umcRN 19,425 Views
Joined: Nov 28, '10;
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I just had to post this in response to the dozens of posts I see from nursing students or new graduates that want to work in peds because "kids are so cute," and "I want to take care of babies," and "I don't want to change adult diapers."
As anyone who has worked in pediatrics could tell you, peds nursing is not easier than adult nursing, and at times it is more difficult.
In peds, you might be assigned 5 patients, just like on a med surg floor. But your patients can't all speak for themselves. They can't press their call button to tell you when they are in pain, can't breath well, or their IV site is burning. You have to constantly be alert for these, and many other problems because our patients can't report them.
In peds, you have to care for the patient and the family. Some family members are great. Others are incredibly anxious, questioning everything you say and do and constantly asking you to check on little Jimmy because they are positive something is wrong. Other families are demanding. They think that because their child is in the hospital, so are they. They want meals, blankets, pillows, and expect you to supply them with Tylenol for their headaches and money for transportation home.
In peds, everything is tiny. Those veins you have to stick on an adult? 1/4 the size on a young child. Those urethra's it's so hard to find when cathing little old ladies? Microscopic on a newborn baby girl.
Peds nurses don't just have to know standard adult doses (650 mg of Tylenol), but we have to know mg/kg dosages as well. And we have to be able to calculate them quickly in order to catch a mistake in an order and prevent an unsafe dose.
Giving medications? 95% of your adult population will be more than happy to swallow their pain pill, or all 20 of their medications in one gulp. In peds, you're trying to convince a stubborn three year old to open their mouth so you can get the syringe of medication in them. They cry and kick and fight and more times then not they end up with half the medication on them and half on you. Don't even try to convince a toddler that amoxicillin tastes like bubble gum. They know the difference.
Finally, accidents in peds can be just as big and messy as adults. Spend three hours with a two year old with explosive diarrhea. Change the diaper 6 times, change the bed linen four times, change your scrubs once, and give the child three baths. Trust me, you'll be begging for an adult who can tell you when they need to use the commode, even if they do need help wiping.
New to NICU here, SO for some of you this may not be too interesting. However saw a full gestation c-section, severe IUGR, 3 missing limbs, trisomy 18, anomaly of the airway, trachea had to be inserted while still attached to placenta, straight to oscillator, then Ecmo the following day. It was interesting learning experience from afar but sad at the same time. I feel honored to have had the experience to see the birth. Maybe as I become more seasoned I will have the opportunity to take those type of cases. Although, that was a rarity on my unit I hear.
Babies scream bloody murder when you take their temperature. Crying does not mean a baby is suffering. It IS a little prick. The prick itself takes a second. The baby is, as another poster said, more annoyed than anything else. They will typically stop crying as soon as you pick them up or give them a bottle.
I've seen my fair share of suffering children. Their suffering was caused by, oh, cancer, severe abuse/shaken baby syndrome and severe congenital malformations. Never by a simple heel stick.
And if you're still so angry about this 6 months after the fact that you feel the need to come on a nursing message board and yell at a bunch of nurses who never took care of your child, well then perhaps you need to speak to a professional who can help you work through this.
I've never worked peds and I've never been a parent. But I have been at the bedside for nearly 37 years, and I've noticed that not all visitors are good advocates for the patient -- and some of them are too self-involved to be ANY sort of advocate. Some are, in fact, detrimental to the patient. It is for those visitors you have restrictions in place. I cannot imagine that people become any more selfless, intelligent or even common sensical just because the patient is a child.
When I hear nurses talk about visitor restriction it makes me want to pull my hair out...especially in pediatrics!!! There are times when you have to escort the parents from the room when you are doing an invasive procedure (lines, drains, etc) but during routine care they should be encouraged to stay!!! They are the advocate for their child! Patient safety is inhibited when you do not allow the parent at the bedside not when they are at the bedside. That way of thinking should be left in the 20th century...
I've thought about these nurses so much during the past several weeks. You have our love and concern. Thank you for all you do. Take time for yourselves and know that you have so much love and support coming in from all over the US and beyond.
Hopefully the hospital has provided the staff with debriefings and counseling.
I am guessing you are all referring to the CA case. Family claims insurance is still paying. No one can refute due to privacy laws and parent won't consent to disclosure.
This thread reminds me of an experience I had in college. My clinical instructor sent me to the MICU for the day. The nurse I was assigned to was caring for a man- relatively young, 40s or 50s, with end stage multiple myeloma. He was a full code, intubated, NG tube, foley, rectal tube, cental line, tube in basically every orifice of the human body. On the front of his chart was a document labeled "living will."
1. I do not wish for CPR to be performed
2. I do not wish to remain on a ventilator for a prolonged period of time
3. I do not wish for artificial nutrition via a feeding tube
His siblings were his next of kin as he was a life-long bachelor. Despite these written wishes, they insisted that he would "want everything done." He didn't want everything done. He had end stage cancer and he knew it. He wanted to be allowed to go peacefully.
This happened 8 years ago and it bothers me when I think of it to this day. If my family ever did that to me, I'd haunt the hell out of them once I finally broke free of my body (and I've told them as much).
Here's a great article about what happens in the situation where the patient's wishes are not followed:
The patient described in the OP had a good outcome. We are all going to die. She decided she was ready. Given all that was going on with her, she was going to die either way. She decided she wanted no more suffering before the inevitable.
I wanted to add a few thoughts to the discussion...
First, "terminal weans" and/or hospice care are NOT euthanasia. The line is difficult for those outside the field to see, but for starters, you can research the "principle of double effect." We give medications that have the possibility to somewhat hasten death, but it is not our intent to do so. In this case, motive has a great deal to do with it. If a COPD hospice (DNR-CC) patient is short of breath and nearing death, I will give morphine (as ordered by the MD) without hesitation to relieve their suffering. Morphine is a narcotic, a vasodilator, and also acts on the sensory cortex to relieve the sensation of dyspnea (shortness of breath). As such, morphine helps with pain AND breathing.
For what it's worth, nurses who may seem "unfazed" to the casual observer are not necessarily heartless. Rather, nurses must "be" what the family and pt. need them to be. I am often moved by many of the situations and patients I encounter, but if I - the caregiver - am sobbing, how does that help the family? This is not to say that I have never shed a tear, but as a whole, I must be the emotional support for the family and patient.
Lastly, you commented that it was hard for you to understand how this lady could "sign her life away." However, you mentioned she was on a vent, on dialysis, and had a wound vac. The devil is in the details here. If you have witnessed the violent reaction of anyone who is endotracheally suctioned, you have an idea that this is very uncomfortable. Hemodialysis - likewise - is a horrendously uncomfortable, time-consuming, and restrictive process. Patients are poked - several times a week - with a large-bore needle to access their dialysis site. For hours (pretty much an entire day), they are connected to machinery. When their blood is cleaned of its toxins, they are helped temporarily, but the vast change in their system's equilibrium causes them to feel exhausted. So they bounce back and forth between feeling crummy because they need dialysis and feeling crummy because they got it. The wound vac is another discomfort. I don't know the nature of this lady's wound, but typically vacs are reserved for those long-standing wounds that just won't heal any other way. The wound might be infected, or chronic, or smelly...or all of the above. Each vac change - which is typically several times a week - involves peeling off an adhered dressing, applying and/or packing in a new one, and connecting it back to suction. All of this is frequently significantly uncomfortable. Not to mention the times when the wound vac starts beeping in the middle of the night because it is clogged, or loses suction, and requires an urgent dressing change. Put all of this together (and much more that we likely don't know), and I can absolutely see why the patient might decide to enjoy a short, blissful time of not being poked and prodded.
I hope that you will look into hospice/palliative care some more, as I am very passionate about the need for this field. But even if you never do, and even if you never work in this area, I hope that you can recognize that each patient has a right to determine what treatment they receive...even if that's no treatment at all. We must advocate for patients' decisions, even if we don't agree with them or understand them. I hope this information gives you a bit of an idea on why some patients and families choose hospice and palliative care.
Yes,they can breathe on their own(some can) but if they were left off the vent and 02 for 2.5 hrs longer,then they would die.
I'm sorry if I sound like an idiot,but I don't understand,seeing as I take care of kids in similiar situations.
The boy I described earlier only had an EEG;parents won't consent to other tests.
His pupils also don't react when light is shown into them.
Their religion also states that death occurs after the heart stops beating.
((HUGS))...it is never easy to see these things but as a nurse you will find that there are worse things than death.
There was a time that we were not allowed to removed "alert" patients from life support. We would torture these poor patients until they became so swollen that their skin oozed serosanguinous fluid continuously and their eyes would become so edematous that they would ooze from their sockets and the patients eyes would not close. They were trapped in a living hell. Torture for the family as well as the patients when there was no hope for recovery.
As a nurse when you care for these patients day in and day out it is sometimes a relief to allow nature to take it's course especially if it is the patients wish. It is a relief to finally know that their suffering will finally end and they will finally know peace. In the presence of terminal illness and medical intervention has reached and end point and there is not cure....the best thing to do is let go. To keep torturing these poor patients day in and day out when you KNOW your efforts are futile and will NOT change their outcome it draining.
The vials of morphine were not to end her life but to make her passing comfortable. In no way did the nurses give her morphine to hurt her...but they did make her comfortable and ease her suffering. Nurses will find relief that a patient's pain and suffering is ending especially when we care about them...they will use pet terms and phrases that ease their own discomfort and pain as they reach to their peers for affirmation that everything is ok.
The reality of nursing is that their are worse things than death. To allow a patient to reach their own decision and take control of their destiny is a beautiful thing. For many years we tortured patients and families..... knowing the end and charge the family thousands of dollars for what we all knew would be death.
While nurses seem chipper and normal...it is called professionalism. We still have a job to do and will cry later in our cars on the way home. You cannot fall apart and leave the family without support....it is your job to help the patient and family at this difficult time. YOU are the rock and support...it is your job.
Nursing is a tough job. You have to be strong enough...nursing isn't for the faint of heart.
It will all make sense someday.....((HUGS))
If the patient is deemed competent and wants to give up the fight, they have the right to make that choice.
Terminal weans usually get enough Morphine to be out of it, but usually not enough to cause the death itself. I've seen orders written "titrate to effect" essentially meaning give enough until they aren't breathing anymore, but most nurses aren't that cruel and we usually just give enough to keep them comfortable, maybe a little under the weather, and time will take its toll.
Nurses doing terminal weans appear chipper because it's a sad situation. If you walk in to the patient's room looking all gloomy, the family sees that and they get even more down about things. Appearing happy and friendly, to a certain degree, actually makes the whole process easier for the family.
If you can't stand watching patient's die when they choose to, nursing might not be the career for you, or at least the hospital setting. It's even worse watching people die who did not choose to. Often you'll see patient's needlessly clinging to life because of some insane family member. They have 90 bed sores, no mental function, lungs/heart/kidneys/liver all completely shot, yet the family won't let go; that's tougher to watch than someone sound of mind choosing to go out with dignity.
We've all met this type of mom before. It's 2330, her 8 year old daughter is struggling to breathe, and you know for a fact you saw them two weeks ago for the same thing. You also know for a fact you gave her a prescription for an inhaler, a follow-up appointment with a pediatrician for asthma, and got the information for applying for state aid for medical assistance. Yet, there they are, the child anxious and pale, the mother unable to make eye-contact and answering in quiet, short statements.
A little eye-rolling as you walk into the room helps you keep your tongue civil during the H&P. Definitely an asthma attack, the kind you had educated this mom about avoiding and preventing two weeks ago. You sigh in frustration (and a wee bit of anger) without realizing it, but the mother does. She shrinks a little more in the chair, stares at the floor at little harder, and tightens her hand around her daughter's hand. Her behavior sets your teeth on edge, and you hurry out of the room so you don't say anything you think will get yourself in trouble later.
As you head down the hall to let the on-call know that FF#3 is waiting for a neb, you shake your head that just about anyone can have kids nowadays, and wonder at that mom's gall to come in and be so diffident when it is clearly her fault that child is having another attack. You make sure to share your opinion with the nurses at the station. Venting helps.
Meanwhile in that room, a very anxious mother, who is struggling with an Atlas-sized load of guilt, tries to sooth her anxious child while they both wait uncomfortably for the doctor. Mom knows what you think of her. You aren't as unbiased and neutral as you thought. She can't tell you why they are here on a cold snowy night, at least not straight out, and you didn't ask.
She can't tell you that her husband has threatened to kill her and the daughter on numerous occasions if she ever thought about leaving him.
She can't tell you that he broke two ribs and tore out a chunk of her hair the size of a golf-ball when she tried saving up money for the daughter's birthday presents. He needed that money, there was beer to be bought.
She can't tell you that he disabled her car four times in the past two weeks while he was out drinking, and one of those times fell squarely on the day of the child's appointment.
She can't tell you that he routinely takes all of the money out of her purse, and she can barely feed her daughter, let alone get medication for her.
She can't tell you that he's a twice convicted felon, and because he won't leave, and won't let her leave, she can't get federal or state aid, because one of those felonies involved drugs.
She can't tell you these things, because he's out in the car, partially drunk, with a gun hidden under the seat, and if she takes what he thinks is too long, this might be the night he uses it.
So she hides. She does what she can, and tries to keep her daughter and herself alive. She takes all of your judgement and frustration and internalizes it, reinforces her belief that she is a horrible person, a horrible mother, and deserves every little bit of scorn and distaste heaped upon her. She knows all this, and yet she brought the daughter to the ER anyways, knowing that you will still care for the daughter, even if you hate the mother. She trusts in your care, your skill, and your oath to care for the ill. She pays you in nickles, dimes, and her self-esteem.
She might not have been able to tell you, and you didn't ask.
Sometimes when we can't get sats on the extremities we'll wrap the probe on an earlobe...or penis if one is available! If you can't get a sat in the diaper though you're not likely to get one anywhere else...
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