hospitalised child

CRISIS AND NURSING INTERVENTION

INTRODUCTION

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LOGO



CHAPTER - 9

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DEFINITIONS

Crisis is an acute time limited phenomenon experienced as an over whelming emotional reaction to a stressful event or the perception of that event. It is the struggle for equilibrium and adjustment when problems are perceived as insolvable.

Crisis intervention is a short term focuses on the solving of the immediate problem, aims to establish the former coping pattern and problem solving ability. It is usually limited to 4 – 6 week period after which resolution will be attained.

TYPES OF CRISIS

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1 2 3

Maturational -each development stage can be referred to as the same.

Situational -arises from an external rather than an internal source.

Adventitious –it is not a part of every day life, is accidental and unplanned

CRISIS THEORY

Erich Lindermann - 1940s conducted study of the grief reactions of close relatives of victims in a club fire. This study formed the foundation of crisis theory and clinical intervention. She showed that preventive intervention in crisis situations could eliminate or decrease serious personality disorganisation and other psychological consequences from the sustained effects of severe anxiety.

Gerald Caplan -1960s defined crisis theory and outlined crisis intervention. Caplan identified four distinct phases of crisis.

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FOUR PHASES OF CRISIS PROCESS

1st phase - A person confronted by a conflict or problem that threatens the self concept responds with increased feelings of anxiety. The increase in anxiety stimulates the use of problem solving techniques in an effort to solve the problem and lower anxiety.

2nd phase - If the usual defence response fails, and if the threat persists, anxiety continues to rise and produce feelings of extreme discomfort. Individual functioning becomes disorganised.

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3rd phase - If the recovering attempts fail, anxiety can escalate to severe and panic levels, and the person mobilises automatic relief behaviour, such as withdrawal and flight. (compromising needs or solutions should be made)

4th phase - If the problem is not solved, anxiety can over whelm the person and leads to serious personality disorganisations. This maladaptive response can take the form of confusion, suicidal behaviour, yelling and running aimlessly.

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Appraising Crisis Systematically:

Systematic process deals with recurrent actual or potential crisises and the impact of these events.

The nurse establishes goals in collaboration with the child,family and the interdisciplinary team members.

The plans to care are then implemented through direct intervention.

Systemic evaluation facilitates the child’s progress towards his or her maximal level of function, especially as it changes during the various stages of development.


Contents

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HOSPITALISED CHILD1

TERMINAL ILLNESS AND DEATH2

3 NURSING MANAGEMENT– COUNSELLING

HOSPITALISED CHILD

Preventive

Best ------ Promotive Hospitalisation

Curative

HOSPITALISED CHILD

Functions Of HospitalisationProvides diversion and relaxation minimiseFeel more secure threatLesser the stress separation to Develop positive attitude to others theAccomplish therapeutic goals child’sCare for sick and injured developmentPrevention of healthPromotion of healthRehabilitation

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PRINCIPLES OF HOSPITALISATION

1.Nurse should begin to build a working relationship with the patients and the child from the first contact with them.

2.Nurse should be aware that all behaviour is meaningful.

3.Nurse should accept the parents and the child exactly as they are.

4.Nurse should have empathy for parents and children.

5.Nurse should let them know that their problems are of importance, the nurse is there to aid their solutions.

PRINCIPLES contd…

6.Nurse must be willing to acknowledge the parents rights to their own decisions concerning their children.

7.Nurse permits the parents and the child to express even negative emotions.

8.Nurse should ask questions limited to a single idea or reference.

9.Nurse should speak the language understandable to parents and the child

10.Health team members should help the parents to feel that there is unity among them.

MODERN CONCEPTS OF HOSPITALISATION

Parent Support

Self Care

Rooming- In

groups

Visiting

Care By Parent Unit

CONCEPTS OF

HOSPITALISATION

VISITING

2 – 8 pm visiting- early morning to bedtimeFlexible unlimited visiting any timeVisiting is determined by child’s need to see parents.If parents are unable to visit frequently,

grandparents, uncles or aunts may visit instead.Siblings of 2 – 12 years are permitted in some

hospitals for certain hours and older siblings fro any time.

Siblings should be accompanied by parent and who have been exposed to infections is not permitted.

Tape recording could be made and played.

ROOMING- IN

Should not prohibit parents to stay at child’s bedside if they desire.

Some hospitals provide a waiting rooms for parents.

Sometimes they can have food with children.If there is no dietary restriction, food should

be brought from home.Parents of seriously ill children could stay

whole night if they desire.

CARE BY PARENT UNIT

Parents live with child, to involve whole family in care of sick.

Child gets attention from familiar person.Main fear about separation is eliminated.When parents are nearby, children can continue to

learn and grow throughout hospital experience.Nurses’ responsibility is to meet needs of child,

prepare parent for this, interpret medical procedures, diagnostic tests, health teachings etc.

Nurse can observe parent’s skills, attitudes, techniques and any problem in parent child relation.

PARENT SUPPORT GROUPS

Parents with common concern should emotionally support and comfort.

This may be conducted by nurses, play therapists or by child life program staff, who act as facilitators or develop a support system among parents.

Parents may feel comfortable enough to move away from hospital routine and ventilate their feelings and concerns to relieve anxiety and stress.

SELF CARE

Assess abilities of child Help to learn self-care skills. Time and method depends on child’s

cognitive abilities, emotional state and readiness to learn.

GROWTH AND DEVELOPMENT OF HOSPITALISED CHILD

Professional team work is importantAll members needed to foster in every area of

growth and development.Hospitals may have school teacher or a

recreational specialist to create pleasant situation.

Psychologists and psychiatrists help with serious emotional problems.

Dietitian, physiotherapist work together focusing different facet of growth, toward full development

PLAY IN ILLNESS

3 year old Christie was due to receive a course of radio therapy. A play program was designed to prepare her for the experience, which involved Christie lying on a large sheet of paper on which her outline was drawn. The purpose of this was to explain the importance of lying still during the radio therapy session. To emphasis this, a water spray was used to show that when she moved it was difficult to spray the correct part of her body.

FUNCTIONS OF PLAY IN ILLNESS

Diversional activities

Social development

Emotional expression

Developmentof moral

value

Creative expression

TYPES OF PLAY

Dramatic play

Energy release

Creative play

PLAY

Drawings

TECHNIQUES OF THERAPEUTIC PLAY INCLUDE:

Stories

MusicPuppets

Pets

SUITABLE PLAY FOR VARIOUS AGE GROUPS

INFANT

• -Baby likes to pat and hug. • -Toys should be soft to hug and provide

comfort.• -Brightly coloured, washable toys.• -Large enough that cannot be aspirated.• -Have smooth edges.• -Soft stuffed animals, soft balls, bath toys, • -Rattles, pots and pans.

TODDLER

They may have favourite toysEnjoys exploring drawersLikes to place things in containers and

dump them out.DollsEngages in parallel play.Nest of blocks.Push-pull toysTelephoneRocking horse or chair

PRESCHOOLER

It is the beginning stage of cooperative play.

They exchange ideas with others. Engages in imitative playCreative play, and dramatic play.Crayons, simple puzzlesPaint with brush, finger paintsDolls, dishesDrums, hornsVideo tapes.

SCHOOLER

Attention span increases, play is more organised, more competitive.

Collection of things will be his hobby.Doll house, dolls, puppets and music.Skipping rope, dress up materials, table games,

bicycle.

ADOLESCENT

Play will not acquire great energy expenditure. They pay attention to special interest.Ball on stringTelephone, easy puzzles, radio, hand puppets, and

cut outs.

A research study conducted by Uttara Chari, Uma Hirisave, and L. Appaji in 2012 reported the benefits of play therapy in paediatric oncology. The study was conducted with a 4 year old girl diagnosed with acute lymphoblastic leukaemia and outcome was examined using a combination of qualitative and quantative assessments. The play therapy manifested in better illness adjustment and general mental well being, enhanced coping and normalisation.

In this study the child initially inhibited, avoided medical toys and engaged in rudimentary play. Her affect was considered and the interaction with the researcher was limited. As sessions progressed, she became active and engaged in various types of play. Her initial avoidance of medical toys followed by repeated enactment of medical procedures carried out on her reflects the mechanism of play therapy in facilitating catharsis and mastery through re-enactment of stressful experiences. Thus as sessions progressed, child’s play become similar to those of healthy children indexing normalisation. This reflects enhanced coping and use of adaptive defences in play sessions.

SCHOOL

Public school teacher is employed by local board of education in paediatric ward.

Use of television, radio or computerised self instruction program enhances contact with school system.

If child is too ill to return to school, continuing class is important as a link with outside world.

Child will keep busy, feels useful and important.This help child to return to school after cure.

PREPARATION FOR HOSPITALISATION Varied emotional changes Unknown environment Exposed to unfamiliar equipment Witnessing frightening sights and

sounds Unfamiliar procedures.www.themegallery.com Company Logo

• For well children who do not need immediate hospitalisation

• For children who are scheduled for hospitalisation

• For all children of all age group

• booklets, films and puppet shows.

• pre admission parties should be conducted.

• Familiarising the hospital before admission and pre hospital counselling

BASIC BELIEFS REGARDING CHILDREN

• The family is the basic unit of society• Each child needs love and security to develop

feelings of trust and self esteem.• Each child is an unique individual with

different needs based on his or her family background, level of growth and development and degree of illness

• Nurse seeks to promote, maintain and restore health in both children and their parents.

• Each ill child should be under the accountable care of one professional nurse.

• The family and child should be included in planning for therapeutic and nursing interventions and for implementing and evaluating the plan of care.

• Within a safe environment, the ill child needs expert physical care, emotional support, play that allows for expression of feelings to promote continued growth.

• Parents who have trusted relation with nurses feel welcome whenever they visit and participate in child care.

• Family members and terminally ill child who are at great stress should be emotionally supported so that child can die with dignity and with feeling of being loved.

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GUIDELINESHOSPITAL ADMISSION

• Assign a room based on child’s developmental age, seriousness of diagnosis, communicability of illness and length of stay.

• Preparing the roommates for the new patient.

• Prepare room for the child and family

• Introduce primary nurse• Orient to the inpatient facility.• Facilities in the room• Unit ( play room, dining room, lab)• identification band.• hospital regulations and schedules• Perform nursing admission list• vital signs, anthropometric

measurements• Obtain specimens• physical examination.

PRE- ADMISSION ADMISSION

Emergency admission• Appropriate introduction• Use of child’s name• Determination of child’s age

and some judgment made about developmental age

• chief complaint from both parents and child.

• general state of health, sensitivity to medication, previous hospitalisation.

ICU admission

• Prepare child and parents for elective ICU admission.

• Guide the child’s appearance and behaviour.

• Emotional support and answer questions.

• Prepare sibling visit.• Encourage parents to stay

with child.

REACTIONS TO HOSPITALISATIONPhysiological reactions

• Temperature elevations: as response to infections

• Convulsions : resulted from rise in temperature

• Immobilisation• Anorexia, vomiting and

diarrhoea• Nutritional deficiencies• Fluid and electrolyte imbalance• Inconsistent weight loss• Lack of growth

Psychological reactions

• Separation anxiety• Stranger anxiety• Sleep deprivation• Loss of self control• Fear of darkness• Fear of death• Sensory overload

REACTIONS OF EACH AGE GROUP

Neonates• Interruption in the early stages of

development• Impairment of bonding and trusting

relationship• Inability of the parents to love and

care for the baby and inability of baby to respond to parents

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INFANT

StressorsSeparation

anxietyStranger

anxietyPainful

invasive procedure

Immobilization

Sleep deprivation

Sensory overload

ResponsesSleep

awake cycle disrupted

Feeling routines disrupted

Displays excessive irritability

Rejection of feed

Crying

Nursing implications

Rooming-in Homely

routine Topical

aestheticsPromote a

quite environment

TODDLER

Stressors Separation

anxiety Reactions of

toddlers are expressed as protest, despair, denial and regression.

Protest Despair Denial Regression Loss of

autonomy and control

Fear of bodily restraint, injury

Reactions Frightened to

sleep in supine position

Think as a punishment

Wonder why the parents are not rescuing


Encourage parental presence

Allow the parent to hold the child in her lap to do any procedure

Give choices anaesthetics Explain the

procedure in sequence

Provide night light

PRESCHOOLER

StressorsSeparation

anxietyLoss of self

controlBodily

injuryPainful

invasive procedure

Fear of dark

Responses

Displace difficulty in separating

Fear of ghost

Fear of body part loss

Fear of pain

AggressionRegression

Nursing

implications


Give choices

anaesthetics

Explain the procedure in sequence

Provide night light

SCHOOLERStressorsLoss of self controlSeparation from

family and friendsBodily injuryPainful invasive

procedureFear of deathLoss of privacyLoss of own

control

ResponsesDisplays increased

sensitivity to the environment

Demonstrates detailed cause for illness



Utilise topical anaesthetics

Explain all the procedure

Encourage peer interaction

ADOLESCENT

StressorsLack of

controlLack of

privacyFear of lack of

body integrityFear of

disfigurementFear of

death / disability

Separation from peer group

Loss of

privacy

ResponsesAnger RegressionWithdrawalBargainingDepression


Include the adolescent in plan of care

Encourage peer group interaction

Parental involvement

Explain each steps of procedures prior

EFFECTS OF HOSPITALISATION ON THE FAMILY OF CHILD

PARENTS Stressors Strange

environment in the hospital

Separation from the child

Unknown events and outcomes

The suffering of the child

Spread of infections to other members in family

Unbearable financial obligations

Reactions anxiety, anger,

fear, disappointment, self blame,guilt

The anxiety interferes with the parent’s ability to care the child, support.

This anxiety could be recognised by the trembling, coarse voice, restlessness, irritability and withdrawal.

Nursing implications Recognise the

need for support Encourage to

obtain help from other family members or friends

Maintain parent child relationship

Parent support group and care by parent unit

Psychological support

Counselling Encourage to

perform the tasks

SIBLINGS

StressorsYounger

childExperiencin

g the changes

Cared for outside by care providers

Received little information about their

sibling

ReactionsAngerResentmentJealousyGuilt


Explanation about the condition

Provision for sibling to remain home

Sibling visits

DISCHARGE FROM HOSPITAL• plan for discharge with the assistance of parents, child

and other health team members. • A discharge preparation involves education for family• The preparation of discharge begins during the

admission assessment.• Short and long term goals are established to meet the

child’s physical and psychosocial needs. • For children with complex care needs, discharge

planning focuses on obtaining appropriate equipment and health care personnel at home.

• The teaching plan involves levels of learning, such as observing, participating with assistance and finally, acting without help.

• All families need to receive detailed written instructions

OBJECTIVES OF PLANNING FOR DISCHARGE1. To make certain that the care given in

the hospital will be continued as necessary at home – the nurse can assist the parent and child to meet the objective by educating them concerning the illness and the essential requirements for care.

2. To share information with other appropriate community resources or agencies to enable them to assist the parents and the child to continue care at home.

hospitalised child

Automotive

outlined crisis intervention

crisis situations

appraising crisis

logo crisis

types of crisis

nursing intervention

preventive intervention

foundation of crisis