enters into hospital , he is most concerned about pain and bodily
injury
• When children experience pain, they become reluctant to enter the hospital
• Children in different age group reacts differently
INFANTS
• infants may express pain by assuming certain positions, such as squirming,
writhing, jerking
• Some infants may cry loudly after the procedure, where as others are easily
calmed by a gentle hug
• Research has found that infants have stored memories acute pain, experiences
and react in subsequent painful events with heightened behavioral responses
to pain.
• Older infants react intensely with physical resistance and uncooperativeness.
TODDLERS
• The older the child, the more elaborate/intense is the protest.
• The child cries, cling to the parent, kick, and generally create a scene. Parents
need to understand that this behavior is a sign of healthy parent-child
attachment.
• The toddler may resist bedtime and eating, temper tantrums, regression (esp.
with toileting and eating).
• By the end of the toddler period a child is able to locate their pain but not able
to describe the intensity of pain.
PRESCHOOLER

• Have fear of injury and pain. They react with verbally abusing their attackers.
Here nurses need to understand that this is just an expected normal behavior
from a preschooler.
• The preschooler fears mutilation. The child who has surgery experiences
increased fear
• Also afraid of intrusive procedures, and because of their literal interpretation of
words, they often imagine treatments to be much worse than they are.
• Imagination can go wild during illness.
SCHOOLER
• Able to describe their pain with words. Most of the time they demand
explanation of procedures from the caregivers
• Older children may be more concerned with missing school and the fear that
their friends will forget them.
• School aged children are more relaxed about having a physical examination or
having the eyes or an ear examined but are uncomfortable with any type of
genital examination
ADOLESCENT
• Body image is paramount during adolescence.
• Because of the development of secondary sexual characteristics, adolescents are
concerned about privacy.
• They may react to pain with much self control but they will not tolerate lack of
privacy during procedures.
• They tend to observe all the procedures you demonstrate on them.
• One has to look for the physical indications, such as limited movement,
excessive quietness or irritability
 EXPERIENCES OF CHILDREN IN HOSPITAL AND THEIR
RESPONSES
• Recent empirical data highlights that adverse effects of hospitalization on
children have been found to be stronger when parents are highly anxious
• Estimates of the incidence of emotional problems of hospitalization has
been reported to vary from 10-30% for severe psychological distress
• Research on pediatric hospitalization has shown that procedure involving
needles and injections or blood test and transfusions often evoke a
distressing and fearful reaction
• Chronically ill children often suffer from additional anxiety
• Hospitalized children are commonly confused, frightened and in need of
support , reassurance and explanation
 EFFECTS OF HOSPITALIZATION ON CHILDREN
• Children may react to stress of hospitalization before , during and after
hospitalization
Individual risk factors:
• rural children may exhibit significantly greater degree of psychologic upset
• Stressors of hospitalization may cause children to experience short and long
negative outcomes
• Common responses include regression, separation anxiety, apathy, fears and
sleeping disturbances
Changes in pediatric population
• Pediatric population in hospitals has changed dramatically over the past two
decades
• With growing trend towards shortened hospital stay, children have more
serious and complex problems than those in the past
• Many of these are fragile newborn and children with severe injuries who have
survived because of technological advances
• The nature of their condition increases the likelihood that they will experience
more invasive and traumatic condition
Risk factors thar increases children’s vulnerability to stress of environment
• Difficult temperament
• Lack of fit between child and parent
• Age ( especially 6m-5 years)
• Male gender
• Below average intelligence
• Multiple and continuing stress
 BENEFICIAL EFFECTS OF HOSPITALIZATION

• Most benefit is recovery from

disease and illness
• Hospitalization also can present
an opportunity for children to
master stress
• Feel competent in coping skills
• It provides children with new
socialization experiences that can
broaden their IPR
 STRESSORS AND STRESS REACTIONS OF FAMILY OF
HOSPITALISED CHILDREN
1. Reaction of parents
2. Siblings Reaction

FACTORS AFFECTING PARENT’S REACTION TO CHILD’S ILLNESS

• Seriousness of threat to child
• Previous experience to illness or hospitalization
• Medical procedure involved
• Available support system , personal ego strength
• Previous coping abilities , cultural and religious beliefs
 POST HOSPITAL BEHAVIOR IN CHILDREN

YOUNG CHILDREN OLDER CHILDREN

• Shown initial aloof to parents • Emotional coldness
• Tendency to cling to parents • Anger towards parents
• New fears • Jealousy towards parents
• Hyperactivity
• Temper tantrums
• Food funkiness
• Attachment to blanket or toy
EVALUATING DIFFERENT STRESSORS AMONG
PARENTS WITH HOSPITALISED CHILREN

• Study conducted by La Clare et al proved that parents are obviously affected

by their children’s illness. Hospital procedures cause anxiety to parents .

• Different studies claimed that parents of hospitalized children likely reported

depressive symptoms, anxiety and poorer over health

• Study conducted on Fieric Hospital 2019 among general pediatric population

showed that parents of hospitalized children experience stress from different
stressors
Contd.
• A study conducted in Italy, among parents of hospitalized children showed
that the parents have high levels of stress and anxiety
• And the study conducted by Zenab et al 2021 among parents of
hospitalized children showed that male parents are tended to be more
stressed than female
 ALTERED FAMILY ROLE
• One of the most common reaction of parents towards sick child is
specialized intensified attention
• The other siblings may regard this as unfair
• Ill children may also feel jealously and resentment from other siblings
• Rivalry between siblings
NURSING CARE OF HOSPITALISED CHILDREN
• Preparation for hospitalization
• Admission assessment
• Preparing child for admission
• Preparing the child and family for surgery
 PREPARATION OF UNIT

• Pediatric unit have adequate provision of care of children and protection

from physical dangers
• The unit should be happy and attractive
• Colorful walls with suitable paintings
• Furniture should be attractive and fast colors
• Floor should be non slippery
Contd.
• Should have different rooms for different purposes
• Must meet the needs of parents and children
• Good lighting, plenty of fresh air, good ventilation
• Spacing should be 6-8 ft.
• Comfortable temperature and humidity of 65%
• Recreational facilities
NURSING INTERVENTIONS
NURSING INTERVENTIONS
Contd.
• Preventing or minimizing bodily harm
• Providing developmentally appropriate activities
• Providing opportunities for play
• Diversional activities
• Toys
• Expressive activities
• Creative expression
• Dramatic play
MAINTAINING SAFETY DURING HOSPITALIZATION !!

• Safety is a critical aspect of care of children in the hospital

• Due to their age and developmental level , children are vulnerable to injury
Contd.
• Ensure that ID band is kept at all times
• Monitor children closely
• Use of restraints
• Side rails
• Therapeutic hugging
 MAXIMIZING POTENTIAL BENEFITS

Fostering parent child relationship

Providing educational opportunities

Providing socialization
 NURSING CARE OF THE FAMILY
• Support family members
• Providing information
• Encouraging parent participation
• Preparing for discharge and home care
CARE OF CHILD AND FAMILY IN SPECIAL HOSPITAL SITUATIONS
Ambulatory or Outpatient Setting
• Child and parent should receive pre admission preparation
• Parents need information in advance
• Parents also appreciate suggestion for item to bring in the hospital
 ISOLATION
• All children especially younger ones need preparation in terms of what they
see, hear or feel in the isolation
• Before entering nurse must introduce themselves and let the child know
their face
• Child child’s condition improved, appropriate play activities must be
provided
 EMERGENCY ADMISSION
• Unless an emergency is life threatening , children need to participate in
their care to maintain a sense of control
• Ensure privacy, accept various emotional responses to fear or pain
• Preserve parent child contact
• Explain all events before or as they occur
 INTENSIVE CARE UNIT

• Family’s emotional need are paramount

• Parents want to know if their children will live or die
• They must know what interventions are given/done
• Parents must be prepared regarding child’s appearance
• Nurse should accompany parents to bedside to provide environmental support
NURSING CARE OF PEDIATICS PATIENTS BY STAGE OF
DEVELOPMENT
INFANTS
• Swaddle, hold, pat and provide other gentle physical contacts with infants
Use a soft voice and calm approach
• Sudden, loud movements frighten them, sing songs or play music to
soothe infants
• Distract the infant during procedures with a rattle or eye catching object.
• Care for the same infant day after a day to promote consistency and
decrease the likelihood of stranger anxiety that is common in infants from
6 months to 18 months.
Contd.
• Provide a favorite toy or blanket to establish trust and consistency in the
hospital setting.
• Infants enjoy peek-a-boo around 9 months of age.
• Offer the infant a pacifier, bottle or have mother breastfeed after a painful
procedure
• Reduce excessive stimuli and promote a quiet environment
• Provide non-nutritive sucking with sucrose during the procedure since this
has shown to calm infants
 TODDLER
• Allow the toddler to sit on the parent's lap during the procedure or exam.
• Use distraction such as the parent blowing bubbles or reading to the child
during the procedure.
• Prepare the toddler no more than one day ahead of time for the procedure
otherwise it can increase anxiety at this age level.
• Ask the child to point to a body part that you are going to examine.
• Show the child the equipment you will use.
Contd.
• raise the child using his/her first name for cooperating.
• Allow the toddler to dress self, use potty-chair, and self feed.
• Perform treatments in a separate room rather than toddler's bedroom so
his/her bed is a safe haven
• Allow the toddler to choose a sticker after the procedure.
• Comfort the toddler after a painful procedure by rocking, singing, offering a
snack, or holding him/her.
 PRE SCHOOL CHILDREN
• Allow the child to touch or play with equipment you will use
• Have the preschooler sit on the parent's lap
• Use drawings to help explain procedures and allow the child to draw both before and after
the procedure to process the information.
• Expect cooperation by using positive statements such as, "Open you mouth
• Use the doll or stuffed animal to practice what is happening to him/her
• Be alert to the comfort level of the child with male or female nurses and to accommodate
the child if possible.
 SCHOOL AGE CHILDREN
• Allow the child to express his/her concerns and provide reassurance.
• Focus on positive behaviors and reinforce these behaviors
• Encourage the child to resume schoolwork as quickly as feasible.
• Be alert to manipulation by the child to avoid a treatment or procedure
• Encourage the child's friends to visit or call the patient.
• Allow the child to choose his/her reward after the procedure
• Teach techniques like counting, breathing or visualization to manage difficult
situations.
 ADOLESECT
• Allow for regressive behavior and expect it
• Respect their need for privacy
• Encourage socialization with peers from within and outside the hospital
• Allow wearing of street clothes in the hospital setting, if possible allow
the child to use electronic equipment such as cell phone, -pad, and/or
computer
• Offer written and verbal complete explanations of the disease and
necessary procedures
• Introduce the teen to other teens with the same health problem
• Be sure snacks are available since this group tends to require more
calories throughout the day
Contd.
• Be alert to manipulation by the child to avoid a treatment or procedure.
• Sometimes this age group is prone to bargaining to delay procedures, so
the nurse should be flexible but aware of this possible occurrence
• .Promote competence and independence in the child and should not focus
on the negative. The nurse must build up the child's spirit.
• Encourage the child to express his/her feelings about his/her experiences in
the healthcare setting.