HOSPITALIZED CHILD

1. INTRODUCTION

Based on the theory that hospitalization can be an unnecessary stress to children, only
those who cannot successfully be managed on an ambulatory basis are now admitted to the
hospital. This was not always true. For example most children with head injuries automatically
stayed overnight for observation. Currently unless a child is unconscious or shows other signs of
neurologic injury he or she is sent to home to be observed by parents for signs of increased ICP.
This policy requires that time be spent in teaching parent skills such as how to take a pulse or
evaluate consciousness. Teaching them requires patience because parents under stress can have
difficulty comprehending instructions however because psychological trauma as well as
excessive health care costs are prevented by allowing a child to return home it is important
teaching.

Often illness and hospitalization are the first crises children must face. Children during
the early years are particularly vulnerable to the crises of illness & hospitalization because stress
represents a change from usual state of health and environmental routine and children have a
limited number of coping mechanisms to resolve stressors, children’s reaction to these crises are
influenced by their developmental age, previous experience with illness, separation or
hospitalization, innate and acquired coping skills, the seriousness of the diagnosis and the
support system available.

A. MEANING OF ILLNESS AND HOSPITALIZATION TO CHILD

Infant

 Charge in familiar routine and surroundings response with global reaction.

 Separation from love object.

Toddler

- Fear of separation, desertion, separation anxiety highest in this age group.

- Relates illness to a concrete condition, circumstances or behavior

Preschool
 - Fear of bodily harm or mutilation, castration, intrusive procedures.
- Separation anxiety less intense than toddlers but strong.
- Causation same as toddler, often considers own role in causation ie, illness as a
punishment for wrong doing.

School Age

- Fears physical nature of illness

- Concern regarding separation from age mates and ability to maintain position in peer
group.
- Perceives an external cause for illness, although located in body.

Adolescent

- Anxious regarding loss independence. Control, identity concern about privacy.

- Perceives malfunctioning organ or process as cause of illness. Able to explain illness.

B. PREPARING THE ILL CHILD AND FAMILY FOR HOSPITALIZATION

Many childhood illness, such as febrile convulsions, appendicitis and asthma attacks
strike suddenly making advance preparation for hospital admission impossible. However, when
hospitalization is planned ahead of time, for orthopedic second stage surgeries, preparation is
possible. As a rule, parents eagerly seek guidance from nurses or what and how much to tell their
children about an anticipated admission. The preparation a parent makes for a child obviously
varies according to the child’s age and individual experience. No matter what the child’s age
however, parents should be encouraged to above all convey a positive attitude. The nurse can
provide further health teachings and clear up all misunderstandings.

1) Preparing the infant

- As because the infant cannot understand explanations, preparation has to be minimal.

- Special items such as favorite toy, blanket, should be packed.
- This objects provide care giver should spend a great deal of time with an infant.

2) Preparing the toddler and pre-schooler

 - Three chief fears of the toddler and pre-schooler are fear of unknown, fear of
abandonment and separation and fear of mutilation.
- These children need preparation clearly aimed at alleviating these fears.
- Bringing a favorite toy can be a help.
- Child could be encouraged to play hospital with dolls

3) Preparing school age and adolescent

- Both school age and adolescents need factual explanations of what will happen during
hospitalization.
- A hospital orientation program in which facts of hospitalization are discussed
- Interact the child with another child who had undergone through the same condition.

4) Preparing the child of a different cultural background

- Make the assurance that proper care will be provided to the child without any
differentiation.

5) Preparing disabled and chronically ill child

- Help children to maintain a contact with their families and school friends during a long
hospitalization period, as they are staying in hospitals for long term care through phone
calls, letters & open visiting.

PREPARING FAMILY CARE GIVERS

- Planning for hospitalization begins as soon as parents know that hospitalization will be
necessary.
- Easing parental anxiety regarding illness and hospitalization is important because infants
and children can keenly sense a parent’s stress.
- As a part of preparation parents should ask questions about the hospitalization so that
they become familiar with the situations. It will help to reduce anxiety.
- Advise parents to ask about the diagnostic procedures required length of hospital stay,
etc.

C. ADMITTING THE ILL CHILD AND FAMILY

 - A child coming to a hospital for an elective admission generally arrives at a reception
area where significant informations are obtained, age, address, etc.
- The child and parent are then brought to the hospital unit
- Nurse should take time to introduce himself/herself to the family.
- When introducing to children, stop down so that the face is level with child’s face.
- Call the child with name or ask for nick-name.
- On admission, all children should have an armband attached giving their name, address,
hospital number.

ASSESSMENT ON ADMISSION

- Be aware of not only what the child is orally describing but also what facial expressions
or nervous manifestation indicates.
- Interview parents on hospital admission for a nursing history to obtain the information
needed to plan nursing care.
- Any medication or food allergies or reactions should be noted on child’s nursing care
plan and pasted over bed.
- Vital signs, height, weight should be recorded to determine overall growth.
- Blood pressure can be taken depending upon age.
- Urine specimen are usually taken for analysis.
- Explain about equipments used and allow the child to touch and handle it.
- Inspect for gross motor ability, when weighing and measuring height.
- Listen for language ability.
- Perform physical examination to gain knowledge for a nursing diagnosis and planning.
- After assessment analyze child’s coping ability will be able to balance the hazards of
hospitalization.

EFFECT OF HOSPITALIZATION ON CHILD

Children may react to the stress of hospitalization before admission, during

hospitalization and after discharge. A child’s conception of illness is even more important than
age and intellectual maturity in predicting level of anxiety before hospitalization. This may or
may not be affected by the duration of condition or prior hospitalization. Therefore nurses should
avoid over estimating the illness concept of children with prior medical experience.

Individual risk factors

- A number of risk factors make certain children more vulnerable than others to the stress
of hospitalization.
- It has also been noted that rural children exhibit significantly greater degree of
psychological upset than urban children, because urban children are familiar with
hospitals.
- Because separation is such an important issue of hospitalization for young children nurses
should be alert to children who passively accept all changes, these, children need more
support and care.
- The stressors of hospitalization may cause young children to experience short and long
term negative out comes.
- Adverse outcome may be related to the length & number of admissions, multiple invasive
procedures and the anxiety of the parents.
- Common response includes regression, separation anxiety, apathy, fears, sleeping
disturbances, especially children younger than 7 years of age.
- Supportive practices such as family centered care, and frequent family visiting, may
lessen the detrimental effect of such admissions.
- A child’s pain experience indicates how the overall hospitalization is experienced.
- Increasing length of hospitalization because of complex medical and nursing care, elusive
diagnosis, and complicated psychosocial issues.
- Without special attention, to meet child’s psychosocial developmental needs in hospital
environment the detrimental consequences of prolonged hospitalization may be severe.
- What the hospital means to pediatric patient depend upon their stage of maturity and
depend upon how accustomed they are to being left with friends.
- If they regard the separation as a punishment of wrongdoing, they will be less able to
cope with it than if they know the real reason for hospitalization.
- Infants may be emotionally disturbed by hospitalization
 - Not only they are separated from parents but also they will have sensory deprivation. If
the nursing personal do not take the time to provide care.
- If the child doesn’t have close physical contact with another human being may result in
emotional trauma.

Beneficial effects of hospitalization

- The most obvious effect is the recovery from illness.

- Hospitalization provides an opportunity for the children to master stress and feel
competent in their coping abilities.
- Hospital environment can provide new socialization experience.
- Child can broaden their inter personnel relationships.
- Psychological status of child also maximized.

CHILDS REACTION TO HOSPITALIZATION AND PROLONGED ILLNESS

- Illness threatens both physiological and psychological development of children.

- Sickness causes pain, restraint of movement, long sleep less periods, restrictions of feeds.
Separation from parent home environment, which may result emotional trauma.
- Hospitalization and prolonged illness related growth and development and cause adverse
reaction in the child based on stage of development.

Reactions of neonates

- Interrupts the early stages of development of a mother child relationship and family
integration.
- Impairment of bonding and trusting relationship.
- Inability of parents to love & care for the baby and inability of baby to respond to parents
and family members.

Reactions of infants

- Infant’s reactions are mainly separation anxiety and disturbances in development of basic
trust.
- Emotional withdrawal and depression are found in the infants of 4 to 8 months of age.
 - Interference of growth and delayed development is also found.
- Older infants have limited tolerance due to separation anxiety which is found as fear of
strangers, excessive cry, clinging & over dependence on mother.

Reaction to toddler

- Toddler reactions are found as protest, despair, denial and regression.

- Toddle protest by frequent crying, shaking crib, rejecting nurses.
- Attention, urgent desire to find mother, showing signs of distrust with anger and fears.
- In despair, toddler become hopeless, looks sad, cry continuously and use of comfort
measures like thumb sucking, fingering lip, and tightly clutching toy.
- In denial, the child reacts by accepting care without protest.
- Toddlers react by regression in an attempt to control stress
- Found to stop using newly acquired skills & may return to the behavior of an infant
during illness.

Reactions of pre-school child

- Pre-school child adopts various defense mechanisms to adjust with stress.

- They react by exhibiting regression, projection, displacement identification, aggression,
denial & fantasy.
- They simply shows similar behavior of toddlers.

Reactions of school-aged

- School aged children are concerned with fear, worry, mutilation, fantasies, modesty &
privacy.
- They react with defense mechanism like regression, negativism, depression, phobia, un-
realistic fear or denial symptoms and conscious symptoms and conscious attempts of
mature behavior.

Reaction of adolescent

- Adolescents are concerned with lack of privacy, separation from peers or family & school
interference with body image or independence or self concept & sexuality.
 - They react with anxiety related to loss of control & insecurity in strange environment.
- They may show anger and demanding or un co-operative behavior
- They may adopt mental mechanisms like intellectualization about disease, rejection of
treatment, depression, denial/withdrawal.

EFFECT OF HOSPITALIZATION ON THE FAMILY OF THE CHILD

- Hospitalization of child is the break in the unity of the family.

- Emotional reaction of each member of the family must be considered to help them to
adjust with stress due to the hospitalization and illness.
- Parents whose children have been admitted to the hospital feel not only separation from
their children but also they may have feeling of inadequacy as others provide care for
children.
- They feel anxiety, anger, fear, disappointment self blame & possible guilt feeling due to
lack of confidence and competence for caring the child in illness and wellness.

The specific causes of parental anxiety related to hospitalization of their children are:

 Strange environment in the hospital

 Separation from the child
 Unknown events and out come
 The suffering of the child
 Spread of infection of other members of the family.
 Unbearable financial obligations
 Society will look upon the illness as a reflection of something wrong of parents.
- There are so many factors which may increase the parental anxiety
- The anxious parent can be recognized by trembling, coarse or waveryvoice , restlessness,
irritability, withdrawal or erratic body movements.
- Hostile and aggressive behavior towards those caring for child.
- The reactions of the parents and family members can be influenced by cultural and
spiritual belief, which may affect the rate of recovery of child.
- Some of the families hesitate to discuss their concern about illness of the child where as
some families want long discussions.
 - Inspect for gross motor ability, when weighing and measuring height
- Listen for language ability.
- Perform physical examination to gain knowledge for a nursing diagnosis and planning.
- After assessment analyze child’s coping ability will be able to balance the hazards of
hospitalization.

D. EFFECTS OF HOSPITALIZATION IN CHILDREN AND FAMILY

1) Stressor’s of hospitalization and children’s reaction

Major stressors of hospitalization includes, separation, loss of control, bodily injury, and
pain children’s reactions to these crisis 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 system available.

a) Separation anxiety

- The major stress from middle infancy throughout the pre-school years, especially for
children ages 16 to 30 months is separation anxiety, also called anaclitic depression.
- During the phase of protest children react aggressively to the separation from the parent.
They cry& scream for their parents and in-consolable by others.
- During the phase of despair the crying stops and depression evident, less active, un-
interested in play
- Third stage is detachment also called denial, the child is finally adjusted to the loss,
becomes interested with the surroundings and forms new relationships.
- This behavior is a sign of resignation and i9s not a sign of contentment
- The child detaches from the parent in an effort to escape the emotional pain of desiring
the parent’s presence and copes by forming shallow relationship with others being
increasingly self centered, and attaching primary importance to material objects.
- Health team member understand the meaning of each stage of behavior and should label
as positive or negative.
- Eg. The loud crying of the protest phase as a bad behavior during quite withdrawn phase
of behavior, health team member may think that child is settling in.
Detachment behavior as a proof of adjustment & child is considered as ideal patient.
Early childhood

Separation anxiety is the greatest stress imposed by hospitalization during early

childhood.

- Children in the toddler stage demonstrate more goal oriented behaviors.

- They may demonstrate displeasure on parent’s return or departure by temper tantrums or
regression to primitive levels of development.
- Temper tantrums, bed wetting or other behaviors are expression of anger or response to
stress.
- Pre-schoolers are more secure interpersonally than toddlers, they can tolerate brief period
of separation from their parents and are more inclined to develop trust in other significant
adults.
- The stress of illness usually renders pre-schooler less able to cope with separation.
- They may show separation anxiety by refusing to eat, experiencing difficulty in sleeping,
crying quietly for their parents withdrawing from others.
- They will express indirectly by breaking toys, hitting other children.

Later childhood and adolescence.

- In school age child being away from family higher than any other fear associated with
hospitalization.
- Hospitalization increase their need of parental security and guidance.
- Middle and late school age children may react more due to separation from usual
activities and peer groups than to the absent of their parents.
- Feelings of loneliness, boredom, isolation and depression are common.
- School age children have irritability and aggression towards parents withdrawal from
hospital personnel, inability to relate to peers, rejection of siblings, subsequent behavioral
problems in school.

Preventing or minimizing separation

- Primary goal is to prevent separation particularly in children younger than 5 years of age.
- Welcome the presence of parents at all time throughout the child’s hospitalization.
 - Many hospitals developed a system of family centered care.
- During the time of separation behavior, nu8rse provide support throught physical
presence
- If behaviors of detachment are evident, the nurse maintains the child’s contact with the
parents by frequently talking about them, encouraging child to remember them etc.
- When helping parents with the fears of separation, nurses should suggest the way of
leaving and returning.
- Parental visits should be frequent
- If the parents can’t room-in they can leave a favorite article from home the children gain
comfort and re-assurance from them.

b) Loss of control

- The major areas of loss of control in terms of physical restriction, altered routine or
rituals, and dependency.

Infants

- In hospital setting, routines may be established to meet hospital staffs need instead of
infant needs.
- Inconsistent care and deviation from infant’s routine may lead to mistrust and decreased
sense of control.

Toddlers

- Toddlers are striving for autonomy, and this goal is evident in most of their behaviors.
- When their ego-centric pleasures meet with obstacles toddlers react with negativism,
especially temper tantrums.
- Loss of control results from altered routines and rituals.
- It can cause regression to toddlers.
- Enforced dependency is a chief characteristic of toddler during sick role most toddlers
react negatively and aggressively to this.
- Prolonged loss of autonomy may result in passively to this.
 - Prolonged loss of autonomy may result in passive withdrawal from interpersonal
relationships. And regression in all areas of development.

Preschoolers

- Pre schoolers also suffer from loss of control caused by physical restriction, altered
routines, and enforced dependency.
- Their specific cognitive abilities which make them feel omnipotent and all powerful; also
make them feel out of control.
- This loss of control is a critical influencing factor in their perception of and reaction to
separation, pain, illness hospitalization.

School age

- Because of their striving for independence and productivity school age children are
particularly vulnerable to events that may lessen their feeling of control and power.
- Altered family roles, physical disability, fears of death, abandonment, or permanent
injury, loss of peer acceptance, lack of productivity and inability ot cope with stress
according to perceived cultural expectation may result in loss of control.
- One of the most significant problems of this age is boredom.
- When physical or enforced limitation curtails their usual abilities to care for themselves,
school age children generally respond with depression, hostility and frustration.

Adolescents

- Adolescents struggle for independence, self assertion, and liberation centers on the quest
for personal identity. Anything that interferes with this poses a threat to their sense of
identity and result in loss of control.

MINIMIZING LOSS OF CONTROL

 - Feelings of loss of control results from separation, physical restriction, changed routine,
enforced dependency and magical thinking.
- Promoting freedom of movement during procedures can be completed by placing child in
parents lap.
- Mechanical freedom can be provided by transporting child in wheel chairs, or beds with
mechanical freedom.
- Maintaining child’s routine: One technique that can minimize the disruption in child’s
routine is time structuring.
- It include scheduling the child’s day to include all those activities that are important to
the child and nurse such as treatment procedures, school work, exercise, television etc.
together nurse, parent and the child then plan a daily schedule with times and activities
written down.
- Encouraging independence; promoting children’s control involves maintaining
independence and the concept of self-care can be most beneficial. Self care refers to the
practice of activities that individuals personally initiates and perform on their own behalf
individuals personally initiates and perform on their own behalf in maintaining health and
well being. Self care activities are encouraged in hospitals other approaches include
jointly planning care, time structuring, making choices in food selection & 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 any may relieve the feelings of powerlessness.

BODILY INJURY AND PAIN:

- In caring for children nurses must have an appreciation of a child’s concerns about bodily
harm and reactions to pain at different developmental periods.

Infants

- Infants may express pain by squirming, writhing, jerking and failing some infants may
cry loudly, where as others are easily calmed by gentle hug.
 - Older infants react intensely with physical resistance and un-co-cooperativeness. They
may refuse to lie still or try to escape with motor activity they have achieved.

Toddlers

- Toddlers reaction to pain are similar to those seen during infancy. They will react with
intense emotional upset and physical resistance to any actual or perceived experience.
Behaviors indicating pain include grimacing clenching teeth or lips, opening their eyes
wide, rocking, rubbing & acting aggressively.
- Young children become restless and overly active is a consequence of pain.
- They usually able to localize the specific painful area.

Pre-schoolers

- Reactions to pain tend to be similar to those seen in toddler hood

- Physical and verbal aggressions are more specific.
- Instead of showing total body resistance, preschoolers may push the offending person
away, try to secure the equipment and lock them
- safely
- some times they may verbally abuse the nurse
- pre-schools can locate pain & can use appropriate pain scales.

School age

- They will have a fear of illness itself, disability & death.

- Fear of intrusive procedures in genital area.
- School age children verbally communicate their pain in respect to location, intensity and
description.
- By 9-10 years of age they show less fright or over resistance and aggression are less
likely at this age unless the adolescent is totally up prepared for a procedure.
- They are able to describe pain experience & can use any of the pain assessment tools.
- They may be reluctant to disclose their pain.

PREVENTING OR MINIMIZING FEAR OF BODILY INJURY

 - Preparation of children for painful procedures decreases their fears.
- Manipulating procedural techniques also minimizes fear
- For children, who is fear of mutilation of body parts, the nurse repeatedly stress the
reason for a procedure and evaluate child’s understanding.
- Employ pain reduction techniques.

Strategies for coping & normal development

- During hospitalization care of the child focuses not only on meeting physiologic needs,
but also on meeting psychosocial and developmental needs.
- Several strategies may be used to help children adapt to the hospital environment,
promote effective loping & provide developmentally appropriate activities.
- These strategies include child life programs, rooming in, therapeutic play, and therapeutic
recreation.

a) Child life programs

- If focus on the psychosocial need of hospitalized children.

- Professional child life specialists, para professionals, & volunteers staff these
departments.
- A child life specialist plan activities to provide age appropriate play time for children
either in playroom or child’s room.
- Some of the activities are designed to assist children in working through feeling about
illness.

Eg: Playing with medical equipment

- Child specialist & nurses formulate plan together to assist children with particular needs.

b) Rooming-In

is the practice of having a parent stay in the child’s hospital room & care for the
hospitalized child.
 - Some hospitals provide cots, others have special built-in beds & in some institutions
parent stays in a separate room on the unit.
- Parent who is rooming in may want to perform all of the child’s basic care or help with
some of the medical care.
- Communication below nurse & parent is important so that the parent’s desire for
involvement is supported.

Therapeutic play

- Play is an important part of the childhood.

- The stress of illness & hospitalization increase the value of play.
- Not only is normal development facilitated by play, but play sessions can provide a
means for the child to learn about health care, to express anxieties to work through
feelings & to achieve a sense of mastery over control over frightening or little understood
situations.
- Play presents an opportunity to deal with the fears & concerns of health experiences are
called therapeutic play.
- Through therapeutic play the nurse may assess the child’s knowledge of his or her illness.
- A common technique involves using body line drawing or stories & asking the child to
draw or talk about illness or injury means to him/her.
- Child may be asked to draw a picture or make a story enabling the nurse to assess fears &
other emotions.
- The good enough-draw-A-Person test help the nurse assess the congnitive level of
children below 3& 13 years of age.
- The gillert index is another tool that help the nurse assess child’s knowledge of the body.
- The same techniques may be used in a slightly different way to teach the child about
surgery or plan activities that allow child to express fears & gain mastery over the
situation.
- A variety of technique may be used to promote therapeutic play. Specific techniques are
chosen to reflect the child’s developmental stage.
- Toddler, play is important for toddler. Through play the explore the environment & learn
to identify with significant people in their lives.
 - Play is also an acceptable way for toddlers to release tensions caused by stress or
aggressive impulses.
- Toddlers should be approached slowly & the initial approach should be made in their
parent’s presence, if possible to decrease feelings of stranger anxiety.
- Playing a variation of peek-a-boo or hide & seek using the curtain surrounding the
toddlers crib or bed help to promote realization of that objects out of sight, such as
parents, do return.
- The use of transitional objects, such as a familiar blanket or stuffed animal, can
temporarily substitute for the security of parents.
- The toddler who is restrained can be read familiar stories. Repetition of stories promotes
a sense of stability in the unfamiliar hospital environment.
- A doll is familiar toy that can be used to recreate a stressful environment, thereby
providing an opportunity for the child to express & work through feelings.
- Other developmentally appropriate toys for toddlers include familiar objects from home
such as measuring cups or spoons, wooden puzzles, push & pull toys.
- Playing with safe hospital equipments (bandages, syringes without needles etc) help
toddlers to over come the anxiety associated with these items.

Pre-schooler

The nurse can intervene to reduce the stress produced by pre-schoolers fear through the
use of some kinds of play.

- A simple body outline or doll can be used to address the child’s fantasies & fears of
bodily harm. Playing with safe hospital equipment may help pre-schoolers to work
through feelings such as aggression.
- Pre schoolers like crayons & coloring books, puppets, felt & magnetic boards, play
dough, & recorded stories.
- Both pre-schooler& school age children may enjoy play with a toy hospital.

School age child

Although play begins to lose its importance in the school age years, the nurse can still use
some techniques of therapeutic play to help the hospitalized
Child deal with stress.

- School age children often regress developmentally during hospitalization, demonstrating

behaviors characteristics of an earlier state, such as separation anxiety & fear of bodily
injury.
- Body outlines & occasionally dolls can be sued to illustrate the cause and treatment of the
child’s illness.
- Terms for body parts that are suitable for older children should be used drawings provide
an out let for expression of fears & anger.
- School age children enjoy collecting, organizing objects & often ask to keep disposable
equipment that has been used in their care. They may use these items later to relive the
experience with their friends.
- Games, books, crafts, computers, provide an outlet for aggression & increase self esteem
in the school age child.
- The type of play used should promote a sense of mastery & achievement.

THERAPEUTIC RECREATION

- Many of the special play techniques used with younger children are not suitable for
adolescents.
- Adolescents do need a planned re-creation program to assist them in meeting
developmental needs during hospitalization.
- Peers are important and the isolation of hospitalization can be difficult.
- Telephone contact with other teenagers & visits from friends should be encouraged.
- Interactions with other teenagers ate a pizza party or a video game or movie night can
help adolescents feel normal.
- Physical activities that provide an outlet for stress are recommended. Even adolescents on
bed rest or in wheelchairs can play a modified form of basket ball.
- The independence of adolescence is interrupted by illness. Nurses can provide choices for
teenagers to assist them in regaining control.
- Giving them options & letting them choose an evening recreational activity can promote
their feelings of independence.
- Passes to leave the hospital for special activity may be possible.
 The nurse in corporate play activities into the daily life of each pediatric patient because
play is a part of child’s total needs.
- The nurse must consider, when planning activities for child, the age, interests diagnosis &
limitations imposed by illness.
- An acutely ill child who is unable to play actively with toys may enjoy listening to
stories.
- Telling a story rather than reading draws children into emotional involvement with it.
- The story teller can ask questions pass comments & can make the child a part of it.
- Other activities children can do are watching a plant grow, watching an anthill or gold
fish in a tank or watching supervised television programmes.
- In the play area, children who are permitted out of bed should be free to develop mental,
motor & social skills and to express themselves. In a variety of art media such as finger
painting or molding with clay.
- Domestic play re-assures them that their own homes are still there & that they are missed.
- Children usually select toys such as doctor, syringes with which they can imitate the
activities seen around.
- Old cloth in such play can be used to restrain hands of a doll in case of fractures to make
bandages to promote healing.
- Puppets are used to demonstrate procedures to children.
- Such activities help children work out feelings about hospitalization.
- Children also enjoy play telephone because they can pretend that they are calling home.
- They also can enjoy clay, paints, pounding boards on which they can express their anger.
- They enjoy tricycles, wagons, through the use of which they develop or exercise their
large muscles.
- Children play areas cannot be kept clean & orderly as judged by adult standars.
- It the nurses are too concerned about the physical appearance of play area during play
time the children feel that the unit personnel do not approve o f their play.
- Children should be taught to take care of toys & a place must be provided to store their
toys.
 - Much can be learned from watching children play in a relaxed environment. Their
approaches to play & their relationship with peers, parents, adults should be observed and
recorded.
- Also to be noted are the degree of their activities attention span, ability to tolerate
frustration, verbal abilities, concept formations.
- In addition, nurse is able to note their comments about home, hospitalization, general
attitudes & behavior.
- It will help the nurse to understand how well the child is coping with the situations &
crisis.
- If the child handle it well, the experience may be of help in mastering problem situations.
- Nurse should have an opportunity to participate with children play activities.
 Story telling-telling stories with themes.
 Water play during bath.
 Television-by instructing them about programs.
 Needle play
 Pre-post operative teaching
 Art.

STRATEGIES TO MEET EDUCATIONAL NEEDS

- If the hospital stay is longer, necessitate special school arrangements. The nurse should
assess the effect of hospitalization on child’s education.
- The child can be provided with school work to do in the hospital or at home when well
enough.
- This minimizes educational deficit & future problems of the child.
- Pencils, papers, work areas, quiet work times should be arranged & also telephone calls
with teachers also be arranged.
- Peers should be encouraged to visit the hospital, send cards, letters or call on the phone.
- When the child returns to hospital the nurse can visit the class room to provide class
mates with information about the child’s medical condition.
- The hospital nurse may contact child’s school nurse when special arrangements are
necessary.
 - Child who is chronically ill can be provided with telephone computer contacts.

FUNCTIONS OF PLAY IN THE HOSPITAL

- Provides diversion & bring about relaxation.

- Helps the child feel more secure in strange environment
- Helps to lessen the stress of separation & the feeling of home sickness.
- Provides a mean for release of tension & expression of feelings.
- Encourages interaction & development of positive attitude towards others.
- Provides an expressive outlet for creative ideas or interests.
- Provides a mean for accomplishing therapeutic goals.
- Places child in active role & provides opportunity to make choices & be in control.

Play in infancy

- Pleasure by touch & manipulation.

5-6 months – infant repeat activities
9 months – repetitive games (pat-a-cake)
12 month - recognition& acknowledgement of other

Play in 2nd year

- 2 to 3 year – fascination with working part of toys talking on toy phone involve parents

Third year – child taught to share

Conflict below parents & child.

Pre-school – competition, mastery of tasks

Genders roles (House, Doctor)

School – Foot ball, basket ball.

STAGE I – PRIMAL FAITH (INFANCY)

- Pre linguistic & pre-conceptual, this stage embodies the trust between parents & infants.
 - Parents & child form a mu8tual attachment and progress through a period of giver &
take.
- The primary care giver provides the infant & the young child with a variety of
experiences that encourage the development of mutuality, trust, love & dependence
progressing to autonomy.

STAGE II – INTUITIVE-PROJECTIVE FAITH (EARLY CHILDHOOD)

- Most typical from ages 3 to 7 years, this stage is characterized by the child forming long
lasting images & feelings.
- Imagination, perceptions & feelings are the mechanics by which the child explores &
learns about the world at large.
- The cultural beliefs of the family influence the child’s concepts of health & sex.

STAGE III- MYTHICAL LITERAL FAITH (CHILDHOOD & BEYOND)

- Beginning at about age 7 years. Children’s beliefs derive from the perspectives of others.
- In addition they are able to differentiate their thinking that from others.
- Stories become the gateway to learning about life.
- In valuing the stories, practices & beliefs, of the family & community, the child reaches
stage III of faith development.
- Some people remain at this level throughout life.

STAGE IV – SYNTHETIC –CONVENTIONAL FAITH (ADOLESCENT PERIOD AND

BEYOND)

- In this stage a person’s experience extends beyond the family to peers, teachers, & others
members of the society.
- As a result of cognitive abilities, the individual is aware of the emotions, personality
patterns, ideas, thoughts & experience of self & others. i.e. the mutual inter-personal
perspective taking. As a result the individual has a cluster of values & beliefs in concern
with others.
- Understanding the level of spiritual development of children of various ages is important
for the nurse in providing appropriate support.
 - Through the process of values clarification, the nurse can assist parents & children in
exploring alternatives & deciding what is right from them.

SPIRITUALITY DURING INFANCY

- Fowler describes spiritual development during the period of infancy as stage I, primal
faith.
- During the early years, the infant forms an attachment for parents that develop trust, hope
& autonomy as a result of the give & take relationship.

SPIRITUALITY DURING TODDLER AGE:

- Toddlers have only a vague idea of God & religious teachings because of their immature
cognitive process.
- However routines such as saying prayers before meals or at bedtime can be very
important & comforting.
- Near the end of toddlerhood, when children use pre-operational thought, there is some
advancement of their understanding of God.
- Religious teachings, such as reward or fear of punishment (heaven/hell) and moral
development may influence their behavior.
- During toddler period, the child has intuitive projective faith i.e. the faith derived
primarily from parents or significant others.
- The child imitates religious behavior such as bowing the head in prayer, but not
understand the meaning.
- The toddler is still egocentric & cognitively unable to understand religious concepts &
explanations may be easily misconstrued.
- The world of the toddler consists of those concrete things and persons that can be seen &
touched, abstract concepts are not understood.

III SPIRITUALITY OF PRE-SCHOOLER

- Children knowledge of faith & religion is learned from significant others in the
environment, usually from the parents & their religious practices.
- However, young children’s understanding of spirituality is influenced by their cognitive
leave)
- Preschoolers have a concrete conception of a god with physical characteristics, who is
often like an imaginary sdfas.
- They understand simple bible stories & memorize short prayers but their understanding
of the meaning of these rituals is limited.
- They benefit from concrete representations of religious practices such as picture Bible
books, & small statues, such as those of nativity siene.
- Development of the conscience is strongly linked to spiritual development.
- At this age children are learning right from wrong & behave correctlyto avoid
punishment.
- Wrong doing provokes feelings of guilt, & preschoolers often misinterpret illness as a
punishment for real or imagined transgressions.
- It is important that children view of God as one who bestows unconditional love, rather
than as a judge of good or bad behavior.
- Praying to God and observing religious traditions can help children through stressful
periods, such as hospitalization (eg. Prayers before meals/bedtime).
- Preschool children continue in Fowler’s stage of intuitive projective faith.
- Children don’t follow a religion because they understand it but because it is expected of
them.
- Parents or someone they love influences them to do so, or it offers them some other
concomitant pleasure.
- Children cannot be kept spiritually neutral. They hear about religion from other children
& adult, and they see churches & pictures of religious objects.
- Suggestions for religious training in the home include training in the faith held by the
parents.
- Preschool children are old enough to go Sunday school. Any discussion of religion
should be a shared experience below parents & their children. They can be taught that
God is within their lives & that God loves them.
- As the children grow older, they will learn about religions other than that held by their
parents.
 - In the hospital, parents can be involved in the continuing religious training of their
children.
- Their whishes could be considered d& sought when questions arise.

V SPIRITUALITY IN SCHOOLERS

- Children at this age think in very concrete terms, but are avid learners & have a great
desire to learn about their God.
- They picture God as a human & tend to describe him in terms of character traits such as
loving & helping.
- He is a very important person in the lives of many children.
- They are fascinated by the concepts of hell & heaven & with a developing conscience &
concern about rules, they fear going to hell for misbehavior.
- School age children want & expect to be punished for misbehavior & if given the option
tend to choose a punishment that fits the crime.
- Often they view illness or injury as a punishment for a real or imagined misdeed.
- The beliefs & ideals of family & religious personages are more influential than those of
their peers in matters of faith.
- School age children begin to learn the difference below the natural & supernatural but
have difficulty understanding abstractions.
- Consequently religious concepts must be presented to them in concrete terms.
- They are comforted by prayer or other religious rituals & if they are a part of their
religious rituals, & if they are a part of their daily lives, these activities can help them
cope with threatening situations.
- Their petitions to their God in prayers tend to be for very tangible rewards.
- Although younger children expect their prayers to be answered as they get older, they
begin to recognize that this doesn’t always occur & become less concerned when prayers
are not answered.
- They are able to discuss their feelings about their faith & how it relates to their lives.
- In the school years Fowler identified school children as being in the mythic literal faith
stage. He closely associates this stage with piagets concrete operational stage by nothing
that the ability to think logically help to order the world with categories of causality,
 space, & time. In addition these children are able to show concern for other & to capture
meaning of life in stages. During this stage children are learning many specifies about
their religion that will develop into a religious philosophy to be used in their
interpretation of the world. As children reach pubescence they will be less mythical.
Children at this point may drop their religious affiliations & accept family’s preference.

VI SPIRITUALITY IN ADOLESCENTS

- A youngsters move toward independence from parents & other authorities, some begin to
question the values & ideals of their families.
- Others cling to these values as a stable element in their lives as they struggle with the
conflicts of this turbulent period.
- Adolescent need to work out these conflicts for themselves but they also need support
from authority figures/peers for their resolution.
- Often the peer group is more influential than parents, although the values acquired during
the formative years are usually maintained.
- Adolescents are capable of understanding abstract concepts & of interpreting analogies &
symbols.
- They are able to empathize, philosophize & think logically.
- Most are searching for ideals & speculate about illogical statements & conflicting
ideologies.
- Their tendency toward introspection & emotional intensity often makes it difficult for
others to know what they are thinking.
- They tend to keep their thoughts private feelings that on w will understand these feelings
that they perceive to be unique and special.
- However they may reveal deep spiritual concerns.
- They need support & encouragement in their struggle for understanding & the freedom to
question without censure.
- Greater levels of religiosity & spirituality are associated with fewer high-risk behaviors &
are more health promoting behaviors.
- Nurses play an important role for teens by providing an opportunity to discuss issues
regarding spirituality.
 - According to Fowler adolescents are in the stages of synthetic conventional faith.
- In this stage diverse self image are integrated into a coherent identify- a deity.
- Personal & social values evolve to support this identity & the adolescent is united with
others in emotional solidarity.
- During this time the adolescent begins to question religious concepts and beliefs of
childhood & explores various religious affiliations & cults.
- This may be a period of conflict for parent & adolescent. A young person without
religious ties may be attracted to any new or different religious cults.

Education concerning death.

- Death, a topic that many people would like to ignore, has become an increasingly popular
subject for students in high schools.
- The subject of death may be integrated into various courses in the curriculum or it may be
discussed in one special course.
- The need has arisen because students generally have been isolated from the facts of death
that used to be learned naturally at home.
- A variety of books exploring the subject are available for children & adolescent.
- Parents also may need help in exploring their feelings & discussing death. Many adults
find it difficult to address this topic because of past experiences or unresolved feelings.