Course

Nursing Care of Pediatric Patients by Stage of Development

Course Highlights


  • In this course you will learn about providing medical care for children.
  • You’ll also learn the basics of different age brackets and nursing care of pediatric patients.
  • You’ll leave this course with a broader understanding of how to communicate with children while providing excellent healthcare.

About

Contact Hours Awarded: 3.5

Morgan Curry

Course By:
Kathy Wiejaczka
MSN, RN

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The following course content

The pediatric population presents unique challenges to nurses. The expert in nursing care of pediatric patients recognizes s recognizes that developmental stage plays a pivotal role in the approach of each child. In this course we will discuss how to care for children of each developmental stage, including expert tips and tricks for pediatric nurses. 


Introduction to Nursing Care of Pediatric Patients  

Pediatric nurses carry a heavy responsibility for caring not only for this vulnerable, highly diversified population with complicated and intermingled medical needs but also understanding the importance of their emotional needs. Their emotional needs must become the top priority.

As nurses we are tasked with advocating and providing for the best interests of this sometimes-fragile population. We accomplish this by decreasing the stress and fear reactions that might occur if we do not strategize before we provide care to a child.

Although regression is expected with hospitalized children of all ages, it is the nurse’s responsibility to foster growth and acclimation within the healthcare setting. Children have stated that their worst fears during hospitalization are those related to nursing interventions such as needle sticks during IV insertion or injections (1).

As a former special education school nurse consultant for the emotionally impaired population, I cannot stress the significance of recognizing children’s emotional needs. If we take the time to address these needs prior to any hands-on procedure or even touching the child not only will our job be easier but also we will have respected the child’s personal space thereby earning his/her trust.

This course will address many aspects of developmentally appropriate interventions in  in a layout that is easy to comprehend and utilize in your practice. Children are resilient but we must give them a sense of control to build trust with healthcare providers.

The primary guiding principles are to involve families in their care as the basis of creating a solid relationship with the child and facilitating success in their treatment. The secondary guiding principle with children is we must help them become aware of what they feel before we ask them to control their behavior (2). Some children may not be equipped to express their feelings depending on their age.

They may not have the vocabulary to express those fears, anxieties, anger, happiness, and other feelings. We must guide them to express these feelings if not with words then with activities, otherwise those feelings are very likely to result in negative behavior. This course will give you up-to-date ideas, suggestions, and activities to improve your care to your pediatric population.

Real-World

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Self Quiz

Self Quiz

Ask yourself…

  1. List some ways you would like to improve when talking to children about their health.

Current Practice in Nursing care of Pediatric Patients

According to the Center for Disease Control (CDC), in 2017 hospitalized pediatric patients in the United States comprised 6.6% of the total hospitalized patients across all ages with a total of 73,529 pediatric patients (3). Those pediatric patients admitted are complex with comorbidities in many cases.

Currently nurses face increased patient caseloads in the hospital, homecare, and clinic settings and consequently their time is at a premium. The suggestions for interventions in this course will assist the nurse to provide care that is timely and diminish emotional meltdowns by understanding the child throughout his/her developmental stage.

The way a nurse approaches his/her patients can do a great deal in encouraging a frightened or wary child. Research has shown children tend to be extremely resilient when well supported (2). Children who have access to protective factors are better able to overcome adversity and traumatic events.

These protective factors are personal qualities such as personality; family connections; coping skills; feelings of control and self-confidence (4). Through adversity children can learn how to process life based on their own experiences, how they have dealt with those experiences in the past, and responses from others such as parents, nurses, and other healthcare providers. In short, children use these events to reflect back in a positive way for future stressful experiences.

A pediatric nurse deals not only with the child but also with all the anxieties and demands of the parents. In addition a study by Tubbs-Cooley et al. (2019) found the intense intellectual pressures and time constraints of nurses are factors in the quality of care as much as patient volume and acuity.

Nurses experience intense stress to complete their vital tasks with patients and this is another factor in their abilities to deliver quality care. Hospital administrators, nurse managers and nurses themselves must address this level of stress and the time constraints to help facilitate quality of care. Children are equipped with abilities to detect hidden stress and this reflects on how they perceive and react to a given situation.

Real-World

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  1. Think about your interactions with pediatric patients. Could you re-phrase your conversations to be more developmentally appropriate? If so, how?

Family Responses to Illness and/or the Hospitalized Child 

It is the nurses’ responsibility to promote a sense of security in pediatric patients. In fact, it is the most important item on our to-do list in the healthcare environment of pediatric patients. Feeling secure depends on a sense of physical and psychological safety. 

Parents are the most vital key to promoting this safety in the pediatric patient. Parent’s presence at the bedside is the best way to decrease anxiety and increase this sense of security in children. Nurses must do everything in their power to decrease parental stress and anxiety and that will directly impact the child’s positive coping abilities. 

In order to help families adapt to the hospitalization of the child the nurse should: 

  • Build trust with the family by communicating frequently with them including siblings. This includes education in simple, concrete facts that encourages parents to ask questions. The nurse should ask questions that are open ended to the child, parents, and siblings. 
  • Understand that parent’s presence in their child’s hospitalization is an extension of the child in order for the child to make sense of what is happening to him/her. 
  • Encourage parents to stay in touch with siblings at home if parents are staying at the hospital. 
  • Establish a relationship with the sibling and explain the medical condition of his/her sibling in simple terms. Also, include the sibling in therapy with the patient so the sibling feels he/she is helping his/her sick sibling. 
  • Instill a sense of hope in parents by carefully choosing words that elicit hope. 
  • Focus on the positives in every situation. 
  • Encourage parents to visit their child anytime, stay overnight, and/or call the nurse for an update. Nurses need to assess how much parents would like to be involved and support their choice. The primary goal should be no separation of parent and child in children under 5 years of age (6). 
  • Identify key family members and decision makers in the child’s care. 
  • Teach parents how to talk to their child about the medical procedures, equipment, status, and health concerns. Prepare parents ahead of time for tough conversations with children to lessen both the parent’s and the child’s anxiety level. 
  • Teach parents how to talk calmly, how to touch to calm the child, and the power of eye contact during procedures (7). Parents have a key role in lessening anxiety through coping skills. Children can sense parent’s emotional upheaval so working to lessen parent’s emotionality is crucial to helping children cope. 
  • Parents and nurses need to respond to an anxious child with empathy, compassion and acknowledgement. 
  • Here are some examples of therapeutic communication with a child in Nursing care of pediatric patients: 

Avoid Saying: 

Say Instead: 

“Don’t worry” “Can you tell me more about your worries?” 
“It’s no big deal” “I can see why you are feeling anxious, let’s think of something positive.” 
“You’ll be fine.” “I am here for you.” 
“There’s nothing to be afraid of.” “Let’s talk about this.” 
“You just need to sleep more” “Let’s mediate together.” 
“I’ll do it” “I know you are anxious right now, but I am here for you and know you can do it.” 
“It’s all in your head” “Let’s talk about what’s worrying you while taking a walk.” 
“This will only take a few minutes” “This will be really quick.” 

“I need to give you a shot” 

(Children sometimes think shot means being shot with a gun.) 

“I need to give you some medicine.” 

“I’m going to take your temperature” 

(Young children may think you are going to take something from them.) 

“I want to find out how warm you are.” 

Adapted from Hurley (2018) and Fastaff (2015) 

 

 

Real-World

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Self Quiz

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  1. How can nurses help patients and families adapt to acute illness and hospitalizations?

Developmental Considerations for Appropriate Nursing Interventions in Nursing Care of Pediatric Patients

Children face a loss of control, limits on their mobility, powerlessness, pain, and discomfort, to name a few emotions and negative consequences occurring while ill. It is the nurse’s responsibility to help children cope with medical procedures and their illness. The best way to facilitate this is through an atmosphere of trust. Trust is best created and fostered through strategies that are researched to be effective.

There are strategies that occur across developmental stages and these will be addressed first before discussing specific strategies based on the developmental age groups. These age groups will be divided into infant, toddler, preschool, school age, and adolescence in this course. These groups will be explored below for the best nursing interventions using evidence-based practice. Therapeutic play will be addressed in the section following this one.

General Interventions Across the Developmental Spectrum

There are some interventions and principles that hold true for children of all ages. Pediatric nurses should strive to incorporate these principles into their practice regardless of the age of the developmental stage of the child.

Children grasp information best when it is appropriate to their cognitive level of development.

Offer choices to every child when performing even routine tasks such as obtaining his/her blood pressure. This will promote a sense of control in the child. Asking “what arm would you like me to use to check your blood pressure?”

Create a daily schedule so that the child is aware of what to expect throughout his/her day.

Use humor and laughter to lighten up the air with children.

Use time-out coupons, for example three per procedure that the child can use to halt the procedure for 2 minutes (9). This gives control to the child to better cope with the procedure.

A pre-surgical tour of the hospital can lessen anxiety and promote cooperation.

Children need a regular schedule in the hospital that mirrors home life as much as possible, but that is also consistent from day to day in the hospital setting. Research has shown that without a regular schedule for children of all ages, a child can feel confused and insecure adding to emotional upheaval, stress, and adaptability (9).

Nurses should stoop down to the child’s level physically. Eye to eye contact is important to develop a trusting relationship. The use of a short stool works well to get at their eye level.

Introduce yourself and ask the child personal questions such as “What is your favorite toy?” or “Who is your favorite cartoon character?”

Nurses should smile at their pediatric patients. Children of all ages appreciate this approach from babies to adolescents. Who doesn’t like a friendly, calm approach?

Regardless of the age of the child, use his/her name. It soothes children and parents alike. It shows respect for individuality and lessens anxiety in children and parents. Never refer to a child by his/her diagnosis.

Children of all ages from toddlers through adolescence love to help. Through their role in their own care, it can alleviate stress and build trust. For example you could ask the child to hold your otoscope until you need it. Teach them the tools of the trade. At the same time you are educating about a possible career choice for one of them.

Say simply, “I need your help to stay very still. Can you do that?” This activates the child to engage in your activity with helpfulness.

Consider using a therapeutic dog in the hospital setting as a distraction and calming technique when appropriate (9). Animal assisted therapy has shown to improve the level of anxiety in parents and children. Check with your facility for approval of canine therapy. Or perhaps get permission for the child’s dog to visit in the playroom.

Give children the same time and respect you would give to adult patients (10). This includes decision-making even when they are not able to make decisions on their own. This will enhance their sense of control over their own health.

Secrecy and dishonesty increases a child’s sense of anxiety and fear and undermines trust with the nurse (10).

Nurses should coach children to ask more questions and thereby increase satisfaction with their healthcare providers and more compliance with their disease processes (10).

Never talk down to a child for example in a singsong voice. This is demeaning to him/her.

Encourage parents to bring in posters, photographs, and other items from home to personalize the bedside. This may help the child to feel more comfortable in the hospital setting.

Choose roommates for children, if possible, to promote socialization and foster growth in children. Sometimes nurses can advocate for children with similar disease processes or hobbies to room together in the hospital. This promotes a sense of community facilitating recovery and belonging.

Remind children that their illness is not punishment. Explore this confusion in your pediatric patients. Sometimes children do not have the words to express their fears that they did something wrong to cause their illness or hospitalization.

Use words and sentence length that matches the child’s level of understanding. A common way to measure this is the number of words in a child’s sentence should equal his/her age plus one (6).

Use crayons and paper freely. First demonstrate by drawing yourself and encourage child’s expression.

Give children time to feel comfortable with you. Speak to the parents first.

Help children understand they can face their fears. Promote courage by stating, “I know you’re scared and I’m here to help you.”

Give hope and courage to children through praise by stating how “brave” and/or “good” they are.

Communicate with puppets, dolls, or stuffed animals first before asking questions directly of a young child.

If a child is ticklish when you are examining his/her abdomen, place the child’s hand down first on his own abdomen and place your hand on top of his. Then slowly deviate off of his hand to examine the abdomen.

Parents should not be asked to restrain their child. This interferes with the trust relationship the child has with his/her parent (6)

Allow children to pick a toy out of the toy box to play with during the procedure and then afterwards they can pick a gift out of the box and return the toy.

Involve the medical social worker to assist in therapy with pediatric patients.

Tell children it is okay to cry, do not shame them for expressing this emotion.

Stress the positive benefits of procedures for example, “After this bandage change your sore will heal quicker.”

Real-World

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Self Quiz

Self Quiz

Ask yourself…

  1. What are some themes you notice about the general interventions?
  2. Think about an experience you had with a pediatric patient that did not go well.
  3. Could any of these interventions have helped you improve the interaction? If so, how?

The Importance of Caring, Consistency, and Humility

Children of all ages must feel a sense of love from their caregivers. Children are barometers of emotions in those people surrounding them. These emotions can influence negative behavior in hospitalized children. This is a basic tenet but vitally important to working effectively and compassionately with the pediatric population. Children are more likely to push past anxiety and have a sense of safety if surrounded by genuine caring from nurses. Love can best be demonstrated in those quiet moments shared with children, holding, stroking their arm, and/or sharing some fun activity. Children are naturally resilient but need basic emotions of love and trust to foster this resiliency. Sometimes one successful episode is all a child needs to feel that they can complete a procedure or tackle the impossible.

How do we show kindness, yet firmness? How do we show empathy and respect in Nursing care of pediatric patients? These personality traits flow from our inner core but can be learned. Humility allows us to offer choices both to parents and children. We MUST keep this in mind when working with the pediatric population because this will give both parents and children a sense of control. Many negative emotions in a child flow from a loss of a sense of control.

When working with children, this author was always very clear to the child about her expectation that the child would only be able to stay in the health room for 15 minutes but he/she could choose whatever activity would help him/her regroup and get back to the classroom. The following strategies were offered: a short nap, reading a short book to the child, a small snack, hot compress, cold compress, or relaxation exercises. The author was always successful with this approach because the child felt affirmed, respected, and in control which also created an atmosphere of trust.

Source: Microsoft Stock Photos

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  1. What are three elements of working with children that are most important?

Labeling Feelings

Helping children to understand their feelings and label them is an instrumental step in helping them to gain control of the situation and their emotions. Rachel Wagner in her book Flip It reiterates the root to all behavior is feelings (2). She states we must help them identify these feelings before we ask them to control them.

Through the use of feeling charts, (see Appendix A) in Nursing care of pediatric patients we can assist our patients by helping them talk about what they are feeling, by giving them the words for these emotions, such as anger, frustration, happiness, sadness, confusion, or disappointment, and others.

Then explaining that these feelings are usually temporary, normal, and it’s okay to feel them. Competency = less anxiety (2).

Real-World

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  1. Why is it important to help children label their feelings in Nursing care of pediatric patients?

Let’s Talk About Resiliency

Nurses need to assess a family’s resilience that is described as the family’s ability to handle stress and challenges (12). Nurses can help families learn new skills and reinforce confidence in family members to deal with the stress of illness or injury in the child. Sources of support to build resilience in the family are church, family coping mechanisms, flexibility, and social support (12). Nurses can help families see their strengths and transfer competence from their past stresses in life to this event.

There are strategies to strengthen resiliency in children and by doing so children are less anxious, better behaved, and more in control. An important key reminder about resiliency is that we aren’t born with it, we develop it over time with each success, each positive opportunity, and even small words can grow it. Children do not need parents (or nurses) to solve their problems. Resiliency is enhanced when children solve their own problems. Children actually need to experience discomfort to learn that they are capable of adapting, learning, and solving. This builds competence. (12)

How do you build resiliency in kids in Nursing care of pediatric patients? According to Katie Hurley (12), nurses should:

  • Resist fixing problems and instead ask the child how they would fix that problem. Give control back to the child, showing the nurse believes in the child’s problem-solving abilities.
  • Encourage deep breathing to give children something to do to regain control of their emotions.
  • Embrace mistakes as missteps instead of total failures. Teach that mistakes are a learning process and that nothing ventured is nothing gained. We must encourage children to be adventure takers. We must accentuate the positive instead of the negative. We know that resiliency and optimism go hand in hand.
  • Find a way for the child to get fresh air outside or engage in a physical activity if possible. (12)

Real-World

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  1. Recap: How do you build resiliency in children in nursing care of pediatric patients?

Developmental Strategies with Infants

(0-12 months)

We must remember that infants are learning to develop trust in their first year of life. They use all of their senses to develop this trust, such as vision, hearing, taste, smell, and touch.

To care for infants in the healthcare setting the nurse should (11):

  • 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 day to promote consistency and decrease the likelihood of stranger anxiety that is common in infants from 6 months to 18 months. They are more at ease with a consistent caregiver (9).
  • Examine children who are in the stranger anxiety stage by placing them on their parent’s lap and sit opposite to examine them.
  • 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 (6).

Real-World

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Self Quiz

Self Quiz

Ask yourself…

  1. How can you incorporate the interventions above into your practice when caring for infant patients?
  2. Which specific interventions have you previously noted to effective?

Developmental Strategies with Toddlers

(1- 3 years old)

Toddlers are learning much about their environment through exploration and trying to make good choices. Slowly they are learning self-control (9).

To care for toddlers in the healthcare setting the nurse should (9):

  • Allow the toddler to sit on the parent’s lap during the procedure or exam.
  • Give the toddler a choice such as “Would you like me to listen to your heart first or look at your ears?”
  • Refrain from asking the toddler permission to examine him/her because the answer is most likely going to be no. Instead, state calmly and firmly what area you are examining next.
  • 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.
  • Praise the child using his/her first name for cooperating.
  • Allow the toddler to dress self, use potty-chair, and self feed.
  • Name objects with simple explanations.
  • 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.
  • Provide a nightlight in the child’s room.
  • Give the toddler a choice by saying, “Once I have listened to your heart, you can choose to ride in the cart or walk to the playroom” to decrease resistance from the child.
  • Comfort the toddler after a painful procedure by rocking, singing, offering a snack, or holding him/her.

Real-World

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Self Quiz

Self Quiz

Ask yourself…

  1. How can you incorporate the interventions above into your practice when caring for toddler-aged patients?

  2. Which specific interventions have you previously noted to effective?

Developmental Strategies with Preschool Children

(3 years – 6 years)

Preschoolers have a very active imagination and are very concrete in their thinking. They see everything from their own point of view.

To care for preschoolers in the healthcare setting the nurse should:

  • Allow the child to touch or play with equipment you will use
  • Have the preschooler sit on the parent’s lap
  • Give the child choices in your approach to him/her
  • Make up a story about what you are examining or doing such as, “I’m seeing how strong your muscles are” when checking his/her blood pressure (6).
  • 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 your mouth.”
  • Read books to the child to help him/her process what is happening.
  • 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 try to accommodate the child if possible.

Real-World

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Self Quiz

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  1. How can you incorporate the interventions above into your practice when caring for preschool-aged patients?
  2. Which specific interventions have you previously noted to effective?

Developmental Strategies with School Age Children

(6 years – 12 years)

School age children want explanations for everything and are usually satisfied with this approach. They want to examine and understand how the equipment works. They have lots of ‘why’ questions. They have a heightened concern about their body and anything that might mean injury or pain to their body. This concern extends to their possessions (6).

To care for school age children in the healthcare setting the nurse should:

  • Answer all their questions and demonstrate the equipment. Your patience with this age group will usually pay off.
  • 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. Sometimes this age group is prone to bargaining to delay procedures, so the nurse should be flexible but aware of this possible occurrence.
  • Knock on the door before entering the room.
  • 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.
  • Use small talk as a means of distraction during the procedure.

Real-World

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  1. How can you incorporate the interventions above into your practice when caring for school age patients?
  2. Which specific interventions have you previously noted to effective?

Developmental Strategies with Adolescent Children

(12 years – 18 years)

This age group fluctuates between child and adult thinking and behavior (6).

To care for adolescent children in the healthcare setting the nurse should:

  • 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, I-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
  • 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.

Real-World

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  1. How can you incorporate the interventions above into your practice when caring for Adolescent patients?
  2. Which specific interventions have you previously noted to effective?

Therapeutic Play in Nursing Care of Pediatric Patients

Children use play to make sense of their world, to categorize the collective whole of their being with their interactions, dreams, missteps, and joyful attitudes. As nurses, we must facilitate this play through our contact with our youngest patients. Play is very individualized, each child deciding his/her favorite play activity. Therapeutic play decreases negativity, provides motor activity outlet, and helps the child cope. Play provides the child with an active role and control of the situation, and distracts from procedures that cause stress (1).

Here are some examples of therapeutic play:

  • The child using the IV catheter on his/her doll or stuffed animal. Allowing the child to play with the equipment for several days prior to the procedure assists in processing the procedure successfully.
  • Stories can be read to the child or the child can make up his/her own story about the healthcare event.
  • Puppets are especially useful for children to act out what they are experiencing in the hospital setting. Nurses can also have the puppets ask personal questions of the child, and it’s more likely the child will answer them.

Expressive therapy (13) works well with children oftentimes because they are hands-on learners and express their emotions the same way. Here are some examples of expressive therapies that can help children address fear, anxiety, stress, and pain:

  • Art therapy
  • Drama therapy
  • Play therapy
  • Music therapy
  • Poetry therapy
  • Sand play therapy

Specific Play Activities for Specific Procedures (6):

  • Increasing fluid intake can be accomplished by cutting gelatin into fun shapes; using small medicine cups and decorating them; color water with food coloring; make a poster and give rewards when drinking a prescribed amount.
  • Deep breathing can be encouraged through blowing bubbles; blowing a pinwheel or a party blower; suck paper from one container to another using a straw.
  • Range of motion activities can be simulated with activities such as throwing bean bags into a basket; hang balloons and have the child kick them; play Twister or Simon Says; play kickball with a foam ball; provide clay for fine motor exercises; paint or draw on large sheets of paper on the floor; play beauty shop and comb or set hair.
  • Soaks can be imitated by playing with toys in water; washing his/her dolls; picking up marbles in the bath water.
  • Injections can be simulated by letting the child play with the syringes with his/her doll; use syringes to decorate cookies with frosting; allow the child to have a collection of different sized syringes to manipulate.
  • Giving the child something to push like a stroller or wheelchair, and holding a parade can encourage ambulation.
  • Children in traction can have their environment expanded by turning the bed into a pirate ship or airplane with decorations; or moving the bed to the playroom.

Real-World

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Self Quiz

Ask yourself…

  1. Therapeutic play can be a powerful tool for building trust with pediatric patients.
  2. Have you witnessed a caregiver utilizing therapeutic play? If so, what was your experience?
  3. How can you incorporate therapeutic play into your practice?

Cultural Considerations

It is imperative that nurses consider the cultural influences of the children they care for in the nursing care of pediatric patients healthcare setting. Cultural competence includes understanding the values, beliefs, and customs of ethnic groups and how these influence health decisions by that family. All behavior must be judged based on the context of the culture in which it occurs (6). Sometimes children of a minority do not trust that nurses of a majority culture respect them or understand them. This can cause fear and stress in that child and contribute to loneliness and helplessness.

Here are some useful tips to facilitate appropriate interventions (6):

  • Ask open-ended questions about cultural needs and health habits.
  • Facilitate communication with an interpreter or language line telephone.
  • Some ethnic cultures see eye-to-eye contact as aggressive and rude.
  • Although ethnic generalizations are known, there are great variations among individuals regarding how they practice within that culture.
  • Culture can influence a child’s self-esteem.
  • In non-English speaking patients, pain may not get reported because some ethnic people believe that pain means the disease has worsened (2).

Real-World

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Self Quiz

Self Quiz

Ask yourself…

  1. How can you incorporate the interventions above into your practice when caring for toddler-aged patients?

  2. Which specific interventions have you previously noted to effective?

Reducing Pain and Discomfort

Any measures to reduce pain and discomfort are the nurse’s responsibility. Nurses must assess both parents and the child for the level of security, fear, and resistance to the procedure. In addition, differentiating between fear and pain is vital to the correct approach by the nurse (1).

Nurses must support children through parental participation and communication (1). Untreated pain in infants and young children may lead to increased pain perception and chronic pain in adolescents and adults (14).

Pain research has found that children who show more active behavior during the procedure such as crying and flailing oftentimes rate these procedures as less painful than children who cope passively (7).

For this reason we want to always encourage children and parents that it is normal to cry when something is painful. Children should never be shamed or made to feel guilty for crying or screaming.

In order to lessen pain and discomfort the nurse should:

  • Include parents in pain control techniques and teach them their role in pain control for their child. Parents are the most important part of pain management. This role is very child-parent specific and includes coping styles of both the parents and the child (7).
  • Consider using a device called “Buzzy” to decrease the sensation of pain during IV insertion or venipuncture (15). This device uses a combination of cold and vibration to replace pain with movement and temperature. Research has shown this device to be effective in decreasing pain and discomfort during some procedures (15).
  • Provide an outlet through serious gaming for these children. Serious gaming is defined as video games that require active participation by the child through problem solving that has shown to be very effective as a distractor during painful procedures (16).
  • Be open and honest to children in their care. It is better to say, “Sometimes this feels like pushing or pinching and sometimes it doesn’t bother people. You tell me how it feels” instead of, “This is probably going to hurt.” (7)
  • Provide distraction for children to decrease their pain experience, examples include listening to the radio or music; the child singing, deep breathing, blowing bubbles to blow the pain away, yelling as loud or soft as it hurts, visiting with friends or watching TV (7).
  • Teach relaxation techniques to the child and parents such as gently swaying a child, rocking, or having him/her take a deep breath then relaxing his/her body on exhalation.
  • Teach guided imagery to children and parents, examples include asking the child to verbalize relaxing experiences, or have the child pre-tape his/her story of a relaxing event and listen to it during the painful procedure.
  • Encourage positive self-talk with the child. For example, having the child say, “I’m going to feel better soon” or “I know I can do this.”
  • Use topical anesthetics on any age child to decrease the pain sensation during IV insertion or venipuncture procedures.
In order to lessen pain and discomfort based on age specific strategies the nurse should (9):

Infants

  • Encourage holding, cuddling, allowing infants to suck a pacifier, use of sucrose while sucking, and massaging.

Toddlers

  • Encourage reading them stories, massages, blowing bubbles, touching, holding, rocking, listening to music, and coloring.

Preschoolers

  • Encourage playing, reading stories, listening to music, child pretending to be a superhero, watching TV or a video, and engaging in arts/crafts.

School Age Children

  • Encourage the child to breathe rhythmically, use guided imagery, talk about fun experiences, play games, listen to TV, radio or music, and engage in arts/crafts.

Adolescents

  • Encourage the child to breathe rhythmically, use muscle relaxation, use guided imagery, listen to music, watch TV, have visitors, play games, and arts/crafts.

Real-World

Ready?

Self Quiz

Self Quiz

Ask yourself…

  1. Painful experiences can be traumatic for pediatric patients.
  2. How can you use the above interventions in your practice in nursing care of pediatric patients to reduce the perceptions of pain?

Nursing Care of Pediatric Patients with Special Healthcare Needs

As a former special education school health consultant for children in grades kindergarten through 12th grade, this author became proficient at reading students’ needs or discerning when she could not determine their needs and had to rely on other cues. This pediatric population encompasses many complex health issues that may be chronic and lifelong. Beneath all of the tubes, devices, special needs equipment, there is a child who is like many children without special needs. They are longing to be seen, to be heard, and to be accepted as they are.

Some suggestions for nurses when interacting with this population are (17):

  • To leave any labels at the door and interact with this population as individuals with distinct needs similar to the pediatric population at large.
  • Even though a child may have a cognitive diagnosis he/she still shares dreams, hopes, and feelings. These children desire to be seen as individuals who relish conversations with people and interactions. Talk in a normal tone and give them eye contact.
  • A child’s loud verbalization does not necessarily mean pain. Get to know these individuals on a personal level. Oftentimes this verbalization could be laughter. Trust in your own senses to determine the difference.
  • Respect these children’s bodies regardless of ability. Explain to this child what you are doing before doing it.
  • Even though a child with special needs might not interact or talk; provide care, respect, and compassion as you would any other patient.
  • Provide comfort as you would any patient, even though these children express themselves differently. They need love, kindness, and patience.
  • Show advocacy for each child you care for regardless of ability, diagnosis, or IQ. Involve special needs children in the conversation; even though they do not participate verbally, they understand what is happening.
  • Use the checklist developed for non-communicating children to assess the pain level of these special needs children (see Non-communicating children’s pain checklist at http://www.community-networks.ca/wp-content/uploads/2015/07/PainChklst_BreauNCCPC-R2004.pdf) (6).
  • Treat each child with the special care and a patient approach that they so deserve and require.
  • Communication is vital with the child and his/her family members.
  • Nurses must not place judgments on patients but keep an open mind and an open heart to guide patients towards their best healthcare outcome.
  • Nurses have expressed concern with having adequate time to care for the special needs pediatric patient in a holistic manner (18). Nurses desire to engage in a thorough way with these patients and their families in nursing care of pediatric patients, but time constraints limit over-involvement and sometimes lead to frustration and guilt on the nurses’ part. They describe it as an art to balance the time factor with the multiple needs of these patients, and the other patients on the nurses’ caseload.

Conclusion

The pediatric population requires nurses in nursing care of pediatric patients who embrace the cohesive bond between parents and child. The nurse must work well with both to enhance the best care possible for the family. Advocacy takes on many forms as a pediatric nurse; the parent, the child, and the family unit must all be promoted and supported.

Nurses make the difference and their care is multiplied through each patient and each hospitalization. Pediatric nurses through dedication and mutual problem solving with families show responsiveness to children’s experiences, age, and development to meet the child in his/her world.

References + Disclaimer

  1. Karlsson, K., Rydstrom, I., Enskar, K., & Englund, A.D. (2014). Nurses’ perspectives on supporting children during needle-related medical procedures. International Journal of Qualitative Studies on Health and Well Being, 9.doi:10.3402/qhw.v9.23063
  2. Wagner, R. (2019). Flip It. Devereux Advanced Behavioral Health. https://centerforresilientchildren.org/
  3. U.S. Department of Health and Human Services. (2017). National Center for Health Statistic summary health statistics: National Health interview survey. Centers for Disease Control and Prevention. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NH/SHS/2017_SHS_Table_P- 10.pdf   
  4. Fostering Resilience. (n.d.). The 7 Cs: The Essential Building Block of Resilience. http://www.fosteringresilience.com
  5. Tubbs-Cooley, H.L., Mara, C.A., Carle, A.C., Mark, B.A., & Pickler, R.H. (2019). Association of nurse workload with missed nursing care in the neonatal intensive care unit. Journal of American Medical Association Pediatrics, 173(1), 44–51. doi:10.1001/jamapediatrics.2018.3619
  6. Hockenberry, M. J., Rodgers, C. C., & Wilson, D. (2017). Wong’s essentials of pediatric nursing, (10th ed.). St. Louis, Missouri: Elsevier Mosby.
  7. Hasenfuss, E. (2003). Collaboration of nursing and child life: A palette of professional practice. Journal of Pediatric Nursing, 18(5), 359-365. https://doi.org/10.1016/S0882-5963(03)00158-1
  8. Hurley, K. (2018). 10 things never to say to your anxious child. https://www.psycom.net/child-anxiety
  9. Ball, J.W., Bindler, R.C., Cowen, K.J., & Shaw, M. R. (2016). Principles of pediatric nursing: Caring for children, (7th ed.). Hoboken, NJ: Pearson Education.
  10. Hudson, N., Spriggs, M., & Gillam, L. (2019). Telling the truth to young children: Ethical reasons for information disclosure in paediatrics. Journal of Paediatrics and Child Health, 55, 13-17. doi: 10.1111/jpc.14209
  11. Fastaff. (2015). Pediatric nurse: A crash course in talking to kids. https://www.fastaff.com/blog/pediatric-nurse-crash-course-talking-kids
  12. Hurley, K. (2018). Resilience in children: Strategies to strengthen your kids. https://www.psycom.net/build-resilience-children
  13. Filion, J. (2016). 3 types of pediatric therapy to consider. https://www.gebauer.com
  14. Thrane, S.E., Wanless, S., Cohen, S. M., & Danford, C. A. (2016). The assessment and non-pharmacologic treatment of procedural pain from infancy to school age through a developmental lens: A synthesis of evidence with recommendations (review). Journal of Pediatric Nursing, 31(1), e23-e32. doi:10.1016/j.pedn.2015.09.002
  15. Moadad, N., Kozman, K., Shahine, R., Ohanian, S., & Badr, L.K. (2016). Distraction using the Buzzy for children during an IV insertion. Journal of Pediatric Nursing, 31(1), 64-72. doi:10.1016/j.pedn.2015.07.010
  16. Nilsson, S., Enskar, K., Hallqvist, C.,& Kokinsky, E. (2013). Active and passive distraction in children undergoing wound dressings. Journal of Pediatric Nursing, 28 (2), 158-166. doi.10.1016/j.pedn.2012.06.003
  17. Coleman, C.L. & Ahmann, E. (2016). Family matters. Empowered by nurses. Pediatric Nursing 42(4), 193-196.
  18. Ford, K., & Turner, D. (2008). Stories seldom told: Paediatric nurses’ experiences of caring for hospitalized children with special needs and their families. Journal of Advanced Nursing, 288-295.

 

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Use of Course Content. The courses provided by NCC are based on industry knowledge and input from professional nurses, experts, practitioners, and other individuals and institutions. The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NCC. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Knowledge, procedures or insight gained from the Student in the course of taking classes provided by NCC may be used at the Student’s discretion during their course of work or otherwise in a professional capacity. The Student understands and agrees that NCC shall not be held liable for any acts, errors, advice or omissions provided by the Student based on knowledge or advice acquired by NCC. The Student is solely responsible for his/her own actions, even if information and/or education was acquired from a NCC course pertaining to that action or actions. By clicking “complete” you are agreeing to these terms of use.

 

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