Pediatric Nursing Notes: Grief, Child Health Nursing & Perioperative Care

Pediatric Nursing Notes

Grief & Bereavement, Child Health Nursing, and Perioperative Care

Grief and Bereavement in Pediatric Nursing
The Role of a Child Health Nurse in Caring for Hospitalized Children
Principles of Pre and Postoperative Care of Infants and Children

1. Grief and Bereavement in Pediatric Nursing

Grief and bereavement are significant aspects of pediatric nursing that require specialized knowledge and skills. Understanding how children and families experience loss is essential for providing comprehensive care.

Key Concepts: Understanding Grief

Grief is the natural emotional response to loss, while bereavement is the period of grieving after a loss. In pediatric settings, nurses encounter grief related to:

Loss of a child
Chronic illness diagnosis
Loss of normal childhood experiences
Loss of body function or body image
Terminal illness and end-of-life care

Developmental Understanding of Death

Age Group	Understanding of Death	Common Reactions	Nursing Approach
Infants (0-1 year)	No concept of death, but sense separation and changes in routine	Irritability Changes in eating/sleeping patterns Crying	Maintain consistent caregivers Provide comfort through touch Maintain routines
Toddlers (1-3 years)	View death as temporary or reversible	Regression in development Separation anxiety Tantrums	Simple, concrete explanations Consistent routines Allow expression through play
Preschoolers (3-5 years)	Magical thinking; may believe their thoughts caused death; view death as temporary	Guilt Fear of abandonment Behavioral problems	Reassure they didn’t cause death Use simple, concrete language Use drawing and storytelling
School-Age (6-12 years)	Begin to understand permanence of death; may personify death (e.g., as the “grim reaper”)	Concern with fairness Academic difficulties Physical complaints	Honest, factual information Include in rituals when appropriate Help identify coping strategies
Adolescents (13-18 years)	Adult understanding but may lack coping skills; contemplate existential aspects of death	Risk-taking behaviors Isolation Existential questioning	Respect need for peer support Allow participation in decision-making Provide outlets for emotional expression

Mnemonic: “GRIEVE” – Assessment of Grief Reactions

G – Guilt: Assess for feelings of responsibility or blame
R – Routines: Observe changes in daily activities and behaviors
I – Interactions: Note changes in social relationships and communication
E – Emotional expression: Identify how grief is manifested emotionally
V – Vulnerabilities: Recognize risk factors that may complicate grieving
E – Expectations: Understand cultural and familial expectations around grief

Dual Process Model of Grief

Loss-Oriented

Grief work
Intrusion of grief
Breaking bonds/ties
Denial/avoidance of restoration changes

Oscillation

Restoration-Oriented

Attending to life changes
Distraction from grief
Doing new things
Denial/avoidance of grief

Based on Stroebe & Schut’s Dual Process Model (1999)

Nursing Interventions for Grieving Children and Families

Supporting Grieving Children

Use age-appropriate, honest communication about death and loss
Provide opportunities for expression through play, art, and storytelling
Maintain routines and boundaries while allowing flexibility
Include children in rituals and memorialization when appropriate
Connect children with peer support when possible
Monitor for complicated grief reactions requiring additional intervention

Supporting Grieving Families

Provide consistent, honest information about the child’s condition
Create space for privacy and family time during end-of-life care
Facilitate legacy-building activities (handprints, recordings, memory boxes)
Respect cultural and religious practices around death and mourning
Connect families with bereavement resources and support groups
Provide follow-up contact after a child’s death

Clinical Pearl: Memory-Making

Creating tangible memories is vital for families experiencing loss. Memory-making should begin before death when possible. Consider offering:

Hand/footprints or molds
Lock of hair
Photography (consider organizations like Now I Lay Me Down to Sleep)
Recording heartbeats or voices
Memory boxes with significant items

These items provide comfort and validate the child’s existence and importance.

Mind Map: Components of Pediatric Bereavement Care

Pediatric
Bereavement
Care

Nursing Support

Family Support

Spiritual Care

Emotional Support

Psychological Support

Community Resources

Caution: Signs of Complicated Grief

Be alert for indicators that may suggest complicated grief requiring specialized intervention:

Prolonged functional impairment (>6 months)
Persistent denial of death
Intense yearning and preoccupation with the deceased
Avoidance of reminders of the loss
Persistent guilt or anger
Suicidal ideation or intent

Refer to mental health professionals when these signs are present.

2. The Role of a Child Health Nurse in Caring for Hospitalized Children

Child health nurses play a multifaceted role in providing comprehensive care to hospitalized children. Their responsibilities encompass clinical care, emotional support, education, advocacy, and family-centered approaches.

Core Responsibilities of the Child Health Nurse

The pediatric nurse’s role extends beyond technical skills to encompass a holistic approach to the child and family:

Providing developmentally appropriate care
Maintaining safety in the hospital environment
Facilitating family-centered care principles
Coordinating interdisciplinary care
Advocating for the child’s needs and rights
Providing education and emotional support

The Child Health Nurse: Core Competency Areas

Clinical Excellence

Assessment skills adapted to developmental stages
Medication administration with pediatric calculations
Growth and developmental monitoring
Pain assessment and management
Recognition of deterioration signs

Communication

Age-appropriate communication techniques
Therapeutic relationship building
Family-centered communication
Interdisciplinary collaboration
Documentation and handover skills

Advocacy

Promoting child’s voice in care decisions
Ensuring pain is addressed appropriately
Safeguarding and child protection
Facilitating family involvement
Ensuring child-friendly environment

Education

Teaching children about procedures/conditions
Family education for home care
Discharge planning and instruction
Health promotion and illness prevention
Peer education and mentoring

Family-Centered Care in Pediatric Nursing

Mnemonic: “FAMILY” – Principles of Family-Centered Care

F – Facilitate family participation in care
A – Acknowledge family expertise about their child
M – Maintain family strengths through support
I – Include families in decision-making and care planning
L – Listen to family concerns and preferences
Y – Yield control appropriately to empower families

Area of Care	Traditional Approach	Family-Centered Approach
Visiting Hours	Restricted to specific hours	24-hour access for parents/primary caregivers
Procedures	Parents asked to leave	Parents offered option to remain present with support
Information Sharing	Limited disclosure, medical terminology	Complete, honest information in understandable language
Care Planning	Determined by healthcare team	Collaborative process including family input
Education	Provided near discharge	Ongoing throughout hospitalization
Siblings	Limited or no access	Accommodated with preparation and support

Minimizing the Impact of Hospitalization

Strategies to Reduce Hospitalization Stress

Environmental Interventions:

Child-friendly décor and furnishings
Play areas and age-appropriate activities
Space for personal items from home
Reduced noise and appropriate lighting
Privacy considerations

Psychological Interventions:

Preparation for procedures
Therapeutic play opportunities
Maintenance of routines when possible
Consistent caregivers
Developmentally appropriate explanations

Clinical Pearl: Therapeutic Play

Therapeutic play is a powerful nursing intervention that serves multiple purposes in pediatric care:

Procedural preparation: Using dolls and medical equipment to demonstrate procedures
Emotional expression: Providing safe outlets for feelings through art, puppets, and storytelling
Mastery: Allowing children to “play through” experiences to gain a sense of control
Assessment: Observing play for insights into the child’s understanding and concerns
Normalization: Offering typical childhood experiences in the hospital setting

Remember that play is not just a distraction but a vital therapeutic tool in pediatric nursing.

Communication Techniques for Children

Age Group	Communication Approach	Effective Techniques	Things to Avoid
Infants (0-1 year)	Nonverbal and sensory communication is primary	Gentle touch and holding Soothing voice tones Eye contact Smiling	Loud, sudden noises Multiple caregivers handling simultaneously Extended separation from parents
Toddlers (1-3 years)	Beginning verbal skills but still highly dependent on nonverbal cues	Simple, concrete language Limited choices Demonstration on dolls Use of favorite toys	Abstract explanations Too many choices Lengthy instructions Separating from comfort objects
Preschoolers (3-5 years)	Literal interpretation of language; magical thinking	Concrete explanations Puppet play Picture books Medical play with safe equipment	Medical jargon or euphemisms Words with dual meanings (e.g., “shot,” “dye”) Threatening language
School-Age (6-12 years)	Increased cognitive ability but still need concrete explanations	Simple explanations of how body works Books and diagrams Involvement in care discussions Opportunities to ask questions	Talking only to parents Dismissing fears or concerns Providing too much detailed information
Adolescents (13-18 years)	Capable of abstract thinking but still developing	Respect for privacy Inclusion in decision-making Direct, honest communication Time alone with providers	Condescending tone Ignoring their opinions Forcing parental presence Treating them like young children

Effective Communication Strategies Across Age Groups

Get down to eye level with the child when speaking
Use developmentally appropriate language and avoid medical jargon
Provide honest information while maintaining hope
Allow time for the child to process information and respond
Use multiple communication modalities (verbal, visual, tactile)
Validate feelings and acknowledge the child’s experience
Incorporate play and creative expression as communication tools

Mind Map: Child Health Nurse Roles

Child Health
Nurse

Care Provider

Communicator

Educator

Advocate

Coordinator

Assessor

Protector

Emotional
Supporter

Caution: Signs of Nursing Burnout in Pediatric Care

Working with sick children and their families can be emotionally demanding. Be alert to signs of compassion fatigue and burnout:

Emotional exhaustion and detachment
Decreased empathy and compassion
Physical symptoms (headaches, fatigue, sleep disturbances)
Increased irritability or cynicism
Reduced sense of personal accomplishment

Engage in self-care practices and seek support from colleagues and professional resources. Remember that caring for yourself enables you to provide better care for your patients.

3. Principles of Pre and Postoperative Care of Infants and Children

Perioperative care of infants and children requires specialized knowledge and skills that address their unique physiological, developmental, and psychological needs. The pediatric nurse plays a crucial role in ensuring safe and effective care throughout the surgical experience.

Key Concepts in Pediatric Perioperative Care

Effective perioperative care for children is built on understanding these fundamental principles:

Children are not “small adults” – they have unique physiological responses to surgery and anesthesia
Developmental stage significantly impacts preparation approaches and postoperative care
Family involvement is essential throughout the perioperative period
Psychological preparation is as important as physical preparation
Pain assessment and management must be adapted to the child’s developmental stage

Physiological Considerations in Pediatric Surgery

System	Pediatric Differences	Nursing Implications
Respiratory	Higher oxygen consumption Smaller airway diameter Fewer alveoli Less respiratory reserve	Monitor respiratory status closely Position to maintain airway patency Recognize early signs of distress Have appropriate-sized equipment
Cardiovascular	Higher cardiac output relative to size Lower blood volume Immature baroreceptor control	Calculate fluid needs by weight Monitor for early signs of hypovolemia Prevent fluid overload Use precise equipment for infusions
Thermoregulation	Higher surface area to mass ratio Limited thermal insulation Immature temperature regulation	Monitor temperature frequently Maintain warm environment Use warming devices appropriately Minimize exposure during procedures
Renal/Metabolic	Immature kidney function Limited glycogen stores Higher metabolic rate	Monitor fluid balance carefully Monitor glucose levels Calculate drug doses precisely Shorter fasting times when possible
Pharmacological	Different drug metabolism Varied body composition by age Different drug sensitivities	Calculate all medications by weight Use pediatric dosing guidelines Monitor drug effects closely Use pediatric formulations when available

Preoperative Care

Mnemonic: “PREPARE” – Preoperative Pediatric Assessment

P – Physical assessment and baseline vital signs
R – Review medical history and allergies
E – Evaluate nutritional and hydration status
P – Psychological preparation appropriate to developmental stage
A – Assess laboratory and diagnostic results
R – Review medications and NPO status
E – Educate child and family about expectations

Age-Appropriate Preoperative Preparation

Infants (0-1 year):

Maintain routines as much as possible
Allow favorite comfort items
Prepare parents primarily
Minimize separation from parents
Consider parental presence during induction

Toddlers (1-3 years):

Very simple explanations shortly before procedure
Use of therapeutic play with dolls
Allow security objects
Prepare for sensory experiences (sounds, smells)
Emphasize that parents will be waiting

Preschoolers (3-5 years):

Brief, concrete explanations (1-2 days before)
Picture books and demonstrations
Medical play with safe equipment
Address magical thinking and fears
Emphasize that surgery is not punishment

School-Age (6-12 years):

Simple explanations of body parts and procedures
Diagrams and models
Opportunity to ask questions
Prepare 1 week before surgery
Include in discussions about care

Adolescents (13-18 years):

Detailed information about procedure and recovery
Privacy and confidentiality
Involvement in decision-making
Prepare 1-2 weeks before surgery
Address concerns about body image and peer relationships
Opportunity to speak with providers without parents

Clinical Pearl: Preoperative Fasting Guidelines

Following appropriate fasting guidelines is essential for patient safety while minimizing discomfort:

Intake Type	Minimum Fasting Time
Clear liquids	2 hours
Breast milk	4 hours
Infant formula	6 hours
Nonhuman milk	6 hours
Light meal	6 hours

These are general guidelines; always follow your institution’s specific protocols and the anesthesiologist’s instructions.

Intraoperative Considerations

Key Intraoperative Nursing Considerations

Temperature management: Pediatric patients are at high risk for hypothermia
Fluid management: Precise calculation and monitoring of fluid balance
Positioning: Proper padding and alignment to prevent pressure injuries
Communication: Clear handoff from preoperative to intraoperative team
Family support: Regular updates to waiting family members
Documentation: Accurate recording of all aspects of intraoperative care

Postoperative Care

Immediate Postoperative Period

Airway management and respiratory monitoring
Vital signs assessment q15min until stable
Pain assessment and management
Monitoring for emergence delirium
Assessment of surgical site

Early Postoperative Period

Ongoing pain management
Fluid and electrolyte management
Nausea and vomiting management
Family reunification
Monitoring surgical site

Recovery Phase

Advancing diet as tolerated
Early mobilization appropriate to age
Continued pain assessment and management
Wound care education
Return to age-appropriate activities

Discharge Planning

Family education for home care
Medication teaching
Signs and symptoms to report
Follow-up appointment scheduling
School/activity recommendations

Mnemonic: “COMFORT” – Postoperative Pain Management

C – Choose appropriate assessment tool for developmental stage
O – Observe behavioral and physiological indicators
M – Medicate preemptively and regularly
F – Family involvement in assessment and management
O – Offer non-pharmacological interventions
R – Reassess regularly after interventions
T – Tailor approach to individual needs

Pediatric Pain Assessment Tools by Age

Age Group	Recommended Tools	Key Considerations
Neonates	NIPS (Neonatal Infant Pain Scale) PIPP (Premature Infant Pain Profile)	Focus on behavioral and physiological indicators Consider gestational age
Infants	FLACC (Face, Legs, Activity, Cry, Consolability) NIPS (Neonatal Infant Pain Scale)	Behavioral observation is primary Parental input valuable
Toddlers	FLACC CHEOPS (Children’s Hospital of Eastern Ontario Pain Scale)	May not verbalize pain accurately Behavioral changes common
Preschoolers	Faces Pain Scale-Revised FLACC Poker Chip Tool	Beginning to use self-report Still rely on behavioral observation
School-Age	Numeric Rating Scale (0-10) Faces Pain Scale-Revised Color Analog Scale	Can typically use self-report May underreport to avoid medication
Adolescents	Numeric Rating Scale (0-10) Visual Analog Scale	May minimize pain Privacy concerns important
Cognitively Impaired	r-FLACC (revised) NCCPC-R (Non-Communicating Children’s Pain Checklist)	Parental input essential Establish individual baseline

Non-Pharmacological Pain Management Strategies

For Infants and Toddlers:

Swaddling and containment
Non-nutritive sucking (pacifier)
Sucrose solution for painful procedures
Skin-to-skin contact
Gentle rocking and holding
Distraction with mobiles or toys

For Preschool and School-Age:

Guided imagery and storytelling
Distraction (bubbles, music, videos)
Therapeutic play
Simple breathing techniques
Comfort positioning
Heat or cold therapy when appropriate

For Adolescents:

Relaxation techniques
Guided imagery
Music therapy with headphones
Distraction with electronics
Control over environment when possible
Cognitive behavioral strategies

Caution: Common Postoperative Complications in Children

Be vigilant for these complications that may present differently in pediatric patients:

Respiratory depression: Children are more sensitive to opioids; monitor respiratory rate and depth carefully
Emergence delirium: Common in young children; presents as agitation, disorientation, and inconsolability upon awakening from anesthesia
Postoperative nausea and vomiting (PONV): Higher incidence in children; can lead to dehydration more quickly than in adults
Pain: May be undertreated due to assessment challenges; use appropriate assessment tools
Fluid imbalances: Children have less reserve and can become dehydrated quickly
Psychological distress: May manifest as regression, nightmares, or separation anxiety

Mind Map: Comprehensive Perioperative Care

Pediatric
Perioperative
Care

Preoperative
Assessment

Developmental
Preparation

Family
Education

Intraoperative
Safety

Physiological
Monitoring

Pain
Management

Discharge
Planning

Complication
Prevention

Clinical Pearl: Discharge Teaching for Parents

Effective discharge teaching can prevent complications and reduce readmissions. Use the “teach-back” method to ensure understanding of:

Wound care: Demonstrate cleaning and dressing changes if needed
Pain management: Clear schedule for medications with written instructions
Activity restrictions: Specific guidance appropriate to surgery and age
Diet progression: What foods are allowed and when to advance
Warning signs: Specific symptoms that warrant calling the provider or returning to hospital
Follow-up: Clear appointments with date, time, and location

Provide written instructions in the family’s primary language and consider literacy level. Include pictures or diagrams when helpful.

References

Hockenberry, M. J., & Wilson, D. (2019). Wong’s nursing care of infants and children (11th ed.). Mosby.
American Society of PeriAnesthesia Nurses. (2021). ASPAN’s perianesthesia nursing standards, practice recommendations and interpretive statements. Cherry Hill, NJ: ASPAN.
Sadovich, J., & Kain, Z. N. (2018). Preoperative preparation of children for surgery. UpToDate.
Ferrell, B., & Coyle, N. (2017). Oxford textbook of palliative nursing (5th ed.). Oxford University Press.
Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197-224.
Twycross, A., Dowden, S., & Stinson, J. (2014). Managing pain in children: A clinical guide for nurses and healthcare professionals (2nd ed.). Wiley-Blackwell.
Institute for Patient- and Family-Centered Care. (2022). Core concepts of patient- and family-centered care. Retrieved from www.ipfcc.org
Srouji, R., Ratnapalan, S., & Schneeweiss, S. (2010). Pain in children: Assessment and nonpharmacological management. International Journal of Pediatrics, 2010, 474838.
Fortier, M. A., Kain, Z. N., & Chorney, J. M. (2021). Pediatric perioperative care. American Psychological Association.
American Academy of Pediatrics. (2021). Guidelines for preparing children and adolescents for surgery and procedures. Pediatrics, 148(5), e2021054026.