The Hospitalized Child & Ethical / Legal

Considerations in Child Care

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 Learning Objectives
• Identify the stressors of illness and hospitalization for
children
• Review nursing interventions that prevent or minimize the
stressors of separation, loss of control and bodily injury
during hospitalization
• Outline nursing interventions that support parents, siblings
and family during child’s illness and hospitalization
• Discuss Ethical/ Legal considerations in child care

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 Introduction

• In spite of best preventive and promotive health care, some

children become sick and need hospitalization.

• Preparation of hospitalization is important to prevent

psychological or emotional trauma of hospitalization.

• For emergency hospitalization also, sick children should be

prepared by the parents, health team members and nurses to
promote coping with the traumatic event.

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Preparing the ill child and family for hospitalization

• Preparing the infant: because the infant cannot

understand explanations, preparation has to be minimal.
• Special items such as favorite toy, blanket, should be
packed.
• These objects provide care giver should spend a great
deal of time with an infant.

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• Hospitalized children may experience many
stressors, including:
– Separation from family
– Unfamiliar environment
– Changes in routine
– Fear of pain
– Loss of control
– Unfamiliar procedures
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 Stressor of hospitalization

• Stress represents a change from the usual

state of health and environment
• Children have limited coping mechanisms to
resolve stressors
• Major stressors of hospitalization include
• Separation,
• Loss of control
• Bodily injury, and pain
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 Separation Anxiety (Anaclitic depression)

• The major stress from middle infancy throughout preschool years (age
6 to 30 months)

Stages of separation Anxiety

 The phases through which young children progress when separated
from
their parents are:
 Protest

 Despair

 Detachment/denial
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 Manifestations of Protest (later infancy)

• It takes from few hours to several

days
• Child - Cries

- Screams

- Searches for parent with eyes

- Clings to parent

- Avoids and rejects contact with strangers

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 Manifestations of Protest (Toddler)

• Verbally / Physically attacks strangers

• Attempts to escape to find parent

• Attempts to physically force parent to stay

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 Manifestations of Protest (Preschoolers)
•Preschoolers can tolerate brief periods of separation
•Protest: refusal to eat, difficulty sleeping, crying quietly, angry
(breaking toys, hitting other children), withdrawing from others.
Manifestations of Protest School age children
• React more to the separation from their usual activities and
peers than absence of their parents
•Attaining independence -Act like a man

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 Despair Stage
• Inactive

• Regression

• Withdraws from others

• Depressed

• Uninterested in environment

• Uncommunicative

• Sad and lonely

• Refusal to eat, drink or move

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 Detachment Stage (Denial)

• Increase interest in surroundings

• Interact with strangers

• Forms new but superficial relationships Looks happy

• Occurs after prolonged separation from parent

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 Stages of Separation Anxiety

Summary,

In the stage of protest, when the parents return, the child

readily goes to them.

In the stage of despair, the child may not approach them readily
or may cling to a parent.

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Wong's Nursing Care of Infants and Children.9th
 Loss of Control in Infants and Toddlers

• Loss of control is a significant issue for pediatric patients

during hospitalization, often leading to heightened anxiety
and emotional distress.
• Children in medical settings frequently experience a sense
of helplessness due to their inability to control their
environment, which can result in various psychological
responses.

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 Loss of Control in Infants and Toddlers

 Cry/smile In Infants In Toddlers

 The hospital routines are  Altered routines/ daily rituals causes
established to meet the staff loss of control in toddlers as they
needs not the infant needs, which are developing a sense of
autonomy
creates a loss of control for the
 Unfamiliar surrounding and medical
infant
procedures leads to regression and
 Inconsistent care leads to mistrust negativism or aggression
and decreased sense of control

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 Loss of Control in Preschoolers

 Are egocentric & magical thinkers - limits their ability to understand events

 No preparation……..they perceive the hospitalization as a punishment

 Physical restriction, enforced dependency………. leads to the feeling of

loss control
 They have preoperational thinking - means that explanations are
understood
only in terms of real events
 They interpret any message according to their particular experience
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 Loss of Control in School age and Adolescents

School Age Children Adolescents

• Assume as it affects ppersonal
• Loss of control due to physical
identity and Independence
disability, fears of death or • Hospitalization, physical illness
permanent injury. and separation

• Loss of peer acceptance, lack • Rejection

of • Uncooperativeness
productivity • Withdrawal, Anger, frustration
• Hospital routine

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 Bodily Injury and Pain

• Children report pain as the most stressful aspect of

hospitalization (Hendon, 2007)

Infants
• cry

• Facial expression of discomfort

• Position

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 The Effects of Hospitalization on the Child and
Family
• Children react to stresses of hospitalization before
admission, during hospitalization and after discharge
• Children’s understanding of health and illness is primarily
based on

 Their cognitive ability at their developmental level

 Previous experiences with healthcare professionals

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 The Effects of Hospitalization on the Child and the
Family
Parents
 Disrupt usual routine/ Fears/anxiety

 Coping abilities (made more difficult if lack of financial,

community or family support)
 Guilt is a common response of parents when a child is
hospitalized - They may blame themselves for the child's
illness or for not recognizing it soon enough.
 The nurse should clarify the nature of the problem and
reassure
parents that the child is being
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 The Effects of Hospitalization on the Child and
the Family

Siblings
 Siblings experience loneliness,

 fear, and worry, as well as anger,

 resentment, jealousy, and guilt

 The siblings experience stress equal to that

of the hospitalized child.

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 Preventing or Minimizing Separation

• Use different strategies to minimize the effects of

separation
 Adopt family centered care philosophy- family is an essential
part of
the child’s care and illness experience
 Parent participation in care of child

 Knowledge regarding children behaviors -phases of protest

and
despair are normal
 Sight and sound in the hospital environment
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 Family Involvement in
Hospitalization

FIG. 21-11 Parental presence during

FIG. 21-5 When parents cannot hospitalization provides emotional
visit, other significant persons support for the child and increases the
can provide comfort to the parent’s sense of empowerment in the
hospitalized child. caregiver role. (Courtesy E. Jacob, Texas
Children’s Hospital, Houston.)
02/02/2025 JU-fchsby Mosby, Inc., an affiliate of
Mosby items and derived items © 2009, 2005 fchs.ac.ae
Elsevier Inc.
 Ways to Decrease Separation Anxiety

 Allow the child to cry

 Even if the child rejects strangers the nurse provides

support by
her physical presence using a quite tone with the child
 Parents should not lie to the child about leaving

 The nurse should suggests ways of telling the child that

the
parents are leaving.
 The parents should tell the child the reasons for leaving

02/02/2025
The parents should visit the child frequently
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 Minimizing Loss of Control
 Promoting freedom of movement

 Maintaining the child’s routine, if

possible
 Time scheduling
 Friends and visitors
 Encouraging independence

 Self-care (age-appropriate)

 Schoolwork

 Promoting understanding
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 Providing Developmentally Appropriate
Activities

Using play/expressive activities to minimize stress

 Diversional activities- age appropriate play
activities
 Familiar toys preferably from home

 Expressive activities-encourage emotional

expression
 Therapeutic play

 Creative expression- drawing and painting

 Dramatic play- emotional release, helps children

to learn
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 Maximizing Potential Benefits
of Hospitalization

• Fostering parent-child relationships

• Providing educational opportunities

• Promoting self-mastery

• Providing socialization –social acceptance

from a supportive group with similar
conditions/problems
• Supporting family members

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 Adaptation to Hospitalization
Nursing interventions
Parents
 Tailor nursing care to family’s needs and
preferences
 Maintain positive communication with family

 Ask for parents participation in care

 Explain all aspects of treatment, keep family “in

the loop”
 Provide information to family (i.e. teaching
materials etc.)

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 Adaptations to Hospitalization

Nurses can assist the parents in preparing the child for

hospitalization by…
 Read stories about the experience

 Talk about going to the hospital

 Encourage child to ask questions/ draw

pictures
 Visit hospital

 Plan hospital stay/routine as much as possible

 Be honest
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 Adaptation to Hospitalization
Unanticipated admission

Orientation to unit/environment
 Explain all the procedures
 Opportunities for parents/ child to
express fears
 Stress-reduction methods

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 Care of the Child and Family in Special
Hospital Situations
Outpatient Care
• Preparation of child: can be challenging
• The stress of waiting
• Explicit discharge and follow-up instructions
Isolation
• Added stressor of hospitalization
• Child may have limited
understanding
• Dealing with child’s fears
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 Preparation of the Child and family for
discharge

 Assess the family’s ability to manage the child’s care

 Any special adaptation to home environment/ or other

facility
 Collaborate with parents to teach them treatment
procedures
and proper equipment use
 Have family member demonstrate proper care of
equipment, and any procedures necessary

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 Ethical / Legal Considerations
are required in the areas
of…

 Informed consent

 Preparation for Diagnostic and therapeutic Procedures

 Surgical Procedures

 Compliance

 Family teaching and home care

 Restraints

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 Informed Consent
Should include –
 Expected care

 potential risk

 benefits

 alternatives, and

 what might happen if the patient chooses not to

consent to the procedure

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 Informed Consent is required for..

 Written informed consent of the parent or the guardian is

usually required for medical or surgical treatment.
 Removal of the child from the health care institution

 Release of medical information

 Photographing the child for educational or medical

reason
 Post mortem examination

 Separate informed permission must be obtained for each

surgical
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or diagnostic procedure
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Preparation for Diagnostic and therapeutic Procedures

Psychological preparation
 Establish trust and provide
support
 Parental presence and support

 Provide an explanation

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 Preparation for Diagnostic and therapeutic
Procedures

Physical Preparation
 Performing the procedure (Atraumatic)
 Expect success (be confident in providing
care)
 Involve the child
 Provide distractions
 Allow for expression of feelings
 Provide positive reinforcement
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 Surgical Procedures

Preoperative Care
 Psychological preparation (as earlier
section)
 Preoperative Sedation (Atraumatic)

 Goals – Anxiety reduction, Sedation,

Amnesia,
Antiemetic effect, Reduction of

secretions Postoperative Care

 02/02/2025 Adequate pain management
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 Compliance
• Refers to the extent to which patient’s behavior coincides
with the prescribed regimen in terms of taking medications,
following diets, or executing other life style changes.
• Strategies to improve patient compliance
• Organizational strategies: example - reducing
medication cost
• Educational strategies: example – use of written
materials to reinforce verbal teaching
• Treatment strategies: example – adjusting the timing
of the every-8-hour medication to not conflict with the
child’s sleep schedule.
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• Behavioral strategies – example – positive
 Restraints
 Before initiating restraints, a comprehensive
patient assessment is important
 The least restrictive type of restraint should
be used.
 Parent and child co-operation is essential.

 Restraint use is initiated by protocol

 Continued use needs to be reviewed daily

 Children on restraints need to be monitored

every 2 hours.
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 Reading Assignment

Assessing the Influence of Parental Anxiety on Child

Anxiety During the COVID-19 Pandemic in the
United Arab Emirates August 2020 DOI:10.21203/rs.3.rs-
66841/v1

https://www.researchgate.net/publication/346105112_Assessing_the_I
nfluence
_of_Parental_Anxiety_on_Child_Anxiety_During_the_COVID-
19_Pandemic_in_the_United_Arab_Emirates/link/5fbc141792851c933f
518952/
download

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 References
• Hockenberry, Marylin,J., Wilson, David, 10 th Edition, 2017, Wong's essentials of
pediatric nursing, Elsevier,Mosby
• Marilyn J. Hockenberry & Wilson Winkelstein (2013) Wong’s Essentials of Pediatric
Nursing, 9th Edition, Elsevier Mosby

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