Adult ER nurse....advice on Pedi patients

Esme12, ASN, BSN, RN · Jun 14, 2012

wow......get the enpc course book and read it. pediatrics is a speciality all it's own. their airways are different....smaller and structurally....they can eat and breathe. remember that 1mm of swelling on an adult airway that is 5mm wide is completely than 1mm of swelling on a 1mm airway. vital signs are not a predictor of how sick a kid is for they can compensate forever and by the time they reflect it in their vitals....they are in critical trouble. the cap refill/urine output is a great indicator on the younger pedi population as an indicator of distress and end organ perfusion.

so when did they last pee and how many wet diapers in x amy of time is huge!!!! using accessory muscle is a huge sign of distress.

they need fluid, o2, and keep them warm. a crying and screaming kid is a stable kid....it's the quiet ones that will/should scare you. if the child has a congenital/chronic illness listen to the parent.....they have done this before and can help you.

rhythms for kids....slow, fast, and absent. familiarize yourself with the normal vital signs for the age group!

infants....was the baby full term, what was birth weight, weigh all babies regardless of what the parents say...emphasize how important it is as that is how the medicines are given. small mistakes have huge consequences for the pedi population. if they are small so should the dose be as all doses are weight based.

the enpc (emergency nursing peds course) has a terrific pets triage standard that should be used by all eds.

ciiamppedds: c is chief complaint, i is immunizations, i is isolation (has the child been exposed to any communicable diseases), a is allergies, m is medications,p is past medical history, p is parents impression of the child's condition, e is the event surrounding the illness or injury, d is diet, d is diapers (voids) and s is signs and symptoms

great power point triage assessment

http://webmedia.unmc.edu/bioprepare/2010symposia/goesch-pediatric%20triage.pdf

[TABLE]

[TR]

[TD=align: left]age group[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]respirations[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]heart rate[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]systolic blood pressure[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]newborn[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]30-50[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]120-160[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]50-70[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]infant (1-12 mo)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]20-30[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]80-140[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]70-100[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]toddler (1-3 y)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]20-30[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]80-130[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]80-110[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]preschooler (3-5 y)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]20-30[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]80-120[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]80-110[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]school age (6-12y)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]18-25[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]70-110[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]85-120[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]adolescent (13y +)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]12-20[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]55-110[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]100-120[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]adult[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]16-20[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left] 70-100[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]

[/TR]

[/TABLE]

triage course - nursing continuing education (ce) - nurse ce - ceufast.com

pews.....the pediatric early warning (pew) score system can help nurses assess pediatric patients objectively using vital signs in the pediatric intensive care unit. the scoring system takes into account the child's behavior, as well as cardiovascular and respiratory symptoms.

ahrq innovations exchange | pediatric early warning (pew) score system

this is another great assessment tool for assessment short and sweet but informative.

http://www.ucdenver.edu/academics/colleges/nursing/documents/pdf/sim_pews_tch.pdf

danggirl · Jun 14, 2012

@esme12: Awesome! Thank you so much! I really appreciate this information. You just saved me a ton of time and stress!

emtb2rn, BSN, RN, EMT-B · Jun 14, 2012

Agree with esme. enpc skills can help you identify pedi issues in time to not have to use your pals skills.

Loud baby good baby.

VickyRN, MSN, DNP, RN · Jun 14, 2012

AWESOME post, Esme12! I am going to make a copy of your post to hang in my ER.

Altra, BSN, RN · Jun 14, 2012

Wow, it's a rare ED that does not see kids.

Like most other things, the only way to improve is to keep at it. Seek out the pedi patients when they come in, and if there is another nurse in your ED with prior peds experience, attach yourself to him/her when they assess a pediatric patient. The vital sign reference that Esme12 will be a great help.

Esme12, ASN, BSN, RN · Jun 14, 2012

Thanks..... But.....Please Correct the typo...."Amt of time" not "Amy of time". My teenagers were arguing about breathing each other's air when I was typing... :lol2: .

Way back when dinosaurs walked the earth....we did treat them like "miniature adults" are we were wrong. When we learned better we did better....Peds has always been a focus of mine to make ED nurses unafraid (in non ped academic environments) to care for those kids.

It's actually simple if you know what to look for and learn what and how to intervene. I remember the day I had that epiphany in 1988 at the first PALS course I ever took and then became an instructor and danced with JOY at the ENPC for it directly addresses....catching the signs before the coded.

It started right after I graduated Nursing school. I was the "charge" on nights 2 months after graduating with an LPN on a small community peds unit. A frequent flyer trached CP/CF child was once again in the hospital, after a sequale of events, coded and died.

When I called that code and all those "smart people" came I swore I would never be that uneducated again...I wanted to be them. It sent me to critical care and the ED. I spent all my time and energy learning to be the best I could be.

I LOVE teaching and sharing what I have learned.

Besides. at they end of the day you get to cuddle them, kiss them to make their boo boo's better, and I like that.

FlyingScot, RN · Jun 14, 2012

Cannot stress enough that BP is the LAST indicator of a child in trouble. If it's dropping then you'd better intervene and quickly!!!! Kids rarely cardiac arrest (unless they have some congenital issue but even then it's usually something else). They will respiratory arrest. The moral of this story is that assessment of the respiratory status of a sick child is absolutely critical in preventing a disaster. Slight retractions, while never normal, means watch closely but don't panic yet. Retractions with nasal flaring means bring the emergency respiratory equipment in or near the room. Grunting is an ominous sign of impending respiratory failure which can quickly be followed by cardiac failure. Fix the respiratory issue and you will likely head off the cardiac issue. Broselow tapes are your friend. You cannot adequately monitor an infant swaddled in blankets. Get an overbed warmer and unwrap the baby. Don't be afraid of scalp veins in infants under 12 months. They are easy to get in an emergency and while they freak the parents out the child usually doesn't care. I'm going to try to find some youtube videos of kids in crisis for you.

Kidrn911 · Jun 14, 2012

[color=#b22222]i was in the opposite predictament, i have 8 years experience in a pediatric er with 6 being in a level 1 trauma center. i just passed up a good job in an adult er, adults annoy me, and frankly i don't like their drama. i don't even know half the adult drugs and doses anymore. i took a lower paid position in another pediatric er.

i suggested you read the enpc, pals book. what are you scared of, them coding or just doing basic care?

coding is simple insure your hospital will have a separate pediatric crash cart. on the cart have a binder with the emergency drugs already calculated out per every 0.5kg and up to 50 kg. use a broslow tape for quick weights.

danggirl · Jun 15, 2012

Actually I'm not afraid of them coding; I feel pretty confident administering care during crisis situations. Guess I'm just afraid of basic care (i.e. I was supposed to do a heel stick to obtain blood....um...huh? lol!) and assessment: fear comes from lack of knowledge and experience so...Thank you all for the great posts and information. I strongly dislike being uneducated in certain areas and that is a huge motivator for me to learn as much as I can in order to give the best care and promote the most positive outcomes. Don't think I'll ever be a "pedi nurse" despite the fact that many adults actively hinder their care...I've learned to always listen and then ask "What's the REAL story?" Anyway, thanks again all. I appreciate the advice.

FlyingScot, RN · Jun 15, 2012

Actually I'm not afraid of them coding; I feel pretty confident administering care during crisis situations. Guess I'm just afraid of basic care

That's understandable but a lot of the advice, including mine, are the basic things you need to know to prevent a code. As somebody stated earlier. The margin for error is much smaller. If you have specific questions why don't you go ahead and post them and then we can deal directly with the details you are fuzzy on.

Altra, BSN, RN · Jun 15, 2012

In my experience, nurses unfamiliar with pediatric patients are sometimes just as freaked out by more routine pedi presentations as they are by the prospect of dealing with a really sick kiddo in crisis.

OP - suggest you ask your preceptor or educator or other staff how common pedi situations are handled in your ER.

1. Fevers in kids > 6 months old: is your group of docs aggressive? Do they order labs and urine specimens on virtually every patient who is febrile? Do they insist on straight cath urine specimens or are u-bag collections acceptable?

2. Beads and other misc. items up the nose. (just an aside -- this was my brother's specialty when we were growing up -- we have an endless supply of family stories related to this)

3. What is your docs' approach to otitis media?

4. The art of administering oral meds with a syringe.

5. The art of holding thrashing kiddos (of various sizes) securely. (hint: you might consider taking off shoes)

6. The art of recognizing in a snap which parents are going to be helpful in holding during a procedure, which are going to be passive but make you out to be the bad guy, and which are going to freak out themselves to such an extent that things are going to be 12 times more difficult.