Introduction

Care of the Pediatric Trauma Victim in the Field

Care of the Traumatically Injured Child in the ER or Trauma Center

Care of the Traumaically Injured Child in the ICU

Ethnic, Cultural, and Religious

References

CARE OF THE TRAUMATICALLY INJURED CHILD IN THE INTENSIVE CARE UNIT CONTINUED

DEVELOPMENTAL ASPECTS

The next section identifies and discusses some of the developmental aspects relating to the various age groups and gives some approaches based upon the age of the child.

PLAY is a part of the development for a child.  Play is the way a child learns about themselves, the world and themselves in relationship to the world.  Play is differentiated from other activities and behaviors by six characteristics (Rubin, et al).
They are:

1. A child is intrinsically motivated by play.  No outside stimulus is needed to encourage the child to play.
2. When children are playing, there is no concern for efficiency.  The behaviors are purposeless.
3. Play focuses on the discovery of what the child can do with an object, not just in the identification of the object.
4. Play is make-believe.
5. The child’s play is not guided by externally-imposed rules.
6. The child is actively engaged in the play and gains pleasure from it.  Play is real to the child.

INFANTS

Separation is the overwhelming source of fear for the infant beginning at about six months of age.  This fear can be directed at either parent or at a grandparent if they are actively involved in the primary care of the child, but is usually directed at the mother.  Parents should be allowed to stay with their child during the hospital stay, including in the Intensive Care Unit.  This may not be practical for a variety of reasons, so parents should have visitation privileges at any time during the 24 hour period and should be encouraged to visit.  Robertson (1969) identified three phases of separation anxiety which illustrate the need for parents to be with their children.

The first is protest.  The piercing cry of an infant when the parent leaves can be very traumatic for everyone within hearing distance.  The infant will try to visually locate the parents and often the infant will have nothing to do with anyone who tries to console him/her.  If the nurse has time to play with the infant during the time the parent is present, the child may more readily accept that person for consolation.  Distraction with a toy may assist in the process.

The second phase is despair.  In this phase, the infant may refuse to eat, play or anything but sit and watch the door, waiting for the parent to return.  The infant will look very sad and forlorn and may rock or suck his/her thumb, clutching a blanket or stuffed toy.  The infant may be angry with the parents when the parents return, but are quick to protest again when the parents leave.

The third phase is denial. In this phase the child has resigned to the separation by denying that he/she is longing for the parent.  When the parent returns, they may be surprised to find a child who turns away and ignores them.  Parents can feel as if they are not very important to the child and staff may reinforce this if they think that the child is becoming “well-adjusted” to parental absence.  Both parents and staff need to understand the mechanism going on internally with the child.  Part of the nurses’ role is to assist in the maintenance of the integrity of the family unit.

There are three types of PLAY in which the infant engages (Whaley and Wong, 1983).  The first type is social-affective.  This is where the infant interacts with other people.  They learn fun actions such as sticking out their tongues and other behaviors which they can imitate from adults (or older children).  The second type of play is sense-pleasure.  The infant has enjoyment from stimulation of the senses.  They will look at birds, bright colors (especially if they are in motion), make rocking motions, and enjoy listening to pleasant sounds.  The third type of play is sensorimotor.  They discover that they have hands and feet and that they can have such fun with them.  They begin oral testing of objects and will put almost anything in their mouth.  They begin to enjoy the “game” of throwing items on the floor for someone else to retrieve.  This is one that nurses and parents tire of quickly.

During this time, it is very difficult for the child to have restraints placed, even for his/her own protection.  They need to be placed so that the child has maximum ability to move and to play as much as possible.

TODDLERS

If at all possible, a toddler should not be admitted to a hospital and when one needs to be in Intensive Care, it is a terrifying experience for that child.  The toddler is still very dependent upon and attached to the parents.  The main developmental tasks of this age are to begin to develop some autonomy and self-control.  The toddler begins to see himself as a separate individual from the parent and is beginning to do some things for him/herself.  The toddler now begins to move some distance away from the parents, but comes back frequently to reassure him/herself that the parents are still there.  Parents represent safety and security to the toddler.  Separations from the parents for any length of time are quite difficult, especially if there are other stressors for the toddler.

A stressor for the hospitalized toddler is the stress of being placed back in diapers if he/she has been in the process of toilet training.  Going to the bathroom in the bed is even more stress provoking.  Allow the toddler to use a bedside commode, if possible.

The toddler is very ritualistic about the sequence of his/her activities.  If the same sequences can be adhered to while hospitalized, the stress is lessened for the toddler.  A frequent time for ritual is bedtime.  If the toddler is used to a certain pattern of events leading up to bedtime and that is not followed in the hospital, the toddler may have difficulty going to sleep.

He/she takes comfort from the consistency in the both the environment and in the schedule.  Changes in either one require time for adjustment.  The toddler can understand simple commands, but may say “no” even though he/she means “yes”.  The concept of “yes” develops later than the concept of “no”.

Toddlers believe that events happen because of their thoughts and activities.  They may associate their parents leaving with their “bad” behavior.  The toddler also thinks that one behavior or incident caused the next event to happen.  Toddlers go through a process called animism, in which they give life-like qualities or abilities to inanimate objects.  This may be the reason that toddlers sometimes are terrified of machines and object.

With all of the above development occurring within the toddler, it would truly be a terrifying experience to be in an Intensive Care Unit.  The Intensive Care Unit can be made less terrifying for the toddler by encouraging a parent to be with the child as much as possible and to have the same Nursing staff care for the child.  Minimize the use of restraints and allow the child to sit on the parent’s lap for procedures if possible. Allow the child to “examine” the equipment prior to the procedure.  This will ease his/her fears to some extent.  Enter any of the child’s rituals on the patient care plan, so they can be followed by Nursing Staff if parents are not at the bedside.  Briefly explain procedures just prior to doing the procedure.  Comfort him/her as soon as the procedure is finished.  Acknowledge the child’s feelings, set limits for behavior and then offer the child another activity to substitute for the unacceptable behavior.  Play for the toddler is the way the toddler learns about his/her environment and learns to communicate.  The use of bright mobiles, toys, selected books (preferably a parent to read them to him/her) and some very simple hardwood puzzles are all good quiet activities.  The toddler will listen to audio tapes and will watch some video tapes for very short periods of time.

PRESCHOOLER (AGE 3-5)

Busy, busy, busy describes this age.  This is the time of initiative, eager learning, enthusiasm, ready to explore the world.  Developing verbal, social and motor skills very rapidly.  Has feelings of guilt and anxiety about “bad behavior” and about wishing “bad things” for other people.  May view hospitalization as punishment for “bad thoughts”.

It is important to explain procedures in detail to the preschooler.  Little boys are especially concerned about the genital area because they are fearful of castration as a punishment for “bad behavior”.  Any catheterization or other such procedure will be very frightening unless carefully explained.

If the preschooler is told that parents are leaving and given an opportunity to adjust to that, he/she will usually tolerate short periods of separation.  He/she will question frequently “when will my Mommy be back”, but when reassured, will usually adjust.  If the illness is very serious, or the child is in pain he/she may cry for the parents.  The child may also use inappropriate behavior as a means of protest about the parent’s absence—such as throwing a toy or refusing to do as the nurse instructs.

Cognitive development is continuing to develop, but the child is still having difficulty differentiating between fantasy and reality.  He/she still thinks that there is a causal relationship between events, so he/she may think the hospitalization is a direct result of and a punishment for “bad behavior”.  If the child has been “wishing something bad would happen to….” and that individual is hurt or killed in the traumatic incident which hospitalized the child, the child may be terrified.  The preschooler thinks that there must be a reason for everything, so is constantly asking “why”.  The child still prefers a routine, but adjusts more easily than the toddler.  His/her attention span is also increasing.

Explain all procedures in advance, in order to decrease the child’s anxiety.   Be honest.  If it is going to hurt, tell the child that it is, but translate the amount of pain to something with which the child can relate, or have the child count through the procedure with the nurse.  Parents can be helpful in these explanations.  Have someone hold the child’s hand.  Talk with the child after the procedure to elicit his/her viewpoint about the procedure.  This gives the nurse an opportunity to clear up any questions and/or misconceptions.  The child should be given an opportunity to discuss the traumatic episode as well as his/her experience in the ambulance and in the trauma center.

Play for this age preschooler can actually be used as a therapeutic tool to encourage the discussion of feelings in order to reduce anxiety about what has happened to him/her.  The child may reenact the situation multiple times, playing different roles each time until he/she has mastered the anxiety.  Puppets are a good tool to use with preschoolers because the puppets can voice feelings that the child has not yet voiced.

THE SCHOOL AGE CHILD (6-12)

This is the industrious age.  Children are achieving goals.  They are active not only in school, but in many extra activities such as athletic programs, dance, etc.  Friends are important and peer group approval becomes important.  The child is less dependent upon the family, but is an integral part of the family.  Interrupting family and/or friends is anxiety-producing.  While the child enjoys spending time away from the family, when he/she is sick, it is important to have the family support, especially from parents.

This developmental period includes the process of logical thought development and the beginning of deductive reasoning.  The child is proud of accomplishments and new responsibilities; however, the child who experiences repeated failures will have lowered self-esteem.  The child needs good explanations as to procedures and treatments.  He/she will usually be quite cooperative.  Crying and protest behavior will occur and the nurse must help the child to understand that this is not an indication of any weakness, but is a rather normal reaction to what has happened.

The school age child will be sensitive to the noise factors in the Intensive Care Unit, but can be entertained with audio cassettes and video cassettes.  Fears are more realistic but loss of control becomes an issue.

Play for the school age child may be the best way to relieve the boredom that becomes evident as soon as the child begins to get well.  This age child can also participate in his/her own care in a modified way as he/she improves.  Videos, audio, cassettes, hand-held computer games are all diversions which the child can quietly enjoy.

ADOLESCENTS

The turmoil of the adolescent years is well documented.  The Intensive Care Unit staff will enjoy special challenges trying to meet the adolescent’s needs.  Stephens (1988) has identified four benefits that adolescents gain from being hospitalized.  These benefits are:  an expansion of their social network, respite from responsibilities, improved physical well-being and a positive perception of self.  The adolescent has several developmental tasks to accomplish during the adolescent years.  They include:  adaption to a rapidly changing body, the development of a sense of identity, including sexual identity, separation from parents and the establishment of an autonomous functioning (Stephens, 1988).

Adolescents display unpredictable and inconsistent behavior, with mood swings, depression and some antisocial behavior.  Whaley and Wong (1983) indicate that if the adult or child exhibited the behaviors that adolescents exhibit, they would be thought to be borderline pathological.  There are three stages to adolescence:  early, middle and late, with indistinct time frames (Hazinski, 1992).  The early years of adolescence are primarily occupied with body image issues.  Early adolescents are concerned about every imperfection.  They are certain that if they can see it, so can everyone else (Elkind, 1970).  They also think they are the only ones who have ever had that particular problem.  The peer group grows in importance, but parental influence is still very strong.  If the adolescent is injured during this time, dependency upon parents is strong, with the primary concern being how this injury will affect their appearance and mobility (Hofmann, et al, 1967).

Mid adolescence turmoil is the most difficult.  The mid-adolescent is still very occupied with appearance and now is also quite concerned about his/her appearance to the opposite six.  Conflict with parents increases.  These conflicts are usually over such issues as autonomy, accountability and self-determination.  The mid-adolescent is experimenting with different ideas, behaviors and roles in the peer group, trying to see what ‘fits” (Hofmann, et at, 1967).  The emphasis during these middle adolescent years is so strongly on appearance and what the peer group will think that if the adolescent is traumatically injured and hospitalized the entire focus will be on how the accident will affect his/her appearance and how will the peer group react.  The mid adolescent will be particularly anxious about anything that will make him/her different (and therefore perceived as unacceptable) to the peer group (Hofmann, et al, 1967).

The late adolescent years (17-22) have somewhat less turmoil.  The adolescent has now worked through some of the issues with parents and will now seek the parent’s advice before making his/her own decisions.  There are many choices during this period.  They include educational choices, job/career choices and marriages.  Traumatic injuries during this period of time potentially could affect all of those decisions.  The critically injured adolescent will be concerned about the effect of the injuries upon his/her future (Hofmann, et al, 1967).

The adolescent is quite capable of being a participant in his/her own care.  They are able to think about long-term consequences of the injuries and adjustments which may need to be made.  There may be some guilt associated with the traumatic accident because the adolescent may have been responsible for the accident.

Adolescents take some dramatic risks, seemingly without concern for their life or for the life of another (Hofmann, et al, 1967).  Adolescents need detailed information in preparation for any procedures.  They may be reluctant to show their lack of knowledge about their bodily systems and will not readily ask questions.

The health care professional should explain without having the expectation that they have an in-depth understanding of their body.  Adolescents sometimes act in dramatic fashion to minor injuries and illnesses.  Part of their reaction is to the way in which information is given.  Approach the adolescent tactfully, without being condescending to him/her.  Because they are fearful of changes in body image due to the injuries, the adolescent may come across as a “know-it-all”, pretentious and conceited (Whaley and Wong, 1983).  The adolescent in the Intensive Care Unit is frustrated because of the helplessness they feel.  A concern is that others will find out just how confused they are, so they hide their confusion, even from themselves.  Separation from the peer group is very upsetting and some provision should be made for friends to visit.  Careful control will have to be maintained or the numbers will be unmanageable.  The adolescent may be glad to be separated from parents, but will have ambivalent feelings about wanting them at the bedside.

Privacy is of immense importance to the adolescent.  They are especially sensitive to any exposure of the genital areas.  All members of the Health Care Team need to be very aware of the potential for embarrassment and provide for privacy during all examinations and discussions with the adolescent.  Lack of respect for the privacy is likely to cause the adolescent more stress than actual pain will cause (Whaley and Wong (1983).

Adolescents may use a variety of coping mechanisms to deal with their stress.  Some will withdraw, some will intellectualize.  They want just the facts and will take notes, ask for reading materials about their injuries; but will have some difficulty coping with the emotional aspects of what has happened to them.

Some will regress to more child-like behavior, becoming more dependent upon the staff and upon their parents.  This enables them to avoid coping with the emotional issues that they just can’t handle at that time (Savedra, 1979).

PLAY for the adolescent needs to take on the form of listening to tapes (through headphones), watching television, writing in a diary, daydreaming, talking with a close friend and later, using a punching bag.

FAMILIES

The health care professional needs to integrate the family into the care of the patient as much as possible.  The attitude should be one of expectation that parents will be at the bedside unless there is a valid reason for them to step out of the room.  This is the child’s family and is the group to which the child will be returning once the hospitalization is over.  The nurse should be careful not to make judgments about the family, but should try to assist them to develop more adequate coping skills.  These families are undergoing tremendous stress.

If the traumatic injury is due to an accident, parents may still be in shock.  The fact that their child is in Intensive Care means, to many people, that the child is near death.  The Intensive Care unit itself may be a stressor because most people have not seen all of the equipment and tubes; and they have not seen them all attached to their child.  They feel very helpless; not even knowing where then can touch the child for fear of dislodging something.  They feel powerless because they are the ones used to being the caretaker and protector (Lewandowski, 1977).

The health care professional needs to recognize that individuals under stress do not function at their usual levels.  Sedgwick (1975) describes seven responses of individuals under stress:

1. Reduced ability to utilize incoming information.  Explanations and information will have to be repeated.  All professionals should try to use the same terminology because parents think they are being given different or conflicting information when different terms are used to explain the same condition.  Give only small amounts of information at one time, because only a small amount will be absorbed.  It may be helpful to write the information and give it to the family so they can discuss and absorb it at a later time.
2. Decreased ability to think clearly and to problem-solve.  Parents may seem confused and unable to process information given to them.  Organizing thoughts, drawing conclusions and making decisions seem almost impossible.  Attention will be given to small details while life-threatening issues are ignored.
3. Reduced ability to master tasks.  The individual under tremendous stress may not even be able to fill out the form correctly and see the line on which they must sign.  This is due to altered perception of the environment and an inability to draw on resources.
4. Decreased sense of personal effectiveness.  The parents may feel lost, not knowing what to do.  Control of their child is now in the hands of someone else and there seems to be nothing that they can do.  Give the parents something to do for the child; rubbing his/her back, putting a cool cloth on the forehead, something simple, that takes no thought or decision making ability.
5. Reduced ability to make effective, constructive decisions.  The health care professional needs to give information to parents in a very structured format, telling them at what point decisions have to be made and making sure that they have all of the information with which to make the decision.  Parents need some private time for discussion before a decision is made.  They need time to just process the information and make the decision.
6. Heightened of decreased sensitivity to self.  Some parents will neglect themselves, devoting all energies to their child, forgetting even to eat.  Others become focused on themselves and may react out of proportion to minor irritants.
7. Decreased sensitivity to the environment.  Stressed parents will miss cues.  Direct communication is the best approach.  The levels of stress described above are in danger of entering a crisis state, where their functioning will be even more impaired.  There are three balancing factors described by Aguilera and Messick (1982).  These are:
   1. A realistic perception of the events.
   2. Adequate situational support.
   3. Adequate coping mechanisms.

A member of the Health Care Team (usually a Social Worker) need to assess the family situation and develop the plan for appropriate intervention if it is needed.

The parents of a critically ill child will go through a process very similar to the grieving process.  These steps include:  denial, anger, bargaining, depression and eventually acceptance.  It takes time for an individual to go through this process.  Not all individuals go through it in the same order and at the same rate (Hazinski, 1992).

THE DYING CHILD

The child in Intensive Care who has been traumatically injured and is dying as a result needs some special attention.  If the child is alert, he/she may initiate some comment about dying.  As this occurs, the nurse can explore the child’s feelings about death with age appropriate comments.  In the traumatically injured, the parents are the more likely ones to need the assistance to cope with the dying issue.  As team members talk with the parents to give condition, the path needs to be paved to actually inform them about the child’s death and to ask about organ donation if the child is potentially a donor.  It is best if one person can consistently give these condition reports and if the parent has a support person present during this time.  Ideally, this is the individual to bring up the issue of organ donation.  Parents who have had this experience have shared that being able to offer another child life seemed to help the “make some sense” out of their child’s death.  They were grateful for being given the opportunity to donate.  When the child dies suddenly, as many happen with the traumatically injured child, the parents are still in denial and shock and may have difficulty focusing on this issue.

THE CHILD IN PAIN

There are several clinical studies which document that the administration of analgesic agents to children is inadequate.  Table 1 illustrates the developmental characteristics of children’s responses of pain.

The child may have difficulty expressing that he/she has pain, but there are physiological signs that the patient has pain and the nurse needs to be proactive in the administration of analgesics.  Some of the symptoms nurses should evaluate are:

1. Marked increases in blood pressure and heart rates.
2. Restlessness and agitation.
3. Irritability with a short attention span.
4. Irritability, with little success in comforting the child.
5. Facial grimaces and holding or favoring the part of the body that hurts.
6. Large fluctuations in transcutaneous oxygen tension (Venus, et al, 1981).

There are several assessment scales for measuring pain in children, but they are not as useful with the child in Intensive Care because of the severity of the child’s condition and the distractions in the Intensive Care Unit (Hazinski, 1992).  Table 2 indicates the children’s development concepts of illness and pain.

Once the nurse has determined that the patient has pain, he/she needs to take the appropriate action to relieve the pain and to make certain that the information which he/she has gained is entered into the patient care plan so that the next nurse caring for the patient will have additional information on which to base his/her decision about the patient’s pain.

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