How to "calm" down autistic pediatric patient?

[carti]

Picked up a part time "Private Duty" nursing gig where I'm basically a babysitter that gets paid like a nurse. All I do is give nebz, GI feedings, CPT vests periodically throughout the 12 hour shifts.

This job sounds pretty easy but the pediatric likes to pull on curtains, throw the remotes, sometimes "refuse" getting her diaper changed by kicking her legs, refuse to stay in bed at times, walk around while she is getting g-tube feedings (tubing can leak).

I feel like the only time I have to myself to "relax" is when she takes a nap or is extremely busy in her iPad. But when she isn't napping, or when her iPad eventually dies, her mind starts working 1000x fast.

I don't have any prior experience to working with autism kids. I know there is a vast spectrum but that's pretty much it. I was told my patient is a 6 year old old with the mind of a 2 year old by my case manager. Should I bring her a doll set? I even thought about buying a "charge while you use" ipad charger so the Ipad works the entire shift. Any ideas?

[Lunah, MSN, RN]

16 minutes ago, carti said:

It isn't my cup of tea but I really need this job so I'm going to stick it out. Besides, I was even offered more shifts because another day shift nurse already quit the case. The family is ran by a single mother (who is at work 24/7) and a bunch of the patients young siblings and little cousins so I can't really quit on the child.

I admire you for coming here and asking questions, and for being willing to continue there. That speaks volumes about you! ? I really hope you are able to have a positive impact, it sounds like everyone is relying on the "one-eyed goddess" (i.e., the tablet) for everything. Please let us know how it goes!

[Jerseygirl31]

As a nursing student and a mother of a two year autistic son, this is repulsing. It’s obvious this is not a good fit for you. You basically want to get paid for having a child lay in bed with an iPad all day. The worst part is you have no shame of coming on a public forum and spilling out this nonsense. Please do yourself, the innocent child and their family a favor of finding a job that you actually have interest in!

[GeminiNurse29]

I have an ASD baby who’s nonverbal. It’s a huge spectrum. Didn’t read all the replies but please talk to her therapy team (is she getting speech, OT, ABA?). And interact with her! Treat her like a normal kid.

[vampiregirl, BSN, RN]

Would it be helpful to start integrating breaks in the iPad use to engage in other activities with your patient instead of using it until the batteries go dead? Maybe consider allowing the iPad to be used during feedings (if they are bolus) or other "quiet times". If all of a sudden you stop using the iPad, I'm guessing the patient won't be very happy! Maybe it would also be helpful to shift your approach from "distracting" your patient to "engaging" your patient. If she is able to focus on the iPad for a length of time, that's great because it means there could be other activities she will be able to engage in.

Starting to create a routine with this patient and addressing the environment can be very useful having a more positive-interactive relationship with this patient. If there is a routine during other day shifts, this might be a good place to start. If the child has PT/OT/ST then maybe ask them for ideas for similar activities you could do with your patient. They may also have ideas as to what calms this particular patient when she starts getting wound up. The other children in the residence may be a good source of info for identifying activities your patient enjoys. Keep in mind kids with autism that I've worked may have a short attention span, especially for a new activity. It also may take several attempts for her to be able to enjoy a new activity. It can also be a trick to figure out what she needs/wants and learning to address those needs/wants early.

Best of luck with discovering some strategies that work for your patient!!

[Lauragfa2000]

I have a very similar patient. She's 2.5 yrs old. Doesn't really talk yet. I learned a little sign language from ST. Please, thank you, more, book. From there we incorporated a few more signs that have meaning to us. Now she's saying a few words.

She's also strictly tube fed. It takes time. I started with her when she was 16 months and she couldn't even hold her head up, let alone sit up. She was 18 months when she learned to crawl. That in itself took weeks of working with her. Once she started walking all she wanted to do was go!!!

Feeding isn't that bad. I refused to put her in the crib or jumper. I put her favorite toys in front of her and we would just play. She loves to be read to. Believe me when I say that wasn't always the case!! It's really just developing a communication style that works.

She was also on a vent 24/7. As luck would have it I was able to wean her off and within a year she was decannulated.

Another thing I worked into her schedule was taking her outside for long walks with moms approval. That gets her relaxed/tired enough to sit for the 2hr feeds and being outside, weather permitting, helped with her sensory deprivation. The benefits of sunshine are also a plus?.

It really sounds like she may be bored and has an excess of unused energy. I would start with the physical and work your way to the developmental aspects of her care.

Not every day is easy and there are days I leave exhausted. She also has a tablet that she can work better than I can. I limit it to an hr total on my 12 hr shift.

My biggest recommendation would be to establish a schedule of activities outside of the crib and tablet. It won't happen overnight but it will come together with some effort.

Best of luck to you and I absolutely feel your frustration!

[Lauragfa2000]

12 hours ago, Jerseygirl31 said:

As a nursing student and a mother of a two year autistic son, this is repulsing. It’s obvious this is not a good fit for you. IYou basically want to get paid for having a child lay in bed with an iPad all day. The worst part is you have no shame of coming on a public forum and spilling out this nonsense. Please do yourself, the innocent child and their family a favor of finding a job that you actually have interest in!

Well, where to start. I'm going to focus on a few of your words. All of the above statements are way out of line.

Have you ever heard the saying the only stupid question is the one you didn't ask? You will find, if you graduate, that asking for help is essential in this line of work. Not just in the beginning. I agree there are aspects to this particular case that are lacking.

I hope you're prepared for the same subjective criticism as you get closer to your graduation date.

As for the no shame, there is NO shame in asking. There is, however, shame in continuing in a situation you know needs corrected without asking.

PDN nursing is a challenge for a lot of reasons that I won't get into here. I've only been a nurse for six years and the last three were PDN. I was privileged to work in office practice/clinical research and SNF. There is so much I need to learn and believe me when I say mine is the first hand up when I need help in any given situation.

[myoglobin, ASN, BSN, MSN]

12 hours ago, Jerseygirl31 said:

As a nursing student and a mother of a two year autistic son, this is repulsing. It’s obvious this is not a good fit for you. You basically want to get paid for having a child lay in bed with an iPad all day. The worst part is you have no shame of coming on a public forum and spilling out this nonsense. Please do yourself, the innocent child and their family a favor of finding a job that you actually have interest in!

ASD can be a very challenging condition to treat depending upon the degree of impairment and other factors. It is likely that the "IPAD" was started by the parents before the OP ever came into the scene. There are effective interventions such as Applied Behavioral Analysis, but there is a reason that these treatments can cost over 100K per year (much more). They take highly trained therapists in an intensive environment. The OP was hired as a nurse not an autism therapist. Furthermore, she came here to seek advice on improving outcomes for her client. How can you denigrate someone sincerely seeking input in order to provide better care?

[Jerseygirl31]

No one expects her to be a therapist but from the start with her tone you could tell she has no real interest in learning anything and just wants an easy check. How would you like it as a mother if you heard someone expects your child to stay in one place with an iPad all day. God forbid actually trying to engage with the child instead of using her diagnosis to not even put forth an effort. I’m stating the obvious that many were thinking but too afraid to say.

[myoglobin, ASN, BSN, MSN]

Again, this is a challenging situation for a variety of reasons including:

a. Many of the behavioral patterns were likely already existing when the OP took over. Especially, the reliance on the IPAD.

b. The degree of impairment seems quite severe. Perhaps there are superior coping/play strategies, but I'm not sure I could do any better and I am a Masters level trained psych NP with over 12 years experience as an ICU RN.

c. Many people want an "easy gig" albeit not at the expense of patient care. I prefer when I go into work and my nights are smooth. Of course this isn't always the case and some nights are miserable.

d. I do my job primarily for the money. If I was independently wealthy I wouldn't work at least not in nursing. Maybe, I would do something else beneficial for humanity like open up orphanages in Africa (like Oprah) or provide "seed money" for micro businesses in third world countries. However, most of us do our jobs primarily for the money.

e. There are few proven interventions for Autism. I'm not even sure that the antipsychotics with the best evidence base in autism (Risperidone) would be indicated here (does the aggression rise to the level of self injury?). There are trade offs including weight gain and potential hyperprolactemia.

f. I once "got reprimanded" by the parents of a child with CP years ago when I worked as a home health aide. Like his brother (who also had severe CP/autism and had a feeding tube) the 12 year old "only" wanted to watch The Price is Right. When I would endeavor to engage the child in "different" play activity he would get extremely agitated and start yelling, flapping his arms, and trying to pull out his feeding tube, and taking off his diaper and flinging stool (if any was present). The parent instructed me very specifically "don't ever turn off his Price is Right or keep him from it again". They literally had 100's of old Price is Right tapes. This was a long established behavioral pattern which no doubt could have probably been improved upon, but doing so was beyond my scope as a home health aide. In the same way changing long established behavioral patterns may present significant obstacles for the OP.

g. Again, there is autism and there is "autism". I am considered at least borderline Asperger's/autistic by most who have known me throughout my life (extreme dislike of eye contact, inability to socially smile, extreme fixation with limited range of subjects like the paranormal, moving to Hawaii, and having our own NP practice, high level of anxiety when my routines are disrupted) to name just a few of my traits that my wife a PMHNP considers autistic. However, I have been able to function at least at a moderate level of success in society. Others "on the spectrum" may struggle with the most basic of ADL's or even controlling body functions. All of which is simply a way to say that what works with one autistic individual may be completely ineffective with another.

[Queen Tiye, RN]

On 11/6/2019 at 8:55 PM, FolksBtrippin said:

Risperidal is approved for autism agitation and works well for kids who get overwhelmed and self injure (headbanging) or have destructive meltdowns. It sounds like this might not be the case for your patient, but keep it in mind.

You will need to experiment a bit with sensory input. Try to find out what is alluring about pulling down the curtains. Does she wrap herself in the curtains? Put them on her face? Get her similar fabric that she can play with, and bring it to her when she goes near the curtains to redirect.

Keep pens and large pads of paper for her to draw on, or put white boards up on the walls.

Take note of triggers. Check your notes for clues. Are the troubling behaviors happening when she's wet? Hungry? Look for sensory triggers.

Self care is important too. Don't feel bad for needing to relax sometimes. When you get to know her really well you will be able to relax when she is relaxed, and you will be able to anticipate those times better.

Great advice. It can be exhausting caring for a child that is on high octane for hours upon hours. Continue to read about how to care for a child with these behaviors and be aware of your own level of frustration and when you need to step back for a moment. Her caregivers should be a great source of advice and you can request the phone number of the previous nurse to find out what strategies she used.

[traumaRUs, MSN, APRN]

STAFF NOTE - several posts have been edited in this thread due to debating the poster, not the topic.

There are many of us with autistic family members so this can be a sensitive topic. However, please be polite and courteous when disagreeing with others.

Thank you

[carti, BSN, RN]

14 hours ago, Jerseygirl31 said:

As a nursing student and a mother of a two year autistic son, this is repulsing. It’s obvious this is not a good fit for you. You basically want to get paid for having a child lay in bed with an iPad all day. The worst part is you have no shame of coming on a public forum and spilling out this nonsense. Please do yourself, the innocent child and their family a favor of finding a job that you actually have interest in!

what nursing school do you go to where they don't emphasize reading comprehension? I want her in bed at times so she doesn't hurt herself or doesn't get all her feedings leaked. I understand I can't have her in bed 24/7 so I'm looking for safe things for her to do that will keep her mind stimulated.