Pediatric Hospitalization Notes

Course Logistics and Reminders

• All EAPs due by 5:00 PM this week.
• Briefing form must be uploaded by tonight.
• Lab due date: Monday, but can be submitted before the 12th.
• SIM due in week 10 (currently), next term it will be in week 9.
• Upload form today, don't wait until next Monday.

Textbook References

• Page 484 (9th edition): Box 21.1 - Preparing a child for treatment or procedure (infants, toddlers, school-age, and adolescents).
• Discusses separation anxiety on pages 485-486.
• FLACC scale is on page 486 (also in lecture handout).
• Know what each category of the FLACC scale assesses.
• Page 487: Pain scales (e.g., Wong-Baker FACES scale).
• Page 498: Discharge planning bullet points.
• Pages 514-515: Metabolism and absorption of medications.
• Page 520: Parent teaching for medication administration.
• Lab includes skills: oral, nose drops, ear drops administration.

Common Reasons for Pediatric Emergency Room Visits

• Fever: Parents often bring children to the ED for high fevers (e.g., 104°F).
  • Parents can initially use antipyretics like Tylenol.
• Ear Infections: Common, especially in young children.
  • Recurrent ear infections may be due to Eustachian tube dysfunction.
  • Antibiotics might become less effective with repeated use.
• Broken Bones: More common in school-age and adolescent children due to harder bones.
  • Fractures can range from buckle fractures to more severe breaks requiring casting.

Child Life Specialists

• Purpose: To provide age-appropriate instructions and preparation to children in hospitals.
• Help children understand procedures in a non-threatening way (e.g., CT scans).
• Cincinnati Children's Hospital has a large child life worker program.

Seattle Children's Emergency Room Insights

• Emergency Room Environment:
  • Aims for a calm, safe and detail-oriented environment.
  • Handles a variety of cases, from critical ambulance arrivals to routine concerns.
• Patient and Family Experience:
  • Prioritizes family comfort and communication during stressful situations.
  • Strives to provide the best and safest care.
• Common Cases:
  • Respiratory distress in newborns.
  • Broken bones.
  • Infections and illnesses especially in young children.
• Key themes observed in patient interaction:
  • Gentle handling of children.
  • Parental involvement during assessments and procedures.
  • Minimizing disruption and maximizing comfort for the child.

Child-Centered Care Principles

• Minimizing Trauma:
  • Aim to reduce trauma and pain during procedures.
  • Use sedation when necessary and appropriate.
• Role of Child Life Specialists:
  • Help children understand medical procedures.
  • Provide education and distraction during interventions.
  • Use age-appropriate language and techniques.
• Importance of Education:
  • Educate children and families about medical processes to alleviate fears.
  • Explain the purpose of medical equipment and procedures.
• Creating Positive Experiences:
  • Strive to make hospital visits as painless and positive as possible.
  • Recognize that a child's ER visit can shape their future attitudes toward medical care.

Preparing Children for Treatment

• Toddlers and Preschoolers:
  • Offer simple explanations.
  • Allow choices when possible (e.g., cast color).
  • Use distraction techniques (reading, etc.).
• Creating Calm Environment: For CT scans, allow them to explore the machine, move them back and forth on the table, talk to them quietly, massage their scalp, etc.
• Reward systems: Giving popsicles, stickers, etc., to reward good behavior.
• School-Aged Children:
  • Allow them to play with equipment (e.g., stethoscopes).
  • Encourage them to talk about their fears.
  • Reward good behavior.
• Pain Management:
  • Anticipate potential pain and minimize it.
  • Use topical anesthetics (e.g., EMLA cream).
  • Use ultrasound to locate veins before IV insertion.

Pain Assessment

• Importance of Nonverbal Cues:

  • Assess nonverbal cues of pain.
  • Use pain scales designed for children.

• Pain Scales:

  • Wong-Baker FACES: For toddlers and preschoolers.
  • Numeric Pain Scale: For mobile, school-aged children.

• FLACC Scale:

  • Use for nonverbal or preverbal children (e.g., intubated children).
  • Assess:
    • Face
    • Legs
    • Activity
    • Cry
    • Consolability

Addressing Fear and Anxiety

• Acknowledge Children's Fears:
  • Recognize that children may have fears related to past experiences or misinformation.
  • Be mindful of how we approach children and potentially incite fear.
• Communication and Explanation:
  • Provide explanations of procedures and treatments.
  • Use age-appropriate language.
  • Ask for permission before touching or examining a child.
• Creating a Supportive Environment:
  • Minimize anxiety.
  • Ensure hospital personnel provide a supportive environment.
• Managing Post-Hospitalization Issues:
  • Prepare parents for potential regression in children after hospitalization.
  • Explain that regression is a normal coping mechanism.
  • Advise parents not to shame or punish regressive behaviors.
  • Address separation anxiety.

Cultural Sensitivity

• Diverse cultural backgrounds may influence patient care.
• Tailor care plans to meet the specific needs of diverse patients.
• Understand and respect cultural differences.
• Common considerations:
  • Smiling and tongue thrusting may be inappropriate
  • Eye contact can be considered discourteous or misleading
• Dietary preferences, home routines, and values should be understood from parents.

Safe Hospital Environment

• Maintain safety measures:
  • Keep side and print rails up on cribs.
  • Ensure children wear IV bracelets.
  • Keep cots and plastic toys away from sockets and appliances.
  • Ensure outside items are safe for use
  • Keep poisonous solutions away from kids
• Safe medication administration.
  • Maintain clear channels of communication.

Medication Safety

• Vital Signs and Assessment:
  • Prioritize vital signs, even if the child is uncooperative.
  • Recognize the significance of blood pressure measurements.
• Managing Fever:
  • Administer antipyretics (Tylenol only; avoid aspirin).
  • Monitor for dehydration.
• Dehydration:
  • Monitor the fontanelles (especially in children under two years of age).
  • Provide oral rehydration fluid (preference) or electrolyte therapy in case intravenous (IV) fluid is needed.
• Pharmacokinetics:
  • Absorption: How medications are absorbed.
  • Metabolism and Excretion: Liver and kidney are the organs that break down and excrete medication.
  • Half-life of medications: Generally, it takes 30-45 minutes for medication to start to take effect orally - the least effective method of taking in oral medication.
  • Distribution: How medications are spread in the body.
• Considerations for Children:
  • Gastric influence may affect absorption in children under two years of age.
  • Kidney function is not optimal until after two years of age.
  • Children under five years of age have a more rapid metabolism than adults.
• Topical Medications: Use sparingly, as children have thinner skin.
• Injections: Monitor skin reactions and follow proper injection guidelines to avoid potential blood-brain barrier breach.
• Teaching Parents: Show appropriate dosage.

Medication Administration Techniques

• General guidelines:
  • Do not mix oral medications with food.
  • Allow children autonomy in assisting with medication.
  • Do not use kitchen teaspoons to measure medication.
  • Use oral syringes or calibrated spoons.
  • Medications for children under 5 are elixir or liquid form.
• Administering Drops:
  • Ear drops: For children under 3 years of age, pull the ear down and back.
  • For children older than 3 years of age, pull the ear up and back.
• Injections:
  • Considerations:
    • Preferred injection site: Vastus lateralis muscle.
    • Use an approximately 5/8 inch needle.
    • Provide comfort measures to ease discomfort.
    • Never compress the blood vessels.
    • Rapid adminstration.
    • Administer sucrose to calm a newborn.