Going from Adult ER to all populations ER

akulahawkRN, ADN, RN, EMT-P · Oct 17, 2014

Youngest kid I've started a line on was a 3 year old that was amazingly calm... due to drinking 1/2 bottle of Triaminic. I can certainly say that the little guy definitely had great veins!

I'm a Paramedic, and now a (looking for work new grad) RN. Peds calls always had me on edge. I would suggest taking a PEPP course or something similar as a bit of a refresher about how to deal with peds assessments. PALS is OK but that mostly focuses on the code and peri-code situations. PEPP (at least for me) seemed better set up to at least give you an idea where to start with that population from a Field Provider standpoint. I pretty much always had a reference card with me so that I could look up their vitals and then all I'd have to do is try to remember the developmental milestones for each age... Though I must admit that it's easier if you've had a kid that pretty much hit all the norms on schedule for that "personal frame of reference" to compare other kids to.

If it's the same job as you posted about in the previous post... I hope you like it there! I had an instructor that was there for many, many years, pretty much from when it opened so very long ago.

Esme12, ASN, BSN, RN · Oct 17, 2014

.get the enpc course book and read it. pediatrics is a specialty 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

OldDude · Oct 17, 2014

I've only dealt with pediatrics. Don't know a darn thing about grown ups. To me....the most important assessment tool in the pediatric population is heart rate. If you have a normal heart rate for the age and the child is awake and alert, they are in no immediate serious physical condition. You'll see elevated pulse rates in cases such as with fever or increased respiratory effort. There will be increased pulse rates with emotional input like crying or pain but you can correlate the two. Otherwise experience will fill in the gaps; like the only way to start an IV on a 4 week old or obtain a urine cath specimen on newborn female is to do it. As a new grad I went straight into the ER. I learned more from the ER tech about IVs and caths than I did from the nurse educators!! Enjoy the little ones. They give accurate histories and don't have any agenda other than wanting to feel better.

foragreatergood · Oct 17, 2014

As stated above - listen to the parents.

The ENCP course is very helpful - applies a systematic approach to assessing how sick a child is, first from a glance, then hands on. The biggest challenge with peds in ER is usually the parents - its like you have 3 patients, not one.

Often the first intervention with infants and young children that appear very sick the second you lay eyes on them - O2.

I would also know where you peds stuff is. Is there a Braslow cart in your dept? As I prepare my rooms for the day I ask myself - if a parent runs in with a seizing/ not breathing child right now what do I need and where is it? A sick baby is scary - and running around looking for pedi electrodes, a tiny 02 mask or calculating a peds adenosine dose makes it worse.

You don't have to be perfect at starting lines in a baby, or even knowledgeable in all the common peds illness, but know where peds equipment is and who your resources are.

All that being said - most kids come in with minor complaints that can be managed without needing an IV. Whew!

Good Luck!

allnurses Guide · Oct 18, 2014

Great advice so far.

Also, remember to talk to the kid directly. Kids hate being talked over as though they can't hear you. Even toddlers can point to where it hurts. If they are shy I ask a series of "silly questions", such as "does your left little hurt? does it hurt over here (point to an elbow), they often giggle a little and say no, so when I get to where it does hurt, the kid will answer yes appropriately.

Editorial Team / Moderator · Oct 20, 2014

I just recerted ENPC, and it is fabulous. It uses the same orderly approach as TNCC.

Our peds visits make up about 50% of our ED population (seriously), so I am glad to have my CPEN. I studied for the CPEN with my PALS book, ENPC book, and I also used Scott DeBoer's CPEN prep book, which is a fabulous resource in itself: https://www.amazon.com/dp/1450782051

Make yourself a little chart of typical vitals to keep with your badge. And always involve the parents, especially when the kiddo has a chronic illness or condition. I have learned so much from the parents over the years!

PedsED-RN · Oct 20, 2014

For initial overall assessment, pay attention to what the kid is doing in the waiting room before you call their name. Young kiddos may be playing around, jumping off the furniture, but once they are in a room are ****** and want to leave, so will be fussy/uncooperative, etc. older kids may be dramatic and exaggerate a bit (especially girls around 13ish) =). But if they are sitting comfortably playing on a phone when they don't know you are looking, that is a good sign. =)

Everything posted so far is great, ENPC is an awesome resource. Just get in as many assessments you can to get the hang of differentiating lung sounds (upper airway gunk will sound like coorifice lungs since they are small all sounds refer throughout). PIVs you will just have to buy the bullet and get a few under your belt to gain confidence. And know that even those of us that only take care of kids still have off day and miss a vein for some unexplained reason even when it seemed like an easy bet. =)

if you ever have questions, I'm happy to help! Good luck, kids are fun!