Page 707 - ACCCN's Critical Care Nursing

684 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

nature at infancy to complete ossification and adult fea- which significantly affect their development and persona-
tures during adolescence, so daily calcium requirements lity. The first five stages are presented below.
increase over childhood and adolescence. 24
INFANTS (STAGE 1)

Integumentary System The first year of life is concerned with developing a sense
of trust, which lays the foundation for all future rela-
Infants have a thinner epidermis, dermis and subcutane- tionships. 38,43 More specifically, the affective exchanges
ous tissue that will continue to mature. This results in a between the infant and the primary caregiver provide a
greater susceptibility to absorption of chemicals, injury foundation for neurological development and lead to the
from adhesive tapes and any shearing force, and loss of creation of neural networks (particularly in the right
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water and heat, particularly in the newborn period. hemisphere) that will influence the infant’s personality
Critically ill children are more likely to develop pressure and relationships with others throughout life. 44,45 Gener-
areas on the occiput, ear, sacrum, heel, or thigh; 50% of ally, up to the age of six months, infants are able to cope
pressure ulcers in children are associated with equipment with limited separation from their mothers; however,
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pressing or rubbing on the skin. A commonly used tool changes to usual routine create anxiety and stress. From
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for assessing risk of development of pressure areas in around 6–18 months of age separation is the major fear,
children is the modified Braden Q scale. This shorter with changes to usual routine and environment resulting
version includes three subscales (mobility, sensory per- in anxiety. Therefore, critically ill infants require paren-
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ception, tissue perfusion/oxygenation) with a cutoff score tal presence and maintenance of normal routines, includ-
of 7 and has comparable psychometric properties to the ing breastfeeding, as much as is practicable.
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adult Braden scale (see Chapter 6). However, recent
evidence suggests that the Glamorgan paediatric pressure TODDLERS (STAGE 2)
ulcer risk assessment scale may perform better than the
Braden Q scale. 27,28 The Glamorgan scale includes ten The toddler period, between 12 months and three years
subscales: anaemia, equipment pressing, mobility, poor of age, is a time for establishing autonomy and indepen-
peripheral perfusion, pyrexia, serum albumin, surgery dence. Control over bodily functions, increasing ability
in last 4 weeks, weight < 10th centile, continence, and to communicate, ability to view the self as separate from
nutrition. 27 others, and being able to tolerate brief separation from
the mother are all developmental characteristics during
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this period. Toddlers tend to be egocentric in how they
DEVELOPMENTAL CONSIDERATIONS view the world, so illness, procedures and separation
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from parents may be perceived as punishment. Their
29
Admission to ICU is very stressful for paediatric patients thinking processes include transduction, animism and
as well as for their family. 30-33 The stressors, combined ritual. Transductive thinking allows a child to link unre-
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with the effects of critical illness, can lead to disturbances lated objects or events, such as separation and endotra-
in normal child development and attachment. The psy- cheal suction if suction occurs after the parent leaves the
chological needs of children and families are not always room. Animism attributes lifelike traits to inanimate
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met. Factors that affect the psychosocial wellbeing of a objects, so the ventilator becomes a hissing monster, or
critically ill child include loss of usual routines and self- monitoring leads may be trying to trap them. Many
control; family presence and role; family and friends’ toddlers have varying levels of ritual or sameness, includ-
visits, comfort and the ICU environment. 29,35-37 ing always eating off the same plate, different foods that
Knowledge and understanding of developmental psycho- should not be touched, or a security toy or blanket.
logy can help nurses assess and plan care for the critically Regression, or loss of recently-acquired skills such as toi-
ill child. 38,39 Identification of internal strengths, external leting, may also occur during critical illness, creating
supports and environmental modification can facilitate further distress. When caring for a critically ill toddler,
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coping and reduce stress in these children. Parental encourage parental presence and maintain as many of the
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support is an important coping mechanism of infants usual rituals and routines as possible to facilitate coping.
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and children during periods of stress. Strategies to faci-
litate coping in children of all ages include: PRESCHOOL CHILDREN (STAGE 3)
Children from 3–5 years of age fall into the preschool
l facilitating parental presence at all times, including
during invasive procedures and resuscitation 41,42 period of development. This period is characterised by
l maintaining normal routines and rituals as much as discovery, inventiveness, curiosity, and the development
38,39,43
possible, including story reading, bedtime routines of culturally- and socially-acceptable behaviour.
and presence of favourite toys Preschoolers can generally verbalise their needs reason-
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l providing appropriate analgesia and sedation as well ably well. While thought processes become less ritual-
as non-pharmacological interventions istic and negative, they are still egocentric and magical
l providing opportunities for play and activities unre- thinking emerges, thus ideas about causality and linking
lated to treatment. events may be faulty. Fears, both real and imagined, are
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prevalent during this period. For example, fears of
Erikson’s psychosocial theory is helpful for understand- monsters or being hurt may occur. They may also feel
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ing childhood development. Erikson’s theory asserts guilty as a result of illness. There is, however, greater
that people experience eight ‘psychosocial crisis stages’ understanding of the passage of time, so parents can leave