The Biggest Challenges of Peds?

VickyRN, MSN, DNP, RN · Jun 17, 2012

I am a clinical instructor, with students on a general pediatric unit.

Some of the biggest challenges I have noted are: 1) families, 2) the vast variety of conditions that we see on the floor, 3) developmental and age differences (you can be taking care of a newborn with r/o sepsis, a 20-month old with anoxic encephalopathy and who is on a ventilator, a 5-year-old with sickle cell anemia and acute chest syndrome, and a 17-year old with anorexia nervosa, all in the same shift), 4) the fact that children are not just "mini-adults," but there are major differences in the treatment of sick children from the standard way you treat sick adults, and 5) pediatrics is much more intricate than medical surgical nursing. Medications must be carefully calculated, based on the child's weight, to the hundredths place. Get used to very small dosages. It is so much easier to make a critical or even fatal error.

mmc51264, BSN, MSN, RN · Jun 17, 2012

I just graduated and thought I wanted to do peds. I was a teacher, I have a child with medical issues and thought it would be a great fit. Until. I had a pt in clinical. A 5yo with severe resp distress. This was at a community-type hospital and she needed to be at a level I or II trauma center. The ped doctor on call was literally pacing at the end of the bed trying to decide if he was going to intubate while we waited for life flight/ground transport to a level I hosp. It unnerved me badly. Being a parent, I could not separate the parent in me. That could just be inexperience on my part. But it was difficult. I also worked home health and had a ped pt for a year and a half. There were times when I would just hold her and cry with her when she was having a bout of whatever it was that was bothering her (she was non-verbal).

I still love the kids, but it is very different to see them in distress than it is an adult, not that seeing anyone in distress is easy, it just seemed more difficult to me.

my 2 cents. :)

umcRN, BSN, RN · Jun 17, 2012

I work peds CICU. I faced my biggest challenge this past weekend when the toddler I spent the morning talking with about mickey mouse coded and rapid deployed onto ecmo 1 hour later. How fast kids can turn and go bad, that's a huge challenge.

applewhitern, BSN, RN · Jun 17, 2012

I worked pediatric ICU at a large teaching hospital. Best job I ever had. We were well equipped for anything, and of course had tons of doctors and residents there all the time. The parents were only allowed to visit a few minutes every few hours, and were never allowed in the ICU when we were sticking the child for any reason. Then I went to work at another hospital where there were no set visiting hours, and the parents were allowed to stay. It was horrible. You couldn't start an IV or anything without the parents watching you, crying, taking up all your time, etc. I will never work with peds again, unless it is an environment where the parents aren't allowed to be in the ICU, except to visit briefly.

umcRN, BSN, RN · Jun 17, 2012

I worked pediatric ICU at a large teaching hospital. Best job I ever had. We were well equipped for anything, and of course had tons of doctors and residents there all the time. The parents were only allowed to visit a few minutes every few hours, and were never allowed in the ICU when we were sticking the child for any reason. Then I went to work at another hospital where there were no set visiting hours, and the parents were allowed to stay. It was horrible. You couldn't start an IV or anything without the parents watching you, crying, taking up all your time, etc. I will never work with peds again, unless it is an environment where the parents aren't allowed to be in the ICU, except to visit briefly.

I'm sorry but the no parents visiting just sounds absolutely horrible to me. I work both NICU & Peds CICU with floating time to PICU at a very large, nationally known teaching hospital and to separate children from their parents when they are at their sickest and most critical time sounds horrendous and cruel to me. At my hospital parents are never asked to leave unless we have to do a sterile procedure and even for my situation I posted above the parents were right outside the room watching us crack the kids chest and put him on ecmo. they wanted to watch and they weren't hysterical, we have staff trained as parents support people and they are utilized during these events. Yes it can be stressful having them hover over you while placing an IV or something else but I have no problem telling parents that if they are interfering with my ability to do care then they must step away or step out and most will listen. If my child were ever in an ICU you can bet your behind I would not be leaving their side except to pee and eat.

I in no way want to hijack this post I just had to put my two cents in on this subject. I actually love having the families around 98% of the time and enjoy talking with them, teaching them and learning about their children from them. Plus they know all the tricks to getting those little ones to take meds or cooperate with procedures.

applewhitern, BSN, RN · Jun 17, 2012

umcRn, I guess it just depends on your experience with the parents. We had one mother who went absolutely ballistic because we had shaved the baby's head to place a scalp vein. We had one who brought a pistol into the ICU and threatened to kill us all. We had one who asked to borrow scissors, then proceded to cut the trach ties on her freshly trached child. The kids we had were the sickest of the sick~ all on vents, etc. I have a lot of fond memories of working on that unit for 6 years. I loved the job. But the kids were just too sick to have parents there. We might have 8 different drips going at once. We also did open heart on the babies that had less than a 5% chance of making it, so I guess it was just a different environment. When a child is a "2 on 1" with two nurses for one child, you can't work while stepping around parents.

umcRN, BSN, RN · Jun 17, 2012

umcRn, I guess it just depends on your experience with the parents. We had one mother who went absolutely ballistic because we had shaved the baby's head to place a scalp vein. We had one who brought a pistol into the ICU and threatened to kill us all. We had one who asked to borrow scissors, then proceded to cut the trach ties on her freshly trached child. The kids we had were the sickest of the sick~ all on vents, etc. I have a lot of fond memories of working on that unit for 6 years. I loved the job. But the kids were just too sick to have parents there. We might have 8 different drips going at once. We also did open heart on the babies that had less than a 5% chance of making it, so I guess it was just a different environment. When a child is a "2 on 1" with two nurses for one child, you can't work while stepping around parents.

I certainly work in the exact same environment as you though we have a large "family friendly" unit that just opened recently with private patient rooms and plenty of room for parents to be out of the way. We certainly have our issues as an inner city hospital, we have banned parents who threaten to bring in guns or decan their child resulting in a code but we don't ban them all. We also have multiple drips, vents, oscillators, heart surgery on patients who wouldnt (shouldn't) be candidates elsewhere, e-cpr, ecmo, cvvh, dialysis, therapeutic hypothermia, patients who require 2-3 nurses all to themselves, transplant, berlin hearts. I still do not think being critically ill should mean parents shouldnt be there. In fact I think the sicker the patient the better for the family to be there, to see that we are doing everything for their child and aren't left wondering if we did something wrong or didnt do something when the child still dies. We work around the parents, we encourage parental contact if it is safe for the child. If the child cannot tolerate it we tell the parents and if there is an issue then it might escalate to behavior contracts or other limits set by social work, security, management or legal if it gets to that. To deny parents contact with their children while they are possibly dying seems inhumane. Even the family we banned we allowed back in with supervised visits by security when it became clear she wasn't going to survive.

Sorry, I am one of the parents support people on my unit and hearing about a place that doesnt allow parents in because the child is "too sick" just makes my blood boil. They NEED that contact, even if they can only touch a hand or a foot, or just sit by the bed or in the back of the room and do nothing, they need to be able to do that and I try my hardest no matter how sick the patient is to allow them some contact during the shift, to keep them updated on the plan of care, to let them know if things are going well or going badly, they deserve to be there and to know. There are too many children in this world abandoned by their parents, left in the hospital with no visits for months, I am certainly not going to discourage the ones who do care from being there.

To the OP clearly you can see the challenges in working peds from these posts and conversations. You have to be a special kind of person to want to work with sick kids and believe me, banning parents is not going to be the norm in most places. Most facilities are going "family-centered" these days so if you want to go into peds be prepared for the parents. The good bad and the ugly. And try to put yourself into their shoes. I can't imagine what was going on in my kiddos parents mind this past weekend. One minute mom was holding him, next minute we were doing compressions and calling ECMO and prepping him to have his chest cracked for cannulation. They are TERRIFIED, angry and don't understand. They will and do lash out and sometimes as the bedside nurse you take the brunt of it and have to realize that that is their way of coping with a stressful situation and its not typically a personal thing. Many do calm down and apologize later.

allnurses Guide · Jun 17, 2012

There are too many children in this world abandoned by their parents, left in the hospital with no visits for months, I am certainly not going to discourage the ones who do care from being there.

Was going to write a post emphasizing that point. Agree 100%. Thanks for a great post.

KelRN215, BSN, RN · Jun 18, 2012

I find the biggest challenge to be parents with unrealistic expectations. There are some kids that will not have a good outcome. When I worked in the hospital, said hospital insisted on advertising its US News and World report rankings so people would walk into the hospital under a banner that said "RANKED #1, BEST PEDIATRIC HOSPITAL" and then there'd be a lot of "what do you mean you can't fix my child? You're the best pediatric hospital in the world, you should be able to fix anything."

That and those who insist on every possible intervention in the world for their terminal child are very emotionally taxing. When you have an essentially dead child trach'd, vented and G-tubed and the doctor has to declare them brain dead and tell the family that support is being discontinued, it takes a toll. Working in pediatrics/knowing that some kids will not have a good outcome, sometimes all you can hope for for those kids is a peaceful death. I have an incredible amount of admiration for parents who are strong enough to say "enough is enough" and allow their children to pass in peace. When even that doesn't happen, it can sometimes feel as though you failed the child. And though it is difficult to watch a child suffer what are essentially useless interventions, you have to still be able to care for that child and their family and realize that you cannot imagine what this family is experiencing and that they may not be at peace with their child's death unless they KNOW that they did everything under the sun to keep her alive.

Along the same lines, I also found it very challenging when people were insistent that some all-knowing spiritual being was going to swoop in at the last minute and save their child. I specifically remember one mother telling me how she knew that there was no way that God would take her only daughter from her. (Parents had waited a very long time for this child who was diagnosed with a highly malignant brain tumor at 4 or 5). As the mother was telling me this, I knew that- medically speaking- her child's condition was terminal and that she was unlikely to survive her disease. But it was all I could do to allow the mom to talk about her beliefs and her faith. The child died a few months later.

Pediatric Critical Care Columnist · Jun 18, 2012

The God's Will argument is very difficult to win. When you suggest that God (or whatever their deity is called) has already decided and we should allow Him to take the child, they'll counter with, "Then why did God allow all these technological advances to be discovered, if not to save my child?" I've heard that one more than once. Makes me a little crazy. God always answers prayers. Sometimes He says, "No"...

When my own child was in PICU many years ago and was hovering between worlds, I used the time I spent walking between Ronald McDonald House and the hospital to talk to God. Finally one day I just thought, "Please. Just make a choice. Either take him, or give him back - but make a choice. Make it clear to me so that I can start learning to live with it." I got my answer the very next day when my kid turned a corner. He turned 29 a few weeks ago. But I was ready to let him go if that's what my answer was, and I would not have regretted it for a moment.

ixchel · Jun 23, 2012

I worked pediatric ICU at a large teaching hospital. Best job I ever had. We were well equipped for anything, and of course had tons of doctors and residents there all the time. The parents were only allowed to visit a few minutes every few hours, and were never allowed in the ICU when we were sticking the child for any reason. Then I went to work at another hospital where there were no set visiting hours, and the parents were allowed to stay. It was horrible. You couldn't start an IV or anything without the parents watching you, crying, taking up all your time, etc. I will never work with peds again, unless it is an environment where the parents aren't allowed to be in the ICU, except to visit briefly.

I would never, EVER leave my child in a hospital where I couldn't be there with them as much as I wanted. I'm going to guess that you are not a parent. The hospital can be absolutely terrifying for both the child AND the parent. No way would my child be there without me.

Sorry for the hijacking. The mama bear in me was fighting to come out for a second.