I'm a nursing student, and I'm probably not going into peds. I have to write a journal entry about my experience in hem-onc last week, and I'm not sure if this is beyond my scope of duties or not . .
So I had this preschooler who had cancer. She had been very sick but was getting better, although she had a long road ahead of her. I felt sorry for her and her family-- I can't imagine how tough it must be. BUT this child was so incredibly rude, demanding, disruptive, and contrary. She would order everyone around and you could tell she enjoyed it-- it was not just that she didn't know about good manners. She growled at people if they tried to say something nice to her. She purposely ignored people. When a doctor was talking to the dad about some important info, she started calling to her dad because he was not for the moment focused on her. Totally normal preschool behavior. Dad said just a minute to her, and turned back to the doctor. She started calling "Hey!" to the doctor and he said let me talk to dad for a minute. She kept saying Hey, and then started throwing candy at him! And hit him in the belly a few times! Dad did nothing about it. Nurses tried to distract her but they were busy hanging a blood product. When nurses tried to assess her she would be very rude, complain about cold hands, etc. but then 2 minutes later would ask for an ice pack.
I know she's sick and all, but is it too much to ask for good manners? As a nurse is there much I can do or is this out of my scope of practice. I know if an adult treated me like this I would be having a nice talk with them about how I'm trying to help them, and would appreciate some respect (in a tactful way) because nurses should not take abuse from clients. But what about a child?
When I have a peds patient who is acting unruly, I try to get on their level and explain to them exactly what I am doing and why. I also let them know that no matter how they act at home, when they are in my office, their mom/dad is the boss and that they need to do what they are told.
But I don't work with terminally ill children either. Not right now at least. Most of the children I see are healthy and coming in for shots, so its understandable even in this case for them to be upset. I couldn't imagine how hard it would be to have a child who is dying, or sick with cancer. I think as a parent I would probably be pretty lax. As the nurse, I would do my best to let that child know what the boundaries are and what is acceptable and what isn't. Give them rewards when they behave. Bribery may not always be good, but when it comes to kids, it sure does work!
I have a treasure chest in my office for the kids to pick a toy out of after they get their shots. Its done wonders for some of my harder to manage kiddos.
I've had a few strong-willed children to take care of. It's hard to understand why they're like that- family situation, diagnosis, etc. But I can't expect every pt to be compliant, polite, sweet.
I had one little 3yo with ALL, neutropenic fever. I almost wish he was more interactive. But he wouldn't use words. Just groan/cry. Anytime I'd be in the room, he'd ignore me. And I am 100% okay with that. He didn't feel good and didn't want me there touching him/his line/forcing tylenol into his mouth.
Then, I had a 4yo girl with pneumonia, left alone all day, was throwing toys at MDs, me, and wouldn't let anyone listen to her lung sounds, would cover her face in blankets, and kick anytime I touched her. I let her decompress. I wasn't about to start a fight. I set up her breakfast, and kept her door open and checked in on her. Dad came back, and she was just as mad at him. It took encouragement/coaxing but eventually dad got her to settle down. It was a lot of negotiating, but we got he to comply with letting us listen to her lungs, flush her IV, hook her up to her med. She got herself plenty of stickers. :) She was upset, sick and tired of being there, just wanted to be left alone.
Now, in your case... if she was being so loud, etc, the MD and dad couldn't carry on a conversation, they could've stepped outside the room, or the doc could've actively engaged the pt. Try having another person engage her, sometimes you just have to find the right personality in someone else. And sometimes nothing works.
I never plan on having the sweetest little pts, and it's a treat when I do. And personally, I'd complain about cold hands as well!
I know she's sick and all, but is it too much to ask for good manners? As a nurse is there much I can do or is this out of my scope of practice. I know if an adult treated me like this I would be having a nice talk with them about how I'm trying to help them, and would appreciate some respect (in a tactful way) because nurses should not take abuse from clients. But what about a child?
You can say something, but it might not do any good, and her parents might not appreciate it much. Your patient might act out more than usual when she's not feeling well. You mention that the nurses were hanging blood products. Your patient might be more opinionated and stubborn than usual when her counts are low.
Adults understand the difference in the way their body feels when their counts are low, or they're developing a fever, or they're becoming septic... they may not understand which of these is happening, but they know something's wrong and are able to verbalize that. Pediatric patients can't. So, much like infants cry when they don't feel well, preschoolers react differently than usual. They may withdraw and become quiet, they may cry, or they may become obnoxious and loud. Your patient's father may understand that, and it could be that this is why he wasn't correcting his daughter; he may have seen this behavior from her before when she has been ill in the past.
As I parent I would love to think that my child would be well behaved under any circumstance yada-yada. However, being that she was preschool-aged I have to give the parents a free pass, I can't imagine how difficult it is for them to deal with their daughter's sickness.
This child has to go through what some adults can't cope with, so I think spoiling her isn't GREAT but I completely understand how and why it is happening. Perhaps if she makes it to an older age and level of maturity the parents might be able to explain things to her better.
This is where the stages of development concerning chronically ill peds patients comes in handy. (That's not meant as a cut to you...it's an effort to guide you in the right direction to help you understand the reasons why the child and the parents might be acting the way they are.)
Because the child is chronically ill, the parent-child relationship has been disrupted. The parents are acting in ways that they most likely would not if their child was healthy, so it follows that the child is too. Parents set the expectations for the child, and those expectations have been skewed because the parents are scared to death of losing that child. Routines, discipline, and expectations seem downright cruel to those parents. Deep down inside, they are saying to themselves, "If my kid has only X months to possibly live, why in the world would I want to spend any of that time punishing her for her behavior?"
What they don't understand (understandably) is that, regardless of the child's illness, that child is still developing and needs the guidance of the parents just as much, if not more than, a healthy child.
Practically speaking, as a student nurse, I'm not sure what you would have been able to do in this situation to address it holistically. That is better left to the primary nurse who has developed a relationship with the family over a long period of time. However, we (I'm a student too) can attend to the moment and try to distract the child so that the doctor and the parent can speak uninterrupted. Sometimes, even the little things we do can make a big difference in a difficult day of the parents and the child in the peds rotation.
Poor little angel, but at the same time children need boundaries. They do have personalities and know what they can get away with. It hurts to see children sick and even some of the best behaved act out at times.
It helps to really make it possible if the parent also agrees that the child should have boundaries and work alongside you to this common goal. It is an experience. My last few $0.01's.
i've run into that a few times where parents have a sick child and set no boundaries because they feel bad for their child. Unfortunately they don't understand that children crave routine and need to have limits set. Sure, it's okay to feel bad for a sick child, but thety're doing her no favors in learning how to assimilate into the real world once the illness has (hopefully) gone into remission.
If she were my patient I would have a discussion with her about how i am happy to take care of her and help her out, but that she needs to be polite and not throw things and so forth. Children that age often respond well if you turn the scenario around and ask them if they would like it if you were rude and yelled at them.
It was obvious to me that my previous patient's demeanor was because of, and encouraged by, her mother's refusal to set behavior limits. She would look you right in the eye and go into demand mode. It was quite obvious that she was aware that the mother would come running into the room to reinforce her daughter's unreasonable demands. Mom spoke about the possibility of the child being able to recover enough to assimilate into a regular classroom or play situation. My unspoken thoughts were, "What a rude awakening this self-centered and demanding little girl is in for".
Just FYI, I am a mother and I do have one child who was very sick and still lives with a chronic illness. We are very familiar with the hospital setting and endless appts, the stress of coordinating experts, home health, therapists and so on. And yet I tried very hard to make things as normal as possible for my child, while still giving allowance for feeling sick, scared, tired and so on. Even when my child was sick, it was not okay to hit or bite me or throw things at the doctor.
I have a classmate who worked with this same ped patient, and her child is very sick also (*very* seriously ill) and she also was put off by this child's behavior and how the parent did not seem to mind that their child was mistreating everyone. There is definitely room for a child to have frustration, fear, pain, and regression. Absolutely. But this child was shown no limits, absolutely none. I didn't expect dad to put her in the corner or anything like that, obviously, but it would have been nice if he had said, "(child), we don't talk to people like that, and we don't throw things at people. Let me listen to the doctor and then I'll do this craft with you." or whatever.
I guess this is one reason I am not going to do peds-- I don't feel "the calling" at all and I know I would have a harder time emotionally dealing with a lot that goes on. I enjoyed my time in Picu and hem/onc and learned a ton, but I'm glad the rotation is over.
I can usually not take things personally with patients, especially when they are feeling horrible and dealing with stress and all that. I have been thanked by several patients in the past for being so kind and patient with them, and a couple of them actually apologized to me about their behavior after I "killed them with kindness" so to speak and figured out they just needed to have someone listen. But this kid was totally running the show and was not shown any kind of limits at all. Even the experienced nurses were hinting about that when we were doing rounds, so I know it wasn't just me.
I just wonder how much of that peds nurse puts up with and where they draw the line. Obviously a preschooler, probably they just let it go. But what about a 10 year old, or a 14 year old? Where do you stop trying to be non-judgmental and compassionate, and start feeling like you are being verbally abused?
What they don't understand (understandably) is that, regardless of the child's illness, that child is still developing and needs the guidance of the parents just as much, if not more than, a healthy child.
Exactly. That's what I was trying to say but couldn't put my finger on it! :-) This child's needs for structure and guidance were not being met, and so I think she was forcing it and pushing until finally someone did set a boundary for her out of necessity for safety.
Specializes in Trauma Surgery, Nursing Management.
I think that Dudette stated very succinctly what the problem entails. This child has had a disruption in her normal development.
When I was working in Peds PACU, I could have written your post. I dealt with a lot of peds ca pts that acted out. They were totally out of control...but THAT is the point! They are terrified. What do we do as adults when we are scared? We try to take control of the situation. This girl has NO control over her situation when she is in the hospital/clinic/dr's office. She knows that some amount of pain is expected at each visit. YES, she is out of control. I feel for her.
But I agree with you as well when you pose the question "When is the behavior so unacceptable that we should speak up?" That is the million dollar question. I had no answer. I just gave the care to these pts that I was trained to give. There is nothing else you can do, really.
Specializes in Nurse Leader specializing in Labor & Delivery.
Exactly. That's what I was trying to say but couldn't put my finger on it! :-) This child's needs for structure and guidance were not being met, and so I think she was forcing it and pushing until finally someone did set a boundary for her out of necessity for safety.
You have to remember that you're seeing one tiny snapshot of this child's life/the parent's interaction with his child.
Dad did nothing about it. Nurses tried to distract her but they were busy hanging a blood product. When nurses tried to assess her she would be very rude, complain about cold hands, etc. but then 2 minutes later would ask for an ice pack.
PedsAtHeart, LPN
375 Posts
When I have a peds patient who is acting unruly, I try to get on their level and explain to them exactly what I am doing and why. I also let them know that no matter how they act at home, when they are in my office, their mom/dad is the boss and that they need to do what they are told.
But I don't work with terminally ill children either. Not right now at least. Most of the children I see are healthy and coming in for shots, so its understandable even in this case for them to be upset. I couldn't imagine how hard it would be to have a child who is dying, or sick with cancer. I think as a parent I would probably be pretty lax. As the nurse, I would do my best to let that child know what the boundaries are and what is acceptable and what isn't. Give them rewards when they behave. Bribery may not always be good, but when it comes to kids, it sure does work!
I have a treasure chest in my office for the kids to pick a toy out of after they get their shots. Its done wonders for some of my harder to manage kiddos.