pediatric child stress, anxiety, fear related to hospitalization

2. Presented By:-
Mr.Meghsham Gholap
Ist M.Sc Nursing
CON,PIMS

3. Introduction
In spite of best preventive and promotive health care, some
children become sick and need hospitalization.
Preparation for hospitalization is an important to prevent
psychological or emotional trauma of hospitalization.

4. Definition
 Hospitalization is admittance to the hospital as a patient.

5. Purpose
Patients are admitted to the hospital for a variety of reasons,
including
 scheduled tests,
 procedures, or surgery
 emergency medical treatment
 administration of medication
 to stabilize or monitor an existing condition.

6. Children's Reaction to
Hospitalization
Major stressor of hospitalization include separation, loss of
control, anxiety, fear, bodily injury and pain. children's
reaction to these crisis are influenced by their
developmental age, their previous experiences with illness
their coping skill and support system available.

7. Anxiety and Fear
For many children entering the hospital is like entering a foreign
world, this result in anxiety and fear.
 Anxiety often stems from the rapid onset of the illness or injury
particularly when the child having limited experience with
disease.
 Fear of childhood include fear of separation from their parent
and family, fear of unfamiliar environment and loosing control.
Therefore when the child is in the hospital he becomes
distressed about the unfamiliar environment, health care
procedure, specially use of needles or associated pain leads to
increase anxiety and fear.

8. Separation Anxiety
Separation anxiety is major stress for children of certain
ages. It usually begins around 8 months and ends at 3
years of age.
John Bowlby describe three stages the infant goes during
separation anxiety –
1. Protest
2. Despair
3. Detachment

9. Protest
 Observed behaviours during later infancy:
-Cries
-Screams
-Searches for parent with eyes
-Clings to parent
-Avoids and rejects contact with strangers
 Additional behaviours observed during toddlerhood.
- Verbally attacks strangers (e.g. "Go away")
- Physically attacks strangers (e.g., kicks, bites, hits, pinches)
-Attempts to escape to find parent
- Attempts to physically force parent to stay
- Behaviours may last from hours to days
- Approach of stranger may precipitate increased protest

10. Despair
 Observed behaviours:
 Inactive.
 Withdraws from other.
 Depressed, sad.
 Uninterested in environment.
 Uncommunicative.
 Regresses to earlier behaviour (e.g. thumb sucking, bed-
wetting, use of bottle).
 Behaviours may last for variable length of time.
 Child's physical condition may deteriorate from refusal to
eat, drink, or move.

11. Detachment
 Observed behaviours:
 Shows increased interest in surrounding
 Interacts with strangers or familiar caregivers
 Forms new but superficial relationships
 Appears happy
 Detachment usually occurs after prolonged separation from
parent; rarely seen in hospitalized children
 Behaviours represent a superficial adjustment to loss

12. Separation Anxiety in Each
Age Group

13. Infant
 At about 6 months of age are
acutely aware of the absence of
parent and become fearful.
 They can sense the anxiety their
parents are experiencing
 To having basic needs of food and
sleep meet by parent and
constraints of hospitalization
results in loss of needs being met.

14. Toddlers
 Separation leads to anxiety.
 Nurses experience protest and
despair in this group.
 Fear of injury and pain
 Regressive behavior
 Temper tantrums

15. Preschooler
 Separation anxiety generally less than the toddler
 Less direct with protests; cries quietly
 May be uncooperative
 Fear of injury
 Loss of control
 Guilt and shame

16. School Age Child
 Separation: may have already
experienced when starting to school
 Fear of injury and pain
 Want to know reason
for procedures and
 Like being involved and wants to
make choices

17. Adolescence
 Separation from friends
rather than family more
important
 Fear of altered appearance
 Will act as though not
afraid when they really are.
 Give them some control to
avoid a power struggle

18. Loss of Control
When hospitalized children experience a significant loss of
control. This loss of control increases the perception of
threat and affects their coping skills
 Child lose control over routine self care, usual task, and
play as well as decision related to care of their own bodies
 Procedure and treatments that occur in the hospital are
disturbing the child
children's needs vary greatly depending on their age, the
major area of loss of control in terms of physical
restriction, altered routines, and dependency are discussed
for each group

19. 1. Infants
2. Toddlers
3. Preschoolers
4. School age children
5. Adolescents

20. Effects of Hospitalization on Child
children may react to the stress of hospitalization before
admission, during hospitalization and after discharge. A
Childs conception of illness is even more important than
age and intellectual maturity in prediction level of anxiety
before admission.
1. Individual risk factor
2. Beneficial effect of hospitalization

21. Individual Risk Factor
 A number of risk factors make certain children more
vulnerable than others to the stresses of hospitalisation.
 Rural children exhibit significantly greater degrees of
psychological upset than urban children.
 Children who are active and strong-willed tend to fare
better when hospitalized than youngsters who are passive.
 Nurses should be alert to children who passively accept all
changes and requests; these children may need more
support than the "oppositional" child

22.  The stressors of hospitalisation may cause children to
experience short- and long-term negative outcomes.
 Adverse outcomes may be related to the length and
number of admissions, multiple invasive procedures, and
the anxiety of parents.
 Common responses include regression, separation
anxiety; apathy, fears, and sleeping disturbances,
especially for children younger than 7 years of age.
 Supportive practices, such as family centred care and
frequent family visiting, may lessen the detrimental effects
of such admissions.
 Research also indicates that a child's pain experience
determines how the overall hospitalisation is experienced

23. Beneficial Effects of Hospitalization
 Although hospitalisation can be and usually is stressful for
children, it can also be beneficial.
 The most obvious benefit is the recovery from illness, but
hospitalisation also can present an opportunity for children
to master stress and feel competent in their coping
abilities.
 The hospital environment can provide children with new
socialization experiences
 The psychological benefits need to be considered and are
maximised during hospitalization.

24. Factors Affecting Children's
Reaction To Hospitalization
OHP

25. Families Reaction to the Child
Hospitalization
Whether planned or unplanned hospitalization increase the
family stress and anxiety level. Parents and siblings have
their own reactions to this experiences.
1. Reaction of Parents
2. Reaction of Siblings
3. Factors influencing family reactions

26. The Nurses Role in Caring
Hospitalized Child

27. Role of Nurses
 In the most instances, the nurse is the primary person
involved in the care of a hospitalized child.
 The nurse is first one to see the child and family and
spend more time with them than other health care
personnel.
 Nurse must try to minimize the Childs distress so that the
hospital stay will be as pleasant an experience as possible.

28.  In a study of hospitalized children (Crole and Smith 2002)
found the nursing care for a hospitalized child occurred in
four phases
1. Introduction
2. Building a trusting relationship
3. Decision making phase
4. Providing comfort and reassurance
All these phases are interconnected for example- if trust is
not established, it becomes difficult to move to the next
phase.

29. Nursing Management
1. Preparing child and families for hospitalization.
2. Admitting the child to the facility.
3. Addressing the effect of hospitalization developmentally.
4. Preparing the child and family for surgery.
5. Maintaining safety during hospitalization.
6. Providing basic care for the hospitalized child.
7. Providing play, activities, and recreation for the hospitalized
child.
8. Promoting schoolwork and education during hospitalization.
9. Addressing the needs of family members.
10. Preparing the child and family for discharge.

30. Preparing Child and Families for
Hospitalization.

31. Admitting The Child To The Facility.

32. Addressing the Effect of Hospitalization
Developmentally.
• When addressing the fear, separation anxiety and loss of
control that occur in hospitalized children, the nurse should
consider Childs age and cognitive/developmental level.
• Interventions are based on how the child's experiences these
stressor at that age.
Guidelines to minimize the effects –
i. Minimizing the fear and anxiety
ii. Minimizing the separation anxiety
iii. Addressing loss of control

33. Preparing the Child and Family for
Surgery.
• The parents should be allowed to stay with the child until
surgery begins, and after surgery in post anesthesia area.
• Preparation and teaching must be geared to child's age and
developmental level.
• Use of animal or dolls helps children what is going to happen
them.

34. Maintaining Safety During
Hospitalization.

35. Providing Basic Care for the
Hospitalized Child.
• Basic care involves general hygiene measures including
bathing, hair care, oral care, and nutritional care.
• Young children are dependent on adult for most.
• If parents are present allow them to provide care for the child
to decrease the Childs stress.
• Older children may perform hygiene measures themselves but
may need some assistance from nurse.

36. Providing Play, Activities, and
Recreation for the Hospitalized Child.

37. Promoting Schoolwork and Education
During Hospitalization.

38. Addressing the Needs of Family
Members.
• Assess the factor that may influence the families reaction to
the child's hospitalization.
• Encourage families to have support system in place before,
during and after hospitalization.
• The practice of family center care include good
communication and ensuring nursing action address the child's
and family's need and preferences
• Increase the child and parents satisfaction with the health care
setting.

39. Preparing the Child and Family for
Discharge.
• Discharge planning actually begins upon admission.
• The nurse assess the family recourse and knowledge level to
determine what education and referrals they may need.
• On discharge children and their parent receives written
instruction about home care and copy of retained in the
medical records.
• Provide and review educational booklets that’s gives basic
health information of a child's disease.
• Explain, demonstrate and request a return demonstration of
any treatment or procedure to be done at home.

40. Generally the discharge instruction include-
• Follow-up appointment information.
• Guidelines about when to contact the physician or nurse.
• Diet.
• Activity level allowed.
• Medication scheduled.
• Specific dates for when the child may return to school or day
care.

41. Nursing Diagnosis
1. Anxiety related to hospital situation, fear of injury,
separation from family, painful procedures as evidenced
by crying, fussing, withdrawal or resistance.
2. Risk for powerlessness related to lack of control over
procedure, treatments, care and changes in usual
routines.
3. Deficient divisional activity related to confinement in
bed or health care facility, lack of appropriate
stimulation from toys or peers, activity restriction as
evidenced by verbalization of boredom or lack of
participation in play.

42. 4. Interrupted family process related to separation from
child due to hospitalization changes in role function as
evidenced by parental verbalization of issues.
5. Self-care deficient related to immobility, activity
restriction, regression, or use of equipments as
evidenced by inability to feed, bathe or dress self care
or other activities of daily living

43. Bibliography
 Teri Kyle and Susane Carmen, essential of pediatric
nursing, 2nd edition, Wolters Kluwer publication, page no
312-337.
 Wong's essential of pediatric nursing, first south Asia
edition, Elsevier publication, page no. 516-535
 Textbook of pediatric nursing, Assuma Beevi T.M.
Elsevier publication, page no. 373-387
 Internet sources