New to Peds

Pediatric Critical Care Columnist · May 31, 2015

Wow loaded questions!!

Social interactions with children will depend on the child's age and developmental stage. It's always a good idea to have a little knowledge of current pop culture. Dora the Explorer is still hanging on, as is Thomas the Tank Engine. Barney is dead, long live Barney! (Thank heaven!) Walk through the toy department at Walmart and see what's there for clues to popular TV and movie references. Children still recognize Sesame Street characters. Dr Seuss is another reasonable topic. For older kids, music and movies are always possibilities. You can ask about school, after-school activities, team sports, hobbies. Older kids often like the Food Network.

When you enter a room, you don't have to change up your usual behaviour just because your patient's a child. A smile, a cheerful tone of voice and being matter-of-fact about things there are no choices for will take you a long way. If you can offer a choice, even a simple one, DO IT! Everybody likes to feel that they have some control. An example, "Good morning, Billy. I'm Terry, your nurse for today. I have some pills that I need for you to take for me. Would you like to take them with water or apple juice? Oh, you're right in the middle of a video game? If I come back in a few minutes would you be able to take them then?"

How much care the parents will provide will depend on a few things. Are they there all the time, or do they send a defined amount of time in the room and then leave? Is the child there for an acute illness, or a longer-term one? You may hear in report that mom is independent with patient's care, needing only access to necessary supplies. Or you may hear that parents are not involved in patient's care at all. Perhaps the easiest way to gauge their involvement is to simply ask them. "Let me know what I can do for Billy and what you'd rather do yourself. Oh, you're doing most of his care? Well, if there's anything you're not comfortable with I'm happy to do it." Of course, there are nursing care tasks that can't be delegated to parents - IV meds, titration of IV fluids, some dressing changes, catherizations, IV starts and so on. But you'll find that parents of children with long-term tunneled central lines are competent to care for those lines, from dressing changes to cap changes to locking them with heparin or whatever has been determined to be the appropriate locking solution. Trach care is usually done by family unless the trach is still quite fresh. Suctioning and tube feeds are also something the long-term families will do without your direction. Always treat parents and older siblings as members of the team. They have a lot of valuable knowledge and skills.

How often you check on them is usually determined by the patient's level of care and your workplace. Nurse-in-room patients are observed continually while routine kids are not. Close observation means someone on staff must observe the patient no less than every 15 minutes. A lot of units round hourly on their routine kids, meaning you would at least see your patients once every hour. You can plan your rounds based on your scheduled interventions. Of course, if there is a need for your presence at an unplanned interval, the parent will find you.

These are all really good topics to bring up when you do your buddy shifts. The person showing you the ropes will know how the unit operates; s/he will also model behaviours for you to internalize. Peds is a very special place to work... let the floor staff show you what works and what doesn't. Be a sponge. You'll learn a lot!

LadyFree28, BSN, LPN, RN · May 31, 2015

I'll try to respond to your questions:

HEllo All,
So I am very close to getting a PRN jobâ€¦.the question isâ€¦â€¦what tips or social interaction differences will I need to be aware of when working with peds?

Be aware of the child's developmental level, including pts with special needs, and intellectual and physical functional levels; become familiar with those differences and make sure your assess the child's developmental level; parents and caregivers usually have that wealth of info.

I am really nervous..I love children but you can't go into the room like a cheerleader but you can't be too serious either?

Take cues from the child; sometimes having a calm, direct approach can go far in keeping a pedi pt calm when they are anxious.

Since the parents will be thereâ€¦how much care do you provide? I am ready to do all the care..but it is confusing for meâ€¦?

Since I have worked in a variety of settings with kids, and you haven't listed if this is a hospital position, sometimes assisting the family to properly hold or cover IV areas properly is ll that's is needed and then they can do or assist their child with ADLs; check with your facility's policy with assisting with ADLs.

How often do you check on your patients? What do you say when you go in the room?

I would suggest that you check your facilities policy; most places have hourly rounding; where I work I usually check depending on acuity (I work in a Pedi ED); so it could be 15, 30, sometimes 60 mins; frequent assessing how the pt is performing after pain medication vs. ADL performance-ie feeding-will have a different way of follow-up; it will also depend on the pt's status and interventions-a child may need quiet, resting periods, so making sure you check on them without disrupting the atmosphere is key.

As long as you are frequently assessing pts, and making sure you are aware of their stability, vs compensating and potential to crump, and being aware of those cues, you will be fine.

Best wishes.

meanmaryjean, DNP, RN · May 31, 2015

My advice is this: Your patient's parents know them better than anyone. If they tell you something's not right with their kiddo- something's not right and you need to pursue it.

I've never had a concerned parent steer me wrong.

KelRN215, BSN, RN · May 31, 2015

Why can't catheterizations be delegated to parents? When I worked in the hospital we had a LOT of chronically cath'd kids due to myelomeningocele. Their parents ALWAYS did their cathing. They do it 6x/day at home. The only time when it raised an issue was a teenager (with myelomeningocele) who'd had some sort of bladder surgery and was on our floor because her shunt had to be externalized and we were the only floor who would take kids with EVDs. Mom was straight cathing her into the toilet so we couldn't get accurate output (which Urology didn't like) but once we told her to do it into a urinal or a hat, she obliged.

We usually didn't have parents touch IVs at all, unless it was in the process of teaching, even if they're flushing the line independently at home. I did once bring everything into the room to do a port needle change for a child whose mother was completely independent with everything (he got weekly factor transfusions at home that she did herself so always accessed him herself) and by the time I came back she'd already deaccessed and reaccessed him though.

OP, make it a habit to talk to the parents at the start of your shift. Most parents will change diapers and feed their kids, you will have a few rare ones who won't help because being in the hospital is a break for them but that has been exceedingly rare in my experience. If you need strict I&O, ask the Mom to leave the diapers for you or the aide and to write down how much the child eats.

Pediatric Critical Care Columnist · May 31, 2015

KelRN, of course kids who are being straight-cathed at home for myelomeningocele/spinal cord injury/whatever would be delegated to parents. In the same way that kids with long-term trachs have their trach care and suctioning done by mom or dad. Kids with chronic health care needs are always the exception.

LoveMyBugs, BSN, CNA, RN · Jun 1, 2015

As Pervious posters have stated, all depends on the age of the child and what area you are working in.

Toddlers I tend to walk in the room and talk with parents 1st, I usually bring bubbles or some other toy to distract and play with while the child warms up to me.

Teenagers I talk to them 1st then parents, want to let the teen have as much control as they can.

Newborns with 1st time parents there is a lot of teaching and hand holding.

The amount of care that is left to the parents...depends what unit you are in.

I have worked rehab where we are training the parents on tracks, g-tubes, and cathing and I have worked PICU where staff dose all the care. And med-surg a mix of both, but you have to ask parents comfort level.

You might have a chronic kid and the parent might need break or you might have a parent who lacks the cognitive or emotional maturity to provide care to their child (sad, but happens).

KelRN215, BSN, RN · Jun 1, 2015

KelRN, of course kids who are being straight-cathed at home for myelomeningocele/spinal cord injury/whatever would be delegated to parents. In the same way that kids with long-term trachs have their trach care and suctioning done by mom or dad. Kids with chronic health care needs are always the exception.

Ok, I get you. Yeah, your average post-op appy who hasn't voided post-op of course you're not going to be like "hey Mom, Suzy needs to be straight cath'd, go for it."

allnurses Guide · Jun 1, 2015

Dora the Explorer is still hanging on, as is Thomas the Tank Engine. Barney is dead, long live Barney!

Barney is dead? Say it isn't so! (I'm kidding)

Anyway, nyc2011 the only tips I might add to the already excellent ones by previous posters is that children are people with all the unique traits adults have. A shy, introverted child would be scared by a "cheerleader", while some children won't calm down without a more animated approach, so learning to observe and adapt works best for me.

An illustration of that I've related before was when my own little bro was starting his chemo protocol (he's a survivor!) and balked at the yucky stuff in the cup, the nurse offered to do a silly dance while he made it disappear. Worked like a charm. I remember thinking "nurses are allowed to be silly sometimes? Cool!"

There is no need to be nervous, really. When you talk to the child, get down to their eye level. If they are holding a favorite toy or have a cute fashion accessory kids love it when you notice those things.

If your job involves a situation where the parents will be there, or it is a long-term situation with chronic illness diagnoses my advice would be to relate to the parents as a partner. I remember one mother who was really put-off by the nurse who actually told her that she was "educating" her re: her child. Yes, we had to document patient education, but being perceived as talking down to parents will kill your rapport with them immediately.

Anyway, all the best in your peds job, if you end up taking it.

Annaiya, NP · Jun 2, 2015

I frequently have concerned parents be completely wrong. However, I never dismiss thier concern until I've verified that it is unwarrented. Always listen to what the parents are telling you, but don't let their opinion cloud your nursing judgement. Many parents get the medical lingo down and they sound like they know what their talking about if you don't know better. I have seen new nurses put too much reliance on what the parents are saying, instead of having confidence in their own assessment skills and nursing knowledge. Learning the art of the pediatric exam and how to work with all of the many parents is the hallmark of an excellent pediatric nurse!