Help with Peds pts in ER

[mysticalwaters1]

Hey everyone! I've moved to my ER department and was wondering if anyone had pointers on how to interact and do nursing procedures on infants and peds pts. Here are several of my concerns and if anyone else has pointers please add on, mainly a lot of it is how to position children to do what you have to do:

1. How to give medicine to infants and toddlers? I usually have a needless syringe and try to stick it in and try to put it to the back of the mouth on one side by a cheek. I thought it would force children to swallow it but many times doing this the child still spits most of it out so what do you guys do?

2. How do you get throat swabs of kids that are not cooperating? If they are screaming I usually can do it but occasionally some I start to go in and they shut their mouth. One doctor held a finger by the jaw on either side of the face.

3. How do you position infants and peds pts for ivs and im.

4. How do you use arm boards for ivs. One peds nurse told me she got annoyed when an elbow guard was on a childs wrist b/c it's suppose to be the elbow to immobilize the arm. So I thought of that but then I had a 2 year old with the iv in a wrist. Even if I used the guard on the elbow she could still use the wrist. I put it on the wrist but should I have used a guard for each area to immobilize it? Or is that more for infants?

Any other pointers especially concerns peds nurses have that ER nurses should do would be helpful and appreciated! I already know to use smaller volume IV solution bags and microdrip tubing I use I believe it's called a butreol container with IV tubing, and don't sacrifice an iv line to get blood.

[babynurselsa, RN]

Many times I will have the parents admin oral meds. The child will typically take them better from the parents than a stranger. Another tip is to provide gentle support to the jaw. If the child is old enough to understand I bring juice along as a chaser.

I typically will use a sheet to swaddle all but the appendage I need for the iv start. THis means less flailing parts to help you with the insertion. A hand behind the elbow or on top of the Knee to "lock" the joint into extension minimalizes movement.

I very rarely, if ever, utilize arem boards. they are just another source of aggravation to an already sick, grumpy little one. I ALWAYS loop back my extension set and tape it so that no direct tension can be pulled on the iv catherer.

Always try to take your time, appear relaxed and friendly (stickers don't hurt).

This reduces apprehension. I spend time chit chatting with the little ones before and while performing any procedure, a little distraction goes a loooooong way. I talk to them aboiut pets, school, the next holiday, just whatever. Or with tiny ones just babble.

Hope this helps.

Good luck

[BSNtobe2009]

I'm not a nurse, but a mom, and with oral meds, if the medication injected in their mouth is more than they 'feel' they can swallow, they will spit it back out. Anything more than 1/2 tsp, they will spit it out if it's put in at once.

Most of the meds for kids tastes pretty good, so I put the syringe in my daughter's cheek, and in about 3 squirts it's gone. I think putting the syringe toward the back of their throat will cause them to choke...I was sitting here typing and it's almost impossible to swallow and not touch your tongue to the roof of your mouth...so if the syringe is in the mouth toward the back of the throat, that may be another reason you are getting it spit back out b/c their instinct is that they will choke on it.

Once I had a med that tasted horrible, so what I did was sit her up, hold her nose, and squirted it in her cheek...this forced her to swallow it. I also had a bottle ready so she could get that nasty taste out of her mouth.

[mommy2boys]

Not a nurse yet, but a mom to 2 boys. With my 2nd son he was admitted to the hospital for phemonia (sp) @10 months. When they started the IV they wraped him snuggly in a sheet w/ only his foot out to place the IV. When they tested him for RSV he stayed in the sheet while they did the test.

I can't help you with the swabing, but for the meds the nurse would place the syringe in between his check and gums and slowly administer the meds. The thing that our nurse did for my son to make him comfortable was to let him check her out before or after she checked him out. (ie listening to his chest, taking his temp, etc) It made it less tramatic for him and he was actually looking forward to "doctor" time.

If all else fails, try stickers or toys. Kids love stickers, band-aids (even when they don't have a boo-boo), or cheap toys.

[navynurse06]

As far as the meds go...I usually let the parents do it or at least hold the child while I swirt in in the side of the cheek than I squeeze the cheeks together before they get the chance to spit it back at me. (its kind of hard to explain online). Sometimes this doesn't always work.

I can't help you with the throat swabs we don't do that many in in pt setting...usually you guys in the ER take care of that!

Ok I have a big issue with how most of the people in our er dress the IVS. We usually always have to redo them. We always use arm boards...it might be irriating to the kid but at least we dont lost the iv...

Then we put the immobilizer over that for the smaller kids that way they can't pick at it. (sorry for the bad spelling!) Also, I hate it when an IV is wrapped with a bunch of kurlex...I hate having to unwrap all that crap so I can see the site. Its just a big mess when you cover the site with Kurlex! Be kind the inpt ward and don't but anything but a tegaderm over where the cannual is going in. I hate having to undress sites so I I see them...it takes the risk of losing a line in the kids. We try to min. the amt of sticks they get. We also used what is called bumper guards (just rolled up 2x2) on the each side of the cannual, but not over it!

As stated before, the best way to hold down a little wiggle worm is to wrap them up in a sheet with whatever limb sticking out that you are working on. It usually takes at least 2 people to hold a little one still for IVs and labs.

The biggest thing with kids is to get down on the same level as them and talk to them not at them or around them. Try to break the ice with them before you start doing a bunch of crap to them! Stickers/toys/prizes are always good ways to be forgiven for the bad stuff you have to do to the kids. Also, do the least invasive thing 1st then most invasive last.

Also, at my hospital if the er is having a hard time getting blood or a line on a kid they call us or the picu/nicu for help. We would rather you do that than poke the kid a million times and ruin any chance we have in getting a line!

Good luck with you peds pts!

[rnsrgr8t]

Here is some suggestions...

1) as far as meds, having the parents give it is a good suggestion, but if you can't do that for whatever reason... the key to getting the meds down, is aiming to the side and back of the mouth and doing small amounts at a time. If you do too much, they will gag esp. if it tastes bad. Make sure they swallow before you give them more, if you are not sure, gently blowing in their face will get them to swallow.

2) For throat cultures, I used to tell kids I was going to "tickle their throat" that made them a little more willing to open up. Second, I would have them sit facing you in the parent's lap. Have Mom use one arm to reach around and gently hold their hands and use the other to gently hold the forehead (like they are feeling for fever) and rest the child's back of their head against their chest. A tongue depressor (although I always tried not to use one) can help keep a kid from clamping down. If they were really throwing a fit, I layed them on the table, had the parents hold the arms up over their head (so the elbows were at the ears) and I would get it that way (cannot move their head that way). If all else fails, you can hold their nose. I often would try and slip a tongue depressor in and wiggle it a little, usually that was enough to open their mouths.

For anything, always try the path of least resistance first, most kids respond well to that. Good Luck!

[Gompers, BSN, RN]

I can only help with infants as I work in the NICU...

To give oral meds to a young infant, you can mix the med with a half ounce or so of their formula or breastmilk. This way they won't choke on the thick, nasty-tasting medicine. If they are allowed to eat normally, give this half ounce of med-laden food first when they're hungry enough to suck it down before they know what's going on, then offer them a regular bottle as a chaser. If they are NPO except for meds, try putting a nipple in their mouth and squirting the med into it. Sucking is more natural for young infants than having the medicine just squirted into their mouths or cheeks.

To restrain an infant for IV placement, swaddle them up very tightly with only the extremity you plan to use exposed. If allowed, give them several dips of sucrose water on a pacifier a few minutes before hand to relax them, keep them sucking, and alleviate pain. Having another nurse hold the pacifier in and helping immobilize the extremity in question also helps a lot.

Armboards...it depends on the size of the child and where the IV is. If the IV is someplace like the wrist or elbow, then you really should use an armboard or splint because they will keep bending at that point which could cause the catheter to weaken, break, and cause an infiltrate. For longevity it's a good idea to use a board at these locations. If the IV is in the hand and the baby wants to keep playing with it, then you might need to do an elbow splint so they can't get it near their mouth or other hand.

[Snuffy]

As far as PO meds, I first explain to the parents what I'm going to do so that they are not shocked when they see it...I have the parent hold the child, I put the oral syringe in the cheek, give a small amount and then gently pinch the nose closed and purse the cheeks. Since real little ones are obligatory nose breathers, they will swallow the meds before breathing again, this also works with older kids too.

In terms of IV starts, a good holder is key! We usually use a papoose board or swaddle them in a sheet.

Most importatnly DO NOT lie to your peds pts! Nothing burns me more than a parent who tells their child "it won't hurt" as I'm preparing to start an IV. I am honest with them, but try to minimize the pain by comparing it to something they know, like a bug bite. RSV washes for kids are easy. Have someone hold the legs, over the knees. I usually try to make it a game, I tell them while they are laying down to stretch their hands above their heads, then I hold their straight arms against the side of the head on either side while my coworker does the wash. This nicely prevents them from turning their head from side to side and getting you covered with snot. And you can never praise kids too much, if they do a good job tell them that and kids love stickers! Cool cartoon band aids will heal all and make any child feel better.

After working with kids for a while, you will get a feel for what is normal for certain age groups and how they view things. (course it doesn't hurt to review the normal developmental stages either, if you can get a handle on those, you can pretty much plan your interactions with them). A lot of nurses who usually don't do peds are scared of peds pts. There's nothing to be scared of, and hey you get to do goofy stuff and nobody thinks you're nuts!!

[mysticalwaters1]

Thanks for all the helpful tips! I'm feeling more comfortable with the peds pts as I work with them more. It's refreshing than the constent 90 year olds I was used to working with! Even ivs are not as intimidating as it once was for me. It was baby night the last few times I worked! I'm finding getting just the right positions go a long way. And I think I was giving too much liquid meds at once to peds pts. I have no kids and not infant relatives so this is all new I appreciate all the input thanks!!!