very badly behaved ped client

[anon456]

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?

[klone, MSN, RN]

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.

Yes, this is kind of what I was thinking in my mind, but couldn't put into words.

OP, I'm sorry if I was rude or curt in my first post.

As the parent of two special needs kiddos, it just struck a chord with me, and hurts my heart to think that other people might be judging their behavior.

And with my youngest the same age as the child in your post, it's hard for me not to personalize it, and I just can't imagine the devastation that family must be feeling to know their baby has a terminal illness.

[anon456, BSN, RN]

Thanks so much for your input! :-) I really appreciate hearing the good and the bad. I'm still very new to this-- and like I said I don't want to peds. It takes a special gift and I know I don't have that gift, at least not yet. I really love working with adults, esp. the elderly ones.

[PostOpPrincess, BSN, RN]

The child is craving limits. She needs to feel secure, and no one is doing it for her. Poor thing.

[RedhairedNurse, BSN, RN]

Thank you for asking this question and starting this thread. It has been very interesting reading the responses.

Also, I was reading articles on the internet pertaining to illness in children and came upon this website, thought I'd post it.

Signs of stress up to 5 years old:

Young children can't often tell you that they are feeling stressed. Their behaviour, however, can revel their level of stress.

Infants, toddlers, and preschool children demonstrate stress by clinging to a parent, crying more than usual, having temper tantrums, displaying regressive behaviours (thumb sucking, bedwetting, fear of the dark, etc.), rocking, biting, and having toilet accidents. Crying, temper tantrums, and wakefulness at night can also be a normal response to a developmental stage. Children often can be frustrated when learning to stand, talk, or master other developmental learning. They will cry more for a few days and then return to their usual personalities. If this persists, it may be a sign of stress.

Signs of Stress in Children - Relaxation Expert (UK)

[MisterSimba, BSN]

"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?"

I don't see how the OP is being judgmental. I've worked with children for over ten years, including preschoolers, and I think it's important to set limits and to ask for good manners. I actually want to be a pediatric oncology nurse, so balancing my experience working with healthy children with caring for sick ones should be an interesting learning experience...

With regard to the child demanding her father's attention when he was talking to the doctor, I think I would try to distract the child (ex. a new toy or video from the playroom, stickers, etc.) but I would also nicely tell her that it's not ok to throw things. As for the growling, I'd say something along the lines of "Doggies growl, but not little girls. Can you use your words so I know what you need?"

Modeling good manners doesn't hurt either: "Thank you for being so good and letting me listen to your lungs!" or "Please don't throw food at the doctor. He just needs to talk to your dad for a little bit. Daddy will be done talking to him soon. Do you want to color/read a story/blow bubbles/put together a puzzle until he's done?"

[ChristaRN]

I work with alot of kids with cancer in my job; they are among my favorite patients actually. We have all kinds of personalities in those kids from the kids who are nothing but sweet and loving to us to those who whine and yell when they see us and everything in between. Many parents ARE NOT hesitant to correct their child if they are blatantly mean to a nurse (MEAN, not just trying to interrupt) but rarely are they mean. I don't know, but after watching a child get so sick from their chemo that they can't keep their face out of a bucket or having mouth sores so bad from that same chemo that they can't bare to take a sip of water I just can't get mad at these kids no matter what. They endure pain no child ever should and I will put up with pretty much anything from these little innocents. I may be an adult but I can pretty comfortably say that I don't think I would handle what those kids go through half as well as they do! Those kids are my heart and MY HEROES! :heartbeat

[tencat]

I work with alot of kids with cancer in my job; they are among my favorite patients actually. We have all kinds of personalities in those kids from the kids who are nothing but sweet and loving to us to those who whine and yell when they see us and everything in between. Many parents ARE NOT hesitant to correct their child if they are blatantly mean to a nurse (MEAN, not just trying to interrupt) but rarely are they mean. I don't know, but after watching a child get so sick from their chemo that they can't keep their face out of a bucket or having mouth sores so bad from that same chemo that they can't bare to take a sip of water I just can't get mad at these kids no matter what. They endure pain no child ever should and I will put up with pretty much anything from these little innocents. I may be an adult but I can pretty comfortably say that I don't think I would handle what those kids go through half as well as they do! Those kids are my heart and MY HEROES! :heartbeat

God Bless you! I don't have enough faith to do the work you do.

[FLAtoNYC]

Just a thought... many of the leukemia protocols include high doses of steriods in induction. This tends to make many of the kids extremely irritable, argumentative, and just plain difficult. I work in peds Onc and try to make my parents understand that this will pass and is an expected but unfortunate side effect of treatment. Add that to an overwhelmed family and a complete distruption of their normal routines... well you can imagine...

[BCgradnurse, MSN, RN, NP]

This is a tough situation. The poor child is sick and I'm sure both she and her parents feel that their lives are out of control. The child may be trying to gain back some control in the only way she knows how-by by being demanding. At her age, it's not on a conscious level, but it still makes it pretty difficult to work with her. I also believe that children need the security of limits, and it's ok to address her behavior in a way she can understand. If it doesn't work the first, second, fifth or sixth time, so be it. She will be hearing the message on some level. And OP, I don't think you're being judgmental at all. You asked a legitimate question because you wanted to understand and learn from the situation. That's how we become good nurses.

[nursel56]

Just a thought... many of the leukemia protocols include high doses of steriods in induction. This tends to make many of the kids extremely irritable, argumentative, and just plain difficult. I work in peds Onc and try to make my parents understand that this will pass and is an expected but unfortunate side effect of treatment. Add that to an overwhelmed family and a complete distruption of their normal routines... well you can imagine...

Definately agree with that one! Chemo, too much fluid in the belly, puking, not being able to go home when you want to. . .etc on a child not old enough or able to cope with it-- all of that.

My little brother had ALL and I worked at that peds hospital, as well. If ever there's a situation where you need to focus on a family dynamic as opposed to just the behavior of the child it's this one! The child's young age means that the family has had very little time to welcome and celebrate her birth and cope with/digest the overwhelming shock that the little being might die before she starts kindergarten. Many times that results in a lovely and well-meaning set of parents forgetting altogether to do those normal things we do to start the building blocks of discipline like saying "no" in a harsh manner and/or "no" to that toy after your child has had to endure yet one more painful procedure even though she didn't do anything to deserve it that you allowed to happen (and yes you feel guilty) because you want your child to live.

At some level you know that bribing your child with the promise of a toy to get him to settle down and calmly accept having pain inflicted on him isn't out of the "good parent" playbook. Normally at age 2-4 a child starts to learn he doesn't control the world. But normal times just don't apply when your child might not be with you for very much longer. Many times if the child has older siblings they are the opposite behavior wise.

If everyone's prayers are answered and the little boy or girl is in remission or well enough to go to school and interact with others the parents realize "oh my gosh we've got our work cut out for us!" in that department but it's almost like they've been underwater for two years and then pop up and start to look around.

[MisterSimba, BSN]

I work with alot of kids with cancer in my job; they are among my favorite patients actually. We have all kinds of personalities in those kids from the kids who are nothing but sweet and loving to us to those who whine and yell when they see us and everything in between. Many parents ARE NOT hesitant to correct their child if they are blatantly mean to a nurse (MEAN, not just trying to interrupt) but rarely are they mean. I don't know, but after watching a child get so sick from their chemo that they can't keep their face out of a bucket or having mouth sores so bad from that same chemo that they can't bare to take a sip of water I just can't get mad at these kids no matter what. They endure pain no child ever should and I will put up with pretty much anything from these little innocents. I may be an adult but I can pretty comfortably say that I don't think I would handle what those kids go through half as well as they do! Those kids are my heart and MY HEROES! :heartbeat

You are awesome! Sounds like you're an angel to these children and their families! :redpinkhe

I have to say, during my peds rotation, I helped take care of some pretty sick kids, and they were all really well behaved. Some of the adults I had in med-surg, not so much!

[sleepysnr]

the parents should have said something to the child.