A pediatric nurse needs to know the history of Child Health Nursing, as it is essential for her to gain an appreciation of the trends leading to our present concepts and practices specific to children. This helps the nurse to understand the current and the future status of pediatric nursing and its scope.
Prehistoric Times (Before 3000 BC)
Little is known about life in prehistoric times. No documents are available regarding the life style of people at that time. ‘Survival of the fittest’ was the rule followed by them. As a result, undesirable babies such as babies through unwanted sex and with congenital defects were made to die. Some primitive people believed that the birth of a deformed infant was a punishment for previous transgressions of the parents. The wanted children are nurtured by their mothers, breastfed, and carefully taught the customs, beliefs and skills. Strong children were considered as an asset to their parents in earning their livelihood. At puberty, girl child took full responsibility as an adult, was expected to produce children and also take care of the family members. Boys became hunters and fathers of future generation.
The concept of the importance of a child to the society gradually emerged as each group settled on an area of fertile land. Instead of being a liability, the child slowly became an asset to the society.
Ancient Civilization (3000 BC to 500 AD)
In India and China, children were reared in the traditions passed down from the previous generations. The practice of medicine combined both medical knowledge and magic. The early people who settled in the valley of the Nile river cared for their children, dressing their infants in loose clothes and encouraging breastfeeding. They encouraged children to learn as well as to participate in outdoor activities.
Adoption of orphaned children and giving them title held an important place in ancient centuries. Medical care for mothers and children was an early concern. Yet there was widespread acceptance of infanticide as a means to eliminate defective children. Fathers had absolute authority over their children including administration of cruel punishments, imprisonment, death or sale to slavery. Even during 1500 BC, the treatment prescribed for adults was different from that of children. Hippocrates referred frequently in his writings about the peculiarities of disease in children.4
Physical beauty was considered important by the early inhabitants of Greece. Thus, children were reared so that they would have well formed bodies. The importance of family was stressed in Rome because its function was to raise strong sons to become good warriors who could serve the state.
Medieval World (450–1350 AD)
War and epidemics were common during this period and these caused great sickness, suffering and death. Leprosy, plague, influenza and smallpox were the most prevalent diseases. The death rate was apparently very high among children. In those times, temples were the centers for healing. The first infant asylum or hospital was found in Italy in 787 AD. It was only a shelter to the abandoned children. Because of the lack of knowledge of standard nursing care and sanitation, conditions in these shelters were extremely poor.
Renaissance and Early Modern World (1350–1800 AD)
During this period many changes took place which altered the course of human life. The dissemination of knowledge was enhanced. Two medical books titled “The Book of Children” by Thomas Phaer (Father of English Pediatrics) and “The Children's Book” by Felix Wurtz greatly influenced the practice of pediatrics. Industrial revolution took place during this period. Child labor was common. The darkest period in child care in Great Britain and Western Europe was during the early 1800s. Children as young as 6–12 years of age worked in cotton mills for 10 or more hours a day. Accidents were common among these children and their wages were very low.
Despite these conditions, many advances in science, medicine, literature and politics were made. During this period, William Harvey discovered blood circulation. Smallpox vaccine was developed by Edward Jenner in England.
Modern World (1800 AD onwards)
During this time, man has made great progress in conquering disease, hunger, thirst, ignorance and superstition. Knowledge about human body and the cause of diseases promoted the development of new medical treatments in treating adults and children.
A concept of public health was developed during this period. Notable applications of this include purification of water supply, sewage disposal, pasteurization of milk, immunization program, maternal and child health program, laws to control child labor, child abuse and adoption, inspection of hospitals and child care facilities.
The recognition of child diseases, which is quite different from adult diseases leads to the development of hospitals devoted for children.
The study of pediatrics began in the latter half of 18th century, under the influence of a German physician, Abraham Jacobi, who was known as the “Father of Pediatrics”. He established the first child clinic in New York and developed American Pediatric Society.
Tremendous progress had occured in the field of pediatrics. Separate departments were established both in the medicine and surgery under pediatric department.
At the end of the 19th century, there were industrialization consequences, childhood illnesses, injuries, child labor, poverty and neglect. These badly affected the development of children. This period was often regarded as the dark ages of pediatrics and the first half of 20th century was known as the dawn of improved healthcare for children.
Establishment of Children's Bureau in the United States in 1912 is another advancement. They studied factors related to infant mortality and maternal death. This leads to Maternity and Child Health Act and MCH programs. In 1940, Spite and Robertson recognized the effect of isolation and maternal deprivation on institutionalized children. Importance was given to the maternal health; changes were made in roomingin, sibling visit, play, 5preparation of child for hospitalization and parent education. In 1952, Universal Children's Day was celebrated by International Union for Child Welfare and UNICEF on November 14th. General Assembly of UN declared the Rights of Children in 1950 (November 20th). Government of India adopted National Policies of children for the development of children in 1974.
Development of Pediatric Medicine in the World
During the 19th century, some physicians devoted their interest in children. But the emphasis was laid on the disease and not on children. Towards the middle of the 19th century, Dr Abraham Jacobi came to USA from Germany and he convinced that diseases in children were totally different from that in adults. He opened a clinic for children in NewYork and conducted special classes about diseases of children. He worked hard for the development of specialty of pediatrics and he played a leading role in the foundation of the American Pediatric Society. Dr L Emmett Holt wrote the ‘Text Book of Pediatrics’ which is still used today.
The first Department of Pediatrics was established at Harvard University in 1888 headed by Dr Thomas Morgan Rotch. Later Department of Pediatrics appeared in all of the medical schools in the country. Gradually superspecialities were started.
Development of Pediatric Nursing in the world
There were some schools which were devoted to the training of nurses in the care of sick children associated with some of the earliest children's hospitals in Philadelphia, Boston, New York etc. Although such supplementary courses were started, University graduate level courses of pediatric nursing did not appear until 1940.
One of the leaders in pediatric nursing at that time was Florence G Blake who contributed much. She became world famous because of her psychological insight into child development and behavior and she incorporated this knowledge into nursing practice. She is also well known for her publications, research and the development of undergraduate and graduate nursing programs.
Another person Florence Erickson also made great influence on the development of graduate programme in paediatric nursing and in nursing research. She was the first to establish education in the nursing care of children at the Doctoral level. Following World War II nursing education and nursing service underwent a marked improvement.
Development of Pediatric Medicine and Pediatric Nursing in India
The world's first pediatricians Kashyapa and Jeevaka were Indians who lived in the 6th century. Kashyapasamhita and VridhaJeevakiv Tantra were on child care and children's diseases. The chapter on Kaumarabrita in Susruta Samhita was perhaps the first record of pediatrics anywhere in the world. The written work of Susruta contains many aspects of child rearing such as infant feeding, diseases of childhood including exanthematous fever, diseases of liver etc. Charaka a physician wrote on care and management of newborn in his Ashtanga Hridaya in 4th century AD.
In India in the earlier periods of nursing training, pediatric nursing was not given much importance. Pediatric nursing as a course was introduced from 1950 onwards when College of Nursing at CMC, Vellore and RAK College of Nursing in Delhi started undergraduate degree program in nursing. Pediatric nursing was included 6in General Nursing and Midwifery Program. But there was no separate theory examination. Pediatric nursing was included as a separate course in graduate programs in universities in Kerala. At present, almost all universities in India include pediatric nursing as a course in the syllabus of graduate nursing programs. In Kerala, the first postgraduate program in pediatric nursing was started at College of Nursing, Thiruvananthapuram in 1996.
PRINCIPLES OF CHILD HEALTH NURSING
Respect the child's needs to regress and help him accept dependence on others if he resists this:
A child is not a miniature adult. He behaves in a different way from an adult. Whenever a new situation or a stressful situation arises, a child cannot adjust with the situation and he will regress, i.e. he will go back to the previous stage of development. He is not able to control himself. The nurse should understand these changes and respect the child's need to regress.
Have an awareness of the child's need for help in reconquering the negative counterpart of the core problem in the stages of development to which he has regressed:
There are certain developmental tasks in each stage of development of a child, that should be accomplished by the child. There is a negative as well as a positive counterpart for each developmental task. In order to lead a successful life, the child has to overcome the negative counterpart and attain the positive counterpart. For example, during infancy, the developmental task is trust vs mistrust. In this, trust is the positive counterpart and mistrust is the negative counterpart. The nurse's role here is to prepare the parents to help the child attain the positive counterpart of each developmental task. When the child has to face a stressful situation, he will regress. Once that stress is resolved, the nurse should help the child reconquer the negative counterpart of the developmental stage to which the child has regressed.
Protect the child-family interpersonal relationship:
The family members are the most important people in the life of a child. The child-family interpersonal relationship will influence the child's personality development greatly. Whenever a child becomes sick, the family members, especially the mothers, become very upset, anxious and this will affect the interpersonal relationship. The nurse should help to relieve the tension of the mother and, thus, will help to protect the child-family relationship. The core of child care is family centered care. The values, beliefs and health practices of a family should be considered while giving care to a child. The family members should be involved in all the activities related to child care.
The nurse should begin to build a working relationship with the parents and children:
- From the time of first contact with them, the nurse should accept the parents and their children exactly the way they are.
- The nurse should have empathy for the parents and children.
- The nurse should be willing to acknowledge the parents’ rights to take their own decision concerning their children.
- The nurse should allow the parents and children to express their emotions.
- The health team members must help the parents to feel that there is unity among them.
Awareness of the feelings of others and readiness to respond to them so as to strengthen their resources to cope up with stress:
When a stressful situation like illness or hospitalization occurs, emotional support is needed to the child as well as to the parents. A mother supports her child mentally as well as emotionally. Even though she provides emotional support, she too needs emotional support. The nurse should notice this and she should provide emotional support to the mother.7
Children can tolerate discomfort and comprehend its real purpose if they are prepared for it
If the child is well prepared before hospitalization or before a painful treatment, he/she can adjust to that situation to some extent than an unprepared child. The preparation and explanation should be according to the level of understanding of the child so that he can comprehend the purposes of that situation.
To child, play is not the time out from daily living, but rather an essential part of it that enables him grow and mature through the various stages of development
For a child, play is very important. It is an essential part of growth and development. It helps the child to grow independently.
DIFFERENCES BETWEEN ADULT AND CHILD NURSING
Childhood period is a period of rapid growth and adulthood is a period of complete growth. A nurse should bear these facts in mind while giving care to both these groups. The differences in illness and nursing care between an immature child and a mature adult are based on the anatomical, physiological and psychological differences.
Anatomical Differences
Size
It is an outstanding difference. A more specific anatomical difference between an adult and a child is the greater size and weight of the newborn baby's head, when compared with body length and weight. This characteristic, coupled with immature motor development, makes handling the baby somewhat different from handling the older child or the adult. It influences the methods and equipment used in care, e.g. small-sized cots, small-sized tubings, etc.
Skull
The sutures of the skull in the newborn baby are not united. The brain is not protected by the skull in the areas of the open fontanels. When intracranial pressure is increased in an infant, the head simply enlarges as the sutures separate. This is not possible in the older child or adult.
The normal shape of the head and the chest of the infant can be altered by constant pressure from lying in one position. This is not seen in older children or adults.
Eyes
The lacrimal gland and ducts are structurally incomplete. Tears are not produced in early infancy. This will make the eyes prone for infection.
Nose
An infant's nasal passages are very small. They are obligatory nose breathers upto six months of age. So, respiratory infections cause difficulty in breathing in infants.
Oral cavity
The infant's tongue is large and the oral cavity is very small, making the baby more prone to develop airway obstruction.
Stomach
In adults, cardiac sphincter of stomach is well developed. In infants, it is more relaxed. So, there is frequent regurgitation and vomiting in young infants.
Eustachian Tube
It is shorter and at more of a horizontal angle than in the adult ear. So, children are more prone to develop frequent ear infections.
Physiological Differences
The differences in the physiologic processes of the newborn infant and the older child 8or the adult are less obvious than anatomic differences.
In addition to the changes in the structure of the various parts of the body, physiologic development influences the child's susceptibility to certain diseases, its symptoms and the probability of the lasting harm.
Basal Metabolic Rate (BMR)
The BMR is very high in a newborn baby. This is due to rapid energy consumption, secondary to rapid cell growth and increased requirement for heat production. Higher BMR leads to increased oxygen consumption and increased calorie requirements. BMR decreases rapidly during 1-1/2-2 years. BMR reaches the adult value at puberty.
Regulation of Body Temperature
The thermoregulatory mechanism is very poor in the case of a newborn baby because of immaturity of the controlling and effector mechanisms, immaturity of hypothalamus and large surface area compared to the weight of the baby. Shivering and sweating mechanisms are absent in newborn babies when exposed to cold and hot environment. These mechanisms are present in adults. But another mechanism of heat production, which is present in newborn babies only, is the presence of brown adipose tissue from which heat can be liberated by non-shivering thermogenesis.
Fluids and Electrolytes
The total body water is about 750 mL/kg of body weight in infants. In adults, it is about 550 mL/kg of body weight. In the newborn baby, approximately 75–80% of body weight is composed of body water, whereas approximately 60% of body weight is body water in the adult man. The percentage of body fluids contained in the extracellular compartment is greater for children up to 2 years of age than it is for adults.
Cardiovascular System
Heart sounds are of a higher pitch and a greater intensity during infancy and childhood than during adult life.
Heart rate is variable and the range of normal pulse rate is wide during childhood, i.e. range of neonatal heart rate is 140–160 beats/minute.
Variations in blood pressure occur more frequently in infancy than in the later period.
Hematologic System
The RBCs of newborn infants are quite different from those of the adults. They are large in infants. The life span of RBC in adults is 120 days, whereas RBCs of newborns have a life span of approximately 2/3rd of adult time. In a neonate, the blood volume is 85 mL/kg body weight, whereas in an adult, it is 60–70 mL/kg.
Gastrointestinal System
The cardiac sphincter of the stomach is relaxed in infants whereas it is tight in adults. Salivary amylase plays an important role in the digestion of starch in infants than it does in the adults, since pancreatic amylase does not reach adult levels for several months after birth.
The liver is immature in newborn period. This contributes to the physiological jaundice, ineffective detoxification of drugs and increased risk for bleeding and hypoglycemia.
Iron reserve is less and is only sufficient to meet the demands upto 6 months of life and after that the children need iron supplements.
Respiratory System
Alveolar sacs are shallow in neonates. The amount of dead air space is large during neonatal and infancy period. So, the respiratory rate is rapid. The alveolar surface area of the adult is about 20 times that of the newborn 9infant. The weight of the adult lung is also about 20 times that of the neonate.
The tissues of the respiratory tract are delicate during the newborn period and infancy and do not produce mucus and do not provide protection from the invasion of micro-organisms. Airways are small in size in young children which contribute to respiratory tract obstruction.
The tonsils and adenoids are relatively large during childhood and are involved in the production of immune bodies. These structures contribute to illness during this age group.
Integumentary System
The eccrine sweat glands are less active in prepubescent children than in adults and in adolescents. The apocrine sweat glands are small and nonfunctional from birth through preschool years. They begin to function between 8 and 10 years of age and their functioning increases during pubescence, adolescence and adulthood.
The sebaceous glands are large in the neonates. They diminish in size after birth and remain small during childhood. They again become active at puberty.
The hair of the neonate is fine and silky. It becomes coarser with development. The newborn baby's nails are soft and thin but become harder and thicker as the child grows older.
Adipose tissue beneath the skin and in other parts of the body accumulates during infancy and then declines to accumulate during the early childhood years. Again at the beginning of school age, adipose tissue starts to accumulate slowly until the pubescent stage.
Urinary System
Young infants cannot concentrate their urine like older children and adults. Chronic renal failure usually does not follow acute renal failure in young children as it does in the adults, because the young kidney can grow and increase the number of functioning cells.
Central Nervous System
Myelination within the central nervous system is incomplete and the connections of the brain are poorly developed at birth. This immaturity accounts for lack of genetically determined pigmentation in the eyes of the newborn. Nerve endings in the retina are not fully developed. So, vision is not completely developed.
Even though the myelination is incomplete, children produce physiological response to pain. Analgesics especially opioids are required in very low doses in children as compared to adults. The reasons are:
- Less efficient blood brain barrier upto 2 years of age allows the drug to cross the blood brain barrier and enter into the brain causing respiratory depression.
- Immature excretory pathways in liver and kidney produces ineffective detoxification of opiates.
Psychological Differences
Psychological reactions to illness differ in various age groups. Unlike adults, each stage of development in a child has its own characteristics and their behavior also differs according to the age. So, the pediatric nurse should identify the psychological reactions of children at each stage of development in order to provide effective care to them. Parents are an important part of a child's life. So, it is important to involve the parents in child's care. The pediatric nurse should provide appropriate care to promote proper psychological and emotional development of children.
In adults, both objective signs and subjective symptoms are important in planning nursing interventions. Since the infants and the young children cannot state how they feel, the nurse should rely solely on the signs.10
Infants and little children are better patients than adults because:
- They live in the present, easily forgetting the past, and not concerned with the future
- Their attention span is short
- They are readily interested in other body sensations—sight, sound, etc.
Differences in Illnesses
Many specific illnesses seen in adults such as appendicitis or pneumonia are also seen in children. But children, because of their immaturity and the various stages of growth and development through which they pass, are prone to acquire conditions which are not seen in adults.
Congenital anomalies such as atresia of the esophagus, imperforate anus or omphalocele are structural anomalies present at birth.
Conditions of neonates such as erythroblastosis fetalis are uncommon in adults. Nutritional disorders are seen more commonly in infancy because of the child's rapid growth during the first year of life, e.g. rickets, scurvy etc.
Young children, because of their intense activity, insatiable curiosity and their immaturity have more accidents such as scalds, falls and poisoning from medications, household solutions than adults do.
Infections are extremely prevalent during childhood, since the children do not have the immunity like adults.
Malignancies such as leukemia, brain tumors, Wilm's tumor or bone tumor are seen in children, but are not as common as in the adults.
Many illnesses related to the process of growth and development, such as failure to thrive are seen during the pediatric years.
Emotional disturbances appear to be increasing in incidence in the pediatric age group.
RIGHTS OF THE CHILD
The United Nations adopted the ‘Declaration of the Rights of the Child’, on 20th November, 1959 to meet the special needs of the child. India was a signatory to this declaration to give the child pride of place and to make the people aware of the rights and needs of children and duties towards them.
The ten basic rights of a child are:
- Right to develop in an atmosphere of affection and security, and protection against all forms of neglect, cruelty, exploitation and traffic.
- Right to enjoy the benefits of social security, including nutrition, housing and medical care.
- Right to a name and nationality.
- Right to free education.
- Right to full opportunity for play and recreation.
- Right to special treatment, education and appropriate care, if handicapped.
- Right to be among the first to receive protection and relief in times of disaster.
- Right to learn to be a useful member of the society and to develop in a healthy and normal manner and in conditions of freedom and dignity.
- Right to be brought up in a spirit of understanding, tolerance, friendship among people, peace and universal brotherhood.
- Right to enjoy these rights, regardless of race, color, sex, religion, national or social origin.
QUALITIES OF A PEDIATRIC NURSE
A pediatric nurse should have all the desirable and preferable qualities of a professional nurse.
She should:
- Be a good listener
- Be a loving person and have liking for the children
- Have patience, pleasant appearance, and ability to understand the child's behavior
- Be able to maintain good interpersonal relations and to provide safety and security to children
- Be friendly, honest, gentle, diligent and humorous
- Have good observation, judgment and communication ability based on scientific knowledge and experience
- Be well informed, skillful, responsible, truthful and trustworthy
- Have emotional stability
- Have adequate knowledge in child care
- Be able to interpret the developmental needs of children of different age group
- Have the capacity to alleviate the traumatic experience of hospitalization by using atraumatic care.
ROLES OF THE PEDIATRIC NURSE
Primary Care Giver
Pediatric nurse should provide preventive, promotive, curative and rehabilitative care in all levels of health services. In hospital, care of sick children, i.e. comfort, feeding, bathing, safety etc. are the basic responsibilities of the pediatric nurse. Health assessment, immunization, primary healthcare and referral are basic responsibilities at the community level.
Health Educator
An important role of the pediatric nurse is to deliver planned and incidental health teaching and information to the parents and children to create awareness about healthy lifestyle and maintenance of health.
Nurse-counselor
Problem-solving approach and necessary guidance in health hazards of children to minimize or, to solve the problem and to help the parents and the family members for independent decision making in different situations are an essential role of a pediatric nurse.
Social Worker
A pediatric nurse can work for children and can alleviate social problems related to child health. She can participate in available social services or refer the child and the family to child welfare agencies for necessary social support.
Team Cocoordinator and Collaborator
Pediatric nurses should work together and in combination with other health team members for better child care. She should act as a liaison between team members and maintain good IPR. She should coordinate all nursing activities with other services necessary for the welfare of the child. She should promote cooperative actions and communication among team members.
Manager
The pediatric nurse should be the manager of pediatric care units in hospitals, clinics and community.
Child Care Advocacy
Child or family advocacy is the basic aspect to comprehensive family centered care. As an advocate, the pediatric nurse can assist the child to obtain the best possible care from the particular units.
Recreationist
This supportive role of a pediatric nurse is important for the child to adjust with the crisis situations imposed by illness or hospitalization. She can organize play-facilities for the recreation and diversion for a child's emotional outlet.12
Nurse Consultant
The pediatric nurse can act as consultant to guide the parents and the other family members for the maintenance and promotion of health and prevention of childhood illness. The nurse can promote self care within the family and prepare self care agents for the children who are unable to take care of their own health. The nurse assesses the children's ability to do self care activities and assist them in developing the ways of self care and self responsibility.
Researcher
Nursing research is an integral part of professional nursing. A pediatric nurse should participate or perform research projects related to child health. Clinical and applied research provides the basis for changes in nursing practice and improvements in the healthcare of children.
REACTION OF CHILD AND FAMILY TOWARD ILLNESS AND HOSPITALIZATION
Parental Reactions
Parents are very much frustrated when their children are admitted in the hospital. When a child is admitted in the hospital, parents experience anxiety, anger, fear, disappointment and, possibly, guilt. The anxious parents can be identified by the trembling coarse, wavery voice, restlessness, irritability, withdrawal or erratic body movements. Anger, hostility and aggressive behavior towards those caring for the child may be evident. When the nurse detects anxiety in the parents, the first task is to identify the causes of anxiety and to give whatever help is possible to alleviate it.
Specific Causes of Parental Anxiety
In addition to their feelings about the illness itself, many factors increase their anxiety, such as:
- Fear of strange environment in the hospital.
- Fear of separation from the child.
- Fear of the unknown and of what will happen to the child immediately and in the future.
- Fear that the child will suffer.
- Fear that the condition is infectious and may spread to other members of the family.
- Fear of unbearable financial obligations incurred through the illness.
- Fear that the society will look upon the illness as a reflection of something wrong with the parents.
The nurse should accept this as normal and natural and never feel that they are uninterested in the child.
Hospitalized Child
Illness or hospitalization threatens both the physical development of children and their sense of trust in other people.
Hospitalization is a completely new experience to infants and young children. Infants may be emotionally disturbed by hospitalization due to separation from parents and sensory deprivation. Sensory deprivation occurs especially when the child is cared in an incubator or in an isolation area or in the ICU.
Sources of Stress During Hospitalization
Psychosocial sources include separation from home, parents, other family members, friends, change in role, anxiety, pain and fear.
Physiological sources are loss of sleep, diagnostic and treatment procedures, trauma, surgery and immobilization.
Environmental sources such as unfamiliar noise, unaccustomed cold or warmth, or other strange sensory stimuli, loss of the daily dark and light cycle.
Biological sources include pathologic organisms.
Stressors of Hospitalization
The major stressors of hospitalization include separation from parents and loved ones, fear of unknown, loss of control and autonomy, bodily injury resulting in discomfort, pain and mutilation, and the fear of death.
Child's Reactions
Children's reactions to these crises are influenced by their developmental age, their previous experience with illness, separation or hospitalization, their innate and acquired coping skills, the seriousness of the diagnosis and the support systems available.
Separation Anxiety
The major stress from middle infancy throughout the preschool years is separation anxiety. It is also called anaclitic depression. It has got three phases:
- Phase of protest
- Phase of despair
- Phase of detachment
Manifestations of Separation Anxiety
- Phase of protest: The baby cries and screams loudly and continually searches for the parent with his eyes. When the baby sees the parent, it clings to him/her. During this phase, the baby avoids and rejects contact with strangers and verbally attacks (goes away) and physically attacks (kicks, bites, hits, etc.) strangers. The baby attempts to physically force the parent to stay in the hospital. These behaviours possibly last for hours to days. Protest, such as crying is often continuous and stops only with physical exhaustion. Protest is increased by approach of strangers.
- Phase of despair: The baby becomes inactive, withdrawn from others, depressed and sad, uninterested in the surroundings. It becomes uncommunicative and regresses to earlier behavior (thumb sucking, bedwetting, etc.). This behavior lasts for variable length of time. The child's physical condition deteriorates from refusal to eat, drink or move.
- Phase of detachment (denial): The child shows increased interest in surroundings and interacts with caregivers and strangers. It forms new but superficial relationships and appears happy. But these behaviors are representative of a superficial adjustment to loss.
This is the most serious phase because reversal of the potential adverse effects is less likely to occur once detachment is established. This phase occurs usually after prolonged separation from parents, rarely seen in hospitalized children.
Loss of Control
One of the factors influencing the amount of stress imposed by hospitalization is the amount of control that children perceive themselves as having. Lack of control increases the perception of threat and can affect children's coping skills. They lack usual sensory stimulations, and additional hospital stimuli like sight, sound, smell are irritating to them. Other causes of loss of control are physical restriction, altered routine or rituals, and dependency.
For example, child's reaction infants attempt to control their environment through emotional expressions.
Trust is established through consistent loving care by the mother.
In hospital, the emotional expressions are misinterpreted and the infant's needs are not met. Inconsistent care and deviations from the infant's daily routine may lead to mistrust and a decreased sense of control.
Toddlers: Restriction of activities, altered rituals and routines, altered care-giving activities, unfamiliar surroundings, separation from parents, medical procedures, etc. disrupt toddler's control over their world.14
Preschool children: Physical restriction, altered routines and enforced dependency, etc. affect preschoolers.
School age children: Altered family roles, physical disability, fear of death or permanent injury, loss of peer acceptance, lack of productivity, inability to cope with stress and boredom may result in loss of control.
Adolescents: Limitations of physical activity and separation from usual support system disrupt their normal life.
Bodily Injury and Pain
Fears of bodily injury and pain are prevalent among children.
Infants: The reactions include excessive cry, variations in heart rate, facial expressions of discomfort and assuming certain positions. Older infants react intensively with physical resistance and uncooperativeness.
Toddlers: The reactions are shown as grimacing, clenching the teeth or the lips, opening the eyes wide, aggressiveness, rocking, rubbing and running away. They react with intense emotional upset and physical resistance.
Preschoolers: Physical and verbal aggression is more specific and goal-oriented. Instead of showing total body resistance, they push the offending person away or pull hand, and try to secure the equipment. They may verbally abuse the person by screaming “go away”.
Schoolers: Schoolers show the reaction by holding rigidly still, clenching their fists or teeth, or trying to act brave. If they display signs of overt resistance, such as biting, kicking, pulling away, crying, etc., they may deny these, reactions later, especially to their peers.
Adolescents: They react to pain with much self- control. Physical resistance and aggression are unusual at this age.
Effects of Hospitalization on the Child
Beneficial Effects
- Recovery from illness
- Opportunity to master stress and feel competent in their coping abilities
- Provide new socialization experiences that can broaden their interpersonal relationships.
Adverse Effects
- Regression
- Separation anxiety
- Apathy
- Fears
- Sleep disturbances.
Nursing Care of a Hospitalized Child
Prevent/Minimize Separation
An important nursing goal is to prevent or minimize separation, especially in the case of under-five children. For this, family-centered care is very important, which identifies the integral role of the family in a child's life and acknowledges the family as an essential part of the child's care and illness experience. The nurse should show a positive attitude towards parents and foster an environment that encourages the parents to actively involve in the child care. While taking care of the child, the nurse should consider the health of the family members also. Parents may feel anxious in their care-giving responsibilities. The nurse should assist them in overcoming these anxieties.
When separation cannot be prevented, many methods can be used to minimize the effects of separation, such as:
- Assign a primary nurse to take care of the child
- Be aware about the child's separation behavior
- Provide support through physical presence
- Establish rapport with the child and communicate effectively
- Allow the child to cry during periods of protest and despair
- If detachment behaviors are evident, the nurse maintains the child's contact with parents by frequent visits, telephone calls, etc.
- Help the parents to recognize that separation behaviors are normal
- Explain to parents how the child reacts after they leave
- Encourage the parents to bring favorite articles from home which provides comfort and reassurance to the children
- Protect the child from frightening and unfamiliar sights, sounds and equipment
- Provide proper explanations and prepare the child for those experiences that are unavoidable.
Minimize Loss of Control
Feelings of loss of control result from separation, physical restriction, changed routine, enforced dependency, magical thinking and altered roles with the family or peer group. Most of these problems can be minimized through individualized nursing care.
- Promoting freedom of movement: Freedom of movement during procedures can be promoted by placing the child in the parents’ lap.When restraints are used, they should be removed to allow the child some period of supervised freedom, such as during bath or during parents’ visit.
- Maintaining child's routine: Altered daily schedules and loss of rituals are stressful for toddlers and preschoolers, and may increase separation anxiety.One technique that can minimize the disruption in child's routine is time structuring.It includes scheduling the child's day-to-day activities that are important to the child and nurse the such as treatment procedures, school work, exercise, television, etc. Plan a daily schedule chart with time and activities written down on it.
- Encouraging independence: Promoting children's control involves maintaining independence and the concept of self-care. Self-care refers to the practice of activities that individuals personally initiate and perform on their own behalf in maintaining health and well being. Self-care activities should be encouraged in hospitals. Other approaches include jointly planning care, time structuring, making choices in food selection and bedtime, etc.
- Promoting understanding: Anticipatory preparation and providing information help greatly to lessen stress and prevent lack of understanding. Informing children about their rights foster greater understanding and may relieve the feelings of powerlessness.
Preventing or Minimizing Bodily Injury
- Preparation of children for painful procedures decreases their fears
- Manipulating procedural techniques also minimizes fear
- For children, who have fear of mutilation of body parts, the nurse repeatedly stresses the reason for a procedure and evaluate child's understanding
- Employ pain reduction techniques.
Provide Developmentally Appropriate Activities
Children who experience prolonged or repeated hospitalization are at greater risk for developmental delay or regression. The nurse who provides opportunities for the child to participate in developmentally appropriate activities normalizes the child's environment and helps reduce interference with the child's ongoing development.16
Play is an important aspect of a child's life. It assumes a critical role in the child's development. It is one of the most effective tools for managing stress. Children who play will cope up positively.
School is an integral part of the school-aged child's and adolescent's development. It is beneficial to provide appropriate educational services when a child's treatment requires a significant absence from school. The nurse can encourage children to resume school work as quickly as their condition permits it.
Maximize Potential Benefit of Hospitalization
Even though hospitalization is a stressful situation for children and families, it also represents an opportunity for facilitating positive change within the child and among the family members.
Hospitalization leads to strengthening of coping behaviours of family and child. It also helps to emerge new coping strategies.
Hospitalization helps the parents to understand children's usual reactions to stress such as regression or aggression. Parents are better able to support the child through the hospital experience and may extend their insight into childrearing practices after discharge. In this way, hospitalization helps to foster parent-child relationship.
Hospitalization provides educational opportunities to family and child. During hospitalization, the child and family may learn about disease, parents may learn about the child's need of independence. Experiences with different health professionals can influence the child's decision regarding a career in healthcare.
Hospitalization provides an opportunity for self-mastery. Younger children have the chance to test out fantasy versus reality. For older children, hospitalization may represent an opportunity for decision-making, independence and self-reliance.
Hospitalization provides an opportunity for socialization. Forming relationship with significant members of the healthcare team, such as the physician, the nurse, the social worker can greatly enhance the child's adjustment in many areas of life.
Supporting Family Members
Providing emotional support for family members involves the willingness to be present and listen to parents’ verbal and nonverbal messages. Nurses can also be supportive by assessing spiritual needs, arranging for clergymen to visit, and respecting and upholding parent's religious beliefs.
Parents may need help in accepting their own feelings toward the ill child. If given the opportunity, parents often disclose their feelings of loss of control, anger and guilt. Helping the parents identify the specific reason for such feelings and emphasizing that each feeling is normally expected, and healthy response to stress, provide them with an opportunity to lessen their emotional burden.
PEDIATRIC HISTORY AND PHYSICAL EXAMINATION
History
History taking is an art in which the examiner will be able to focus only on the relevant parts of history.
Patient's Name and Address
Age in years or months after last birthday. If small infant, number of days old.
Sex: It is important because some diseases have sex-linked inheritance
Race/religion: Certain diseases are common among certain religions.
Informant: Mention whether the informant is reliable or not.
Presenting complaint: Patient's or parent's own brief account of the complaint and its duration. Use the words of the informant whenever possible.17
History of Present Illness
This should be in the examiner's own words. Health immediately before the illness, progress of the disease, order and date of onset of symptoms, etc. should be assessed. Specific symptoms and physical signs that may have developed also should be enquired for. Assess for the aggravating and alleviating factors. Enquire about significant medical attention and medications given and the duration of the treatment.
History of Past Illness
Significant illness in the past, especially those required hospitalization, which may have a direct effect on the present condition should be enquired for:
Antenatal, Natal and Postnatal History
- Antenatal: Take a detailed history about the health of the mother during pregnancy, medical supervision, drugs, diet, infections (e.g. rubella), other illnesses, vomiting, toxemia, other complications; Rh typing and serology, pelvimetry, medications, X-ray procedure, maternal bleeding, mother's previous pregnancy history, etc.
- Natal: Collect history about duration of pregnancy, birth weight, kind and duration of labor, type of delivery, presentation, sedation and anesthesia (if known), state of infant at birth, resuscitation required, onset of respiration and first cry.
- Postnatal: Enquire about APGAR (Appearance Pulse Grimace Activity and Respiration) score; color, cyanosis, pallor, jaundice, cry, twitchings, excessive mucus, paralysis, convulsions, fever, hemorrhage, congenital abnormalities, birth injury, difficulty in sucking, rashes, excessive weight loss and feeding difficulties. The examiner might discover a problem area by asking if the baby went home from hospital with his mother.
Growth and Development
Assess the achievement of various milestones like social smile, head control, turning, sitting, standing, walking, self-feeding and dressing, bladder and bowel control, speech development, etc.
Conclude by commenting whether any developmental abnormality is present or not; if present, whether it is global or confined to one specific area.
Nutrition
Breastfeeding: Find out how long the child was on exclusive breastfeeding; when the cow's milk or formula feed was started, its dilution, whether feeding bottle or spoon was used.
Weaning: Ask when it was started, types of food, weaning difficulties, etc.
Enquire about present food items and calculate its caloric and protein value.
Immunizations and Tests
Be familiar with departmental recommendations for immunizations. List down the date and type of immunization as well as if any complications or reactions.
Family History
Take history about parents (age and condition of health), birth order and spacing.
Marital relationships—Consanguineous or nonconsanguineous.
Siblings—Age, condition of health, significant previous illnesses and problems, stillbirths, miscarriages and abortions.
Age at death and cause of death of immediate members of the family.
Ask about any history of tuberculosis, allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular diseases, kidney disease, rheumatic fever, neoplastic diseases, congenital abnormalities, cancer or any convulsive disorders in the family.18
Socioeconomic History
Education, occupation, income of family members and social relationship of family members.
Environmental History
Type of house, source of drinking water, use of sanitary latrine, any nearby source of pollution, any pets in the house, number of rooms in the house, etc.
Physical Examination
Every child should receive a complete systematic examination at regular intervals. To get co-operation of the child, a small infant should be examined on the mother's lap. A toddler also prefers mother's presence, and older children may be examined while being seated near the mother or on an examination table with the mother nearby.
Approaching the Child
Adequate time should be spent in becoming acquainted with the child and allowing him/her to become acquainted with the examiner. The child should be treated as an individual whose feelings and sensibilities are well developed, and the examiner's conduct should be appropriate to the age of the child. A friendly manner, quiet voice, and a slow and easy approach will help to facilitate the examination.
Sequence of Examination
Skill, tact and patience are required to gather an optimal amount of information when examining a child. Get down to the child's level and try to gain his trust. The order of the examination should conform to the age and temperament of the child.
Wash hands with warm water before the examination begins. With the younger child, examine heart, lungs and abdomen before he starts crying. Lastly look at the throat and the ears. If part of the examination is uncomfortable or painful, tell the child in a warm, honest but determined tone, that is necessary.
Remember that the examiner must respect modesty in the patients, especially as they approach pubescence. Sometimes during the examination, however, every part of the child must have been undressed. It usually works out best to start with those areas which would least likely make the patient anxious and interfere with his developing confidence in the examiner.
General Physical Examination
It is carried out in a systematic fashion. The purpose of physical examination is to collect data as a basis for formulating nursing diagnoses and for evaluating the effectiveness of nursing care. Any abnormalities observed can be referred to a physician for further investigation.
Equipment
Collect all the equipment and keep them ready in good working condition. Equipment are almost similar to that of an adult physical examination.
- Thermometer (Axillary)
- Stethoscope with cuffs of different sizes
- Tongue depressor
- Torch
- Reflex hammer
- Tuning fork
- Weighing scale
- Tape measure
- Snellen chart
- Toys, if required, for distraction.
Vital Signs
Check temperature, pulse, respiration (TPR) and blood pressure.
Measurements
The infant is weighed on an infant scale and older children are weighed on an upright 19platform scale. The height or length is measured by using tape or scale. The head and the chest circumferences are taken by a tape measure. The weight should be recorded at each visit; the height should be determined at monthly intervals during the first year, at 3-month intervals in the second year, and twice a year thereafter. The height, weight and various circumferences of the child should be compared with standard charts and the approximate percentiles recorded.
General Appearance
Observe whether the child appears well or ill, sick or comfortable, tachypneic or dyspneic, level of consciousness, gait, posture, expression, abnormal movements, any abnormal odor, reaction to parents, attitude towards the examiner, nature of cry and degree of activity, and facial expressions.
Skin
The examination of skin includes observing the color (cyanosis, jaundice, pallor, erythema), texture, eruptions, hydration (skin turgor), edema, hemorrhagic manifestations, scars, dilated vessels and direction of blood flow, hemangiomas, café-au-lait areas and nevi, Mongolian (blue-black) spots, pigmentation, turgor, elasticity, and subcutaneous nodules. Striae and wrinkling may indicate rapid weight gain or loss. Observe for hair distribution, its character and desquamation.
Lymph Nodes
Examine for location, size, sensitivity, mobility and consistency of lymph nodes. One should routinely attempt to palpate suboccipital, preauricular, anterior cervical, posterior cervical, submaxillary, sublingual, axillary, epitrochlear and inguinal lymph nodes.
Head to Foot Examination
Head: Carefully examine the size, shape, circumference, asymmetry, fontanel (size, tension, number, abnormally late or early closure), sutures, dilated veins and scalp. Observe for cephalhematoma, bosses, craniotabes, head control, moulding, bruit, etc.
Hair: Hair is examined for hypopigmentation, sparseness, elasticity, pediculosis, seborrheic dermatitis, alopecia and cleanliness.
Face: Observe the face for the symmetry, presence of paralysis, distance between nose and mouth, depth of nasolabial folds, bridge of nose, distribution of hair, size of mandible, swellings, Chvostek's sign, and tenderness over sinuses.
Eyes: Careful examination of the eyes has to be done, which should include the eyelids, eyelashes, lacrimal apparatus, orbit, conjunctiva, sclera, cornea, pupils, lens and ocular muscles. Observe for photophobia, hyper- or hypotelorism, muscular control, nystagmus, Mongolian slant, Brushfield spots, epicanthic folds, lacrimation, strabismus, pallor, icterus, conjunctival congestion, condition of lids, exophthalmos or enophthalmos. Check the pupil size, shape, reaction to light and accommodation, visual acuity, fundi, visual fields, etc.
Nose: Examination of nose includes its shape, mucosa, patency, discharge, bleeding, pressure over sinuses, flaring of nostrils, septum, etc.
Mouth: Very careful examination of mouth is essential. Observe the lips, teeth (number, position, caries, discoloration, malocclusion or malalignment), mucosa, gum, palate, tongue and uvula.
Throat: Tonsils (size, inflammation, exudate, crypts and inflammation of the anterior pillars), mucosa, hypertrophic lymphoid tissue, postnasal drip, epiglottis, voice (hoarseness, stridor, grunting, type of cry and speech).
Ears: Examine the pinnas (position, size), canals, tympanic membranes and hearing. Observe for the presence of perforation, inflammation, discharge, mastoid tenderness and swelling, peculiar tags, etc.20
Neck: Short neck, swelling, thyroid, lymph nodes, veins, position of trachea, sternocleidomastoid, webbing, edema, movement and tonic neck reflex.
Thorax: Thorax is observed for its shape and symmetry, veins, retractions and pulsations, flaring of ribs, shape, size and symmetry. Breast examination is carried out for the position of nipples, gynecomastia, breast development, etc. Palpate the sternum for length, beading, Harrison's groove. Observe scapulas and clavicles.
Lungs: Examine the chest for type of breathing, dyspnea, prolongation of expiration, cough, expansion, breath and voice sounds, rales and wheezing. Palpate for fremitus (tactile or vocal). Percussion is used to determine the density of underlying tissue. Types of sound elicited are flatness or dullness, resonance, etc.
Heart: The heart is examined for its size, shape and sound. Heart sounds are evaluated for rate, intensity, rhythm, quality and normality.
Examine the location and intensity of apex beat, precordial bulging, pulsation of vessels, thrills, murmurs (location, position in cycle, intensity, pitch, effect of change of position, transmission and effect of exercise). Auscultate four areas of the heart, i.e. aortic, tricuspid, pulmonary and mitral areas.
Abdomen: Examine for size and contor, symmetry, skin abnormalities, visible peristalsis, respiratory movements, veins, umbilical hernia, musculature, tenderness and rigidity, distension, tympany, shifting, dullness, tenderness, rebound tenderness, pulsation, palpable organs or masses, fluid wave and bowel sounds. If the liver is palpable below the right costal margin, its total span must be recorded. A deep abdomen palpation must be done on every child.
Male Genitalia: A thorough examination of male genitalia may be carried out. Look for micropenis, hydrocele, hypospadias, phimosis, adherent foreskin, cryptorchidism or for pubertal changes.
Female Genitalia: Genital examination is done by observing the vagina (imperforate, discharge, adhesions), clitoris for hypertrophy and for pubertal changes.
Musculoskeletal system: Determine the range of motion of joints. Observe the joints for swelling, redness, pain, limitation, tenderness and rheumatic nodules. Report hyperflexibility or immobility.
Rectum and Anus: Observe for irritation, fissures, prolapsed and imperforate anus. Note the muscle tone, character of stool, masses, tenderness and sensation.
Extremities
- Examine for deformities, hemiatrophy: Bow legs (common in infancy), knock-knees, paralysis, edema, coldness and asymmetry.
- Hands and feet: Extra digits, clubbing, over-riding, simian lines, curvature of little finger, deformity of nails, flat feet (feet commonly appear flat during the first 2 years), abnormalities of feet, width of thumbs and big toes.
- Peripheral vessels: Presence, absence or diminution of arterial pulses.
Spine and Back: Examine the posture, curvatures (kyphosis, scoliosis, lordosis), rigidity, spina bifida, pilonidal dimple or cyst, tufts of hair, mobility, Mongolian spots and tenderness over spine.
PREOPERATIVE AND POSTOPERATIVE NURSING MANAGEMENT OF CHILDREN
Preoperative Nursing Management
Children experiencing surgical procedures require various preparations.
Factors Affecting Preoperative Care
- Surgery: Major surgical procedures demand longer preoperative admission. Preoperative preparation for the minor procedures may be done on the day of surgery.
- Timing of surgery: Planned surgery allows good preoperative preparation and reduces anxiety and trauma to the child and the family. Unplanned emergency surgery allows no time for preoperative preparation. This is the most stressful situation for the family.
Preoperative Preparation
Preoperative care is the preparation of a patient before an operation. The preoperative period may be extremely short, as with an emergency operation, or it may extend weeks during which diagnostic tests, specific treatments and measures to improve the patient's general condition are carried out.
Legal Preparation
Any patient undergoing surgery, whether it is expected to be major or minor, must sign an operative permit. Patients have the right to know the type of surgery intended and its expected outcome, after-effects, and possible complications. In the case of a child, the written consent is signed by the parent or the guardian.
Psychological Preparation
Preparing the child properly for surgery decreases their anxiety, promotes their co-operation and facilitates a feeling of mastery in experiencing a potentially stressful event. Much of this anxiety can be relieved if the various aspects of preoperative and postoperative care and the type of surgery planned are explained to the child according to the level of understanding of the child.
The surgeon usually explains the surgical procedures in simple terms and gives a general idea of how long the child will be away from his or her parents (explanations to the parents in the case of very small child) during surgery and after recovery from anesthesia. It is reassuring for the child and the family to know, for example, that oxygen administration, blood transfusions, and the use of a nasogastric tube or catheter do not necessarily indicate a critical situation. The use of various equipment are upsetting to children and their families if they do not understand why the equipment is necessary. Spiritual reinforcement during this period may be very important to some children and families and the nurse must also show a willingness to assist the child and the family in obtaining a spiritual advisor if they indicate such a desire.
The anesthesiologist usually reviews the type of anesthesia to be used and the general effects it will have on the child. The nursing staff should explain the hospital routine necessary specific nursing procedures the purpose of diagnostic tests required, and the types of equipment that will be used during the preoperative and postoperative periods.
Physiological Preparation
Except in emergency situations, every effort is made to have the child in a state of optimal health before surgery is performed. Specific diets, protein and vitamin supplements, and other measures to improve the nutritional status may be employed. Intravenous infusions and transfusions of whole blood or plasma may be necessary to improve the fluid and electrolyte status and blood volume. Infections should be brought under control before surgery if they cannot be eliminated completely. Accurate records of the child's vital signs, blood pressure, and urinary output should be properly maintained.
Usually the patient is allowed a light evening meal and then given nothing by mouth after midnight, the night before surgery.22
Physical Preparation
It includes preparation of the surgical area such as shaving, administration of enema, insertion of a nasogastric tube, bath, removal of all jewelleries, securing long hair, removal of hearing aid and spectacles, checking for any loose tooth, tying identification band, wearing theater dress, etc.
Preoperative Teaching
- Review parent's and child's present level of understanding
- Explain the details of exact procedure to be performed
- Plan actual teaching based on child's developmental age and existing level of knowledge
Incorporate parents in the teaching:
- While giving explanations, allow ample time for discussions
- Use concrete terms and visual aids to describe the surgery
- Stress positive benefits of surgery
- Teach the postoperative exercises.
Postoperative Nursing Management
Aim of postoperative care is to assure uneventful quick recovery from anesthesia and prevention of complications. The postoperative period is divided into three phases:
Immediate Recovery Period
- When the child is received from the postoperative area, check the vital signs and record. Check for any special precautions and for any specific instructions. Check for any signs of shock, and if present, report it immediately
- Check all tubings like IV line or central line nasogastric tube and urinary catheters. Secure it properly to prevent accidental removal
- Check the postoperative orders about fluids and antibiotics.
- Maintain strict intake output record.
- Administer analgesics as per order.
- Check the dressings for any bleeding or tightness.
- Check vital signs frequently until they are stable. Each vital sign is compared with the previous one and is evaluated in terms of side effects from anesthesia and signs of impending shock, respiratory compromise or pain.
Intermediate Stage
Inform the parents about the postoperative progress of the child at regular intervals to relieve anxiety.
Monitor vital signs, drains and tubings. Maintain hydration and nutrition. Shift the child to the ward when the condition becomes stable.
Normalcy Stage (Care in the Ward)
Check for any signs of infection, and if present, it should be informed to the surgeon. Encourage early ambulation. If mobility is to be delayed, range of motion exercises and frequent change of position are to be done. The child is encouraged to cough and perform deep breathing exercises. Give normal diet after tolerating fluids and foods.
Provide clear instructions about drug, rest, and follow-up visits at the time of discharge.
BIBLIOGRAPHY
- Dorothy MR, Redding BA. Textbook of Pediatric Nursing, 6th ed, Elsevier.
- Marilyn HJ, Wilson D. Woag's Essentials of Pediatric Nursing, 8th ed, Elsevier, WB Saunders company.
- Nicki PL, Barbara ML. Pediatric Nursing, 2nd ed.
- Parthasarathy A. “IAP Textbook of Pediatrics, 3rd ed, Jaypee Brothers Medical Publishers.