14.2 Role of the Nurse When Caring for Ill or Hospitalized Pediatric Clients

When caring for an ill or hospitalized pediatric client and their parents or caregivers, the nurse takes on many roles and responsibilities. Although specific responsibilities vary by facility, potential roles and responsibilities of the nurse are as follows^[1],[2]:

• Caregiver: The nurse assists the client with completing activities of daily living (ADLs), performs physical assessments, obtains vital signs, administers medications, and performs other nursing interventions involved in direct client care.
• Collaborator: This nurse works with interprofessional team members to ensure the client’s and family’s needs are met.
• Advocate: The nurse represents the client and their family members and ensures the client’s rights and individualized needs are met. The nurse vigilantly monitors medication therapy and prevents pediatric medication errors.
• Educator: The nurse provides relevant health teaching to the client and their family.

Other responsibilities of the nurse are to create a partnership with the parents or caregivers of a pediatric client to ensure optimal care and outcomes. This partnership involves establishing a trusting and therapeutic relationship, providing comfort when needed, and sharing responsibilities such as completing ADLs. Parents should be encouraged to help care for their ill child and assist with bathing and feeding. Additionally, the nurse should try to create a familiar environment for the client, such as following the client’s daily routine as much as possible in the hospital environment and facilitating the provision of familiar foods.^[3],[4]

In addition to hospitalization, ill pediatric clients may receive care in other settings such as clinics and their own homes. Home care for the pediatric client may be complex and involve physical, occupational, and speech therapy; medical equipment; social, nutritional, emotional, and psychosocial support; and nursing care. The nurse coordinates with the family, child, and other members of the interprofessional team to meet the medical and developmental needs of children.

Nurses caring for children in the home need to honor family customs, which helps to establish respect and trust. Parents have the decision-making authority over their children, so nurses educate parents on the treatment plan. Nurses recognize the importance of routines for the child’s security and fit care within the daily family and home routines. Nurses assess and plan around the child’s developmental status, medical care, therapy requirements, and care needs.

Preventing Medication Errors in Pediatric Clients

Despite advances in medication administration, medication errors are still prevalent, especially in the pediatric client. Research shows that potential adverse drug events occur three times more frequently among pediatric patients than among adults. There are several risk factors that can result in pediatric medication errors. Medication dosages must typically be adjusted based on the client’s weight and often include fractional dosing and decimals. Lack of health care provider familiarity with pediatric dosing places children at risk for medication errors. Additionally, due to differences in the way medications are metabolized and absorbed in children, medications may not have the same therapeutic effects or side effects in children as in adults. Most research studies on medications and clinical trials focus on side effects and adverse effects for adults, not children. Furthermore, pediatric clients are at increased risk for medication errors because of their dependence on others for their medical care. Whereas a hospitalized adult client may be familiar with their prescribed medications and stop a potential error from occurring, children are not likely to do so.^[5],[6],[7]

Ultimately, the nurse plays a significant role in preventing medication errors in pediatric clients. Medication safety can be improved by nurses performing the following actions^{[9],[10],[11]}:

• Encourage providers to use computerized order entry to eliminate medication errors that can occur with hand-written prescriptions.
• Follow the “rights of medication administration” and use barcode scanning when administering medication.
• Avoid distractions when preparing and administering medications.
• Perform strict checks on weight-based calculations of pediatric dosages and safe dosage ranges using pediatric drug references. Be aware that pediatric medication dosages should be based on the client’s weight, not age. Pediatric clients should be weighed on admission to the hospital and their weight documented in kilograms because pediatric dosage calculations are typically based on weight in kilograms. Nurses should also note that many pediatric dosages contain decimal points to the tenth or hundredth decimal.
• Do not administer medications until they have been verified by a pharmacist unless it is an emergency situation.
• Ensure that technology used for pediatric medication administration, such as infusion pumps, are calibrated for pediatric use.
• Be aware that medication errors can happen to anyone. Report medication errors based on agency policy and procedures to prevent further errors.
• Help prevent medication errors in the home setting by providing parents/caregivers with easy-to-use measuring devices. Use the teach-back method to ensure that parents/caregivers understand how to administer the prescribed dosage of a medication using the appropriate route at the appropriate time. Provide pediatric reference handouts related to medications, their administration, and potential side effects to report to the health care provider.

Nursing Interventions When Caring for Ill or Hospitalized Pediatric Clients

There are a variety of nursing interventions that can be employed to minimize the stress of illness and hospitalization for pediatric clients, as well as their families. General interventions include atraumatic care, family-centered care, promoting a sense of control, incorporating child life specialists, and other methods described in the following sections.

Provide Atraumatic Care

Atraumatic care refers to diminishing potential physical and/or psychological stressors during illness so clients can focus their energy on healing and wellness. Although there is no single approach to provide atraumatic care, interventions may include the following^[12],[13]:

• Incorporate the use of play when caring for pediatric clients. For example, encourage an elementary school-aged child to use puppets or dolls to demonstrate an upcoming medical procedure.
• Be aware of the sounds in a health care facility that could be frightening to a child. As medical professionals, these sounds may be normal to us but are unfamiliar and can induce fear of the unknown in a child. Explain sounds to pediatric clients so they understand the cause of the sound and its purpose.
• Invite pediatric clients and their parents or caregivers to explore medical facilities and equipment prior to scheduled procedures. This tour increases familiarity with the environment and equipment and encourages questions about the unknown.
• Facilitate a healing environment, such as playing relaxing music, using television as a distraction, or incorporating aromatherapy with essential oils. Creating a pleasant space where clients and their family members or visitors can gather is beneficial.
• Family-centered care and promoting a sense of control are other principles of atraumatic care and are further described in the following subsections.

Promote Family-Centered Care

Family-centered care refers to involvement of the family in caring for their hospitalized or ill child. It encourages the formation of relationships with health care providers, the client, and their family. Studies have shown that employing family-centered care enhances communication and client safety, as well as improves job satisfaction of nursing staff. It can also reduce the stress levels of the pediatric client and help them cope. See Figure 14.1^[14] for an image illustrating family-centered care. Family-centered care can be encouraged by nurses in the following ways^[15],[16]:

• Encouraging family members to be present with the child in the hospital. Parents should be allowed 24-hour access to their children.
• Encouraging family members to assist in the care of their hospitalized child.
• Invite parents or caregivers to be present during invasive procedures when possible.
• Be respectful of the cultural and religious values and beliefs of the family and incorporate them into care planning as appropriate.
• Share accurate and timely information with family members so they can take part in decision-making.

Promote a Sense of Control

Atraumatic care also involves promoting a sense of control for ill pediatric clients and their parents/caregivers by performing actions such as the following^[17]:

• Allow choices as appropriate. For example, the nurse may ask, “In which arm would you like to have the intravenous line placed?”
• Help the child create a schedule for their day in the hospital. The schedule should be similar to their home routine.
• Encourage children to help and take a role in their care. For example, the nurse can ask the child to hold the stethoscope until it is needed.
• Encourage the child to ask any questions they may have before, during, and after procedures.
• Encourage the child to brainstorm how to solve a problem.

See Figure 14.2^[18] for an image of a health care professional promoting a sense of control with a pediatric client.

Collaborate With Child Life Specialists

A child life specialist is a health care professional who provides psychosocial support to children and their families during times of illness or hospitalization. They primarily work in hospital settings but may be available in other health care settings as well. They work closely with pediatric nurses and other health care providers to help children and their parents/caregivers cope during stressful times. See Figure 14.3^[19] for an image of a child life specialist working with an ill pediatric client. Roles and responsibilities of a child life specialist include the following^[20],[21]:

• Employ therapeutic play to help children express their feelings, reduce trauma, and increase knowledge of medical diagnoses and procedures.
• Provide support to children and their family and advocate for their needs.
• Provide age-appropriate medical information.
• Develop and employ age-appropriate methods to reduce trauma in health care settings.

Incorporate Other Methods to Minimize Stressors

Nurses can implement other actions to prevent and minimize physical stressors associated with illness and hospitalization, including therapeutic hugging, distraction, and providing health teaching and emotional support before, during, and after medical procedures.

Therapeutic hugging consists of hugging someone who feels distressed (after asking their permission). It promotes a feeling of connection with the hugger, so the client knows they are not on their own. Research has shown that hugging can decrease the release of stress hormones, decrease blood pressure and heart rate, and boost the immune system. Hugging also increases oxytocin levels, which can increase feelings of happiness and even reduce pain.^[22],[23] See Figure 14.4^[24] for an image of therapeutic hugging.

Distraction can also be a powerful method to reduce physical stressors associated with invasive procedures and interventions. Methods of distraction in children include breastfeeding or the use of a pacifier for an infant, playing games or watching television, reading, blowing bubbles, or playing with toys.^[25]

Nursing staff can also implement these interventions to minimize stressors before, during, and after invasive procedures^[26]:

• Before procedures, health teaching should be provided to pediatric clients and their parents/caregivers on what to expect during the procedure. Teaching should include steps of the procedure, sensations they might feel, and viewing equipment/supplies that will be used during the procedure, if appropriate.
• During a procedure, supine positioning and restraints should be avoided. Studies have shown that children are less distressed when they sit upright because it increases their sense of control. Younger children may be more comfortable sitting on the lap of their parent/caregiver. Distraction may also be beneficial as previously described. Providing choices during a procedure, if appropriate, can also help increase a sense of control. Topical anesthetics should be administered, as appropriate, and the least invasive procedure method should be used.
• After an invasive procedure is over, the child should be comforted, allowed to express their feelings, and receive praise for appropriate behavior.

Follow General Guidelines When Providing Nursing Care for Pediatric Clients

Additional general guidelines when providing nursing care for pediatric clients are as follows^[27]:

• Avoid using complex medical terminology and use words that are age appropriate. Communication should be therapeutic, and ambiguous speech should be avoided. For example, when children need an injection, do not say that they are going to get “a shot.” Some children may associate this word with being shot with a gun. Instead, the nurse should tell the child they are going to give them medicine.
• Be physically at the same level of the child when providing care. Stoop down or sit next to the child to avoid hovering over them.
• Always introduce yourself before providing care and refer to children by their name.
• Ask the child questions and encourage them to talk about themselves.
• Always be honest. Lying to the child will destroy trust and increase their sense of fear.
• Always focus on the positive side of things.
• Be kind, yet firm and share expectations.
• Help children identify and express their feelings. This makes it easier for them to regulate their emotions.
• Encourage deep breathing with the use of bubbles or party blowers.
• Increase fluid intake as indicated by cutting gelatin into shapes or dying water with food coloring.
• Promote ambulation as indicated by providing something to push, such as a wheelchair or stroller.
• Teach clients that it is OK to cry if a procedure is painful or if they are feeling upset.
• Establish boundaries with the family about times it would be inappropriate for the nurse to be involved such as in family arguments, lifestyle choices, and decisions about family activities.^[28]

Implement Developmentally Appropriate Interventions

Additional nursing interventions based on the developmental level of the pediatric client are described in the following subsections.

Infants (Birth to 1 Year)

Nursing interventions that are appropriate for infants in health care settings are as follows^[29],[30]:

• Infants should be provided with physical contact such as being swaddled or held.
• Loud noises and sudden movements should be avoided as these can be frightening.
• Infants can be soothed by singing or playing music.
• Ensure consistent caregivers for infants exhibiting stranger anxiety (which is further discussed below).
• Those experiencing stranger anxiety can also be examined from the lap of their primary caregiver.
• Infants can be distracted with rattles, colorful objects, pacifiers, breastfeeding, or a bottle.

Toddlers (1-3 Years)

Some nursing interventions that are appropriate for toddlers in health care settings are as follows^[31],[32]:

• Encourage a toddler to sit in the parent or caregiver’s lap when possible.
• Offer choices between two simple options when appropriate.
• Avoid asking permission as the answer will frequently be “No.” Instead, tell them what you are going to do next and offer appropriate choices.
• Use distraction by blowing bubbles, reading books, or using toys or stuffed objects.
• Do not teach about a procedure until the day before it is scheduled to prevent unnecessary anxiety.
• Allow toddlers to see equipment before you use it.
• Encourage the child to complete tasks they have mastered, such as getting dressed or feeding themselves.
• Perform unpleasant or pain-inducing procedures in a room other than their own.

See Figure 14.5^[33] illustrating a health care professional using a stuffed object as a distractor with a hospitalized toddler.

Early Childhood (3-6 Years)

Nursing interventions that are appropriate for children ages three to six years in health care settings are as follows^[34],[35]:

• As with the toddler-aged child, the preschooler should also be given choices, be allowed to sit in their parent’s lap, and see any equipment before using.
• Incorporate the use of stories or drawing when teaching or performing interventions.
• Use distractions such as music, watching TV, or doing arts and crafts.
• Encourage therapeutic play with dolls or stuffed animals.
• Read age-appropriate materials about their medical situation.

School-Aged Children (6-12 Years)

Nursing interventions that are appropriate for school-aged children in health care settings are as follows^[36],[37]:

• Be aware that some children in this age group may use manipulation to try to avoid or delay procedures.
• Provide for privacy and knock before entering their room.
• Encourage the child to interact with their friends on the phone or visit with them, as appropriate.
• Use distraction methods such as small talk, guided imagery, breathing techniques, or counting.

Adolescents (12-18 Years)

Some nursing interventions that are appropriate for adolescents in health care settings are as follows^[38],[39]:

• As with school-aged children, adolescents should also be allowed privacy and be encouraged to socialize with their friends.
• Be aware that manipulation to avoid or delay procedures can also occur with this age group.
• Distraction methods for this age group may include electronic devices such as phones, tablets, or computers.
• Encourage independence and the expression of feelings.
• Provide written and oral explanations of their disease process and required treatments.