Pediatric Skills Fair

Pediatric Critical Care Columnist · Apr 12, 2008

The biggest skill to master in peds is gaining cooperation from your patient!

So tips on making interactions easier and more successful with children are always useful. Getting down to their level is a good start. Offering to do your vitals on the stuffy that came in with them, or Mom, helps them see what you're planning to do and takes some of the threat away. Showing them the implements you're using and telling them what they do will make them more amenable, and being truthful is very important. Don't tell them it won't hurt when you know darned well it will. Knowing how to talk to kids is important too, so knowing which words to use and which not to will make a difference. For example, "cut", "needle", "put to sleep" and such are not good choices. "A little opening", "a little tube", "medicine to help you relax" are better choices. You don't have to have the pop culture stuff memorized, but it does help to know who Dora is, and Harry Potter.

As for the "real" skills, you could have someone demonstrating methods of placing IVs in little hands and feet... no tourniquet required and methods for securing IVs, NGs and nasal cannulae that will minimize the risk of losing them while not upsetting the child over much. (Tape removal is a HUGE issue for kids, so the trick is to have the majority of your tape sticking to other tape, and not to skin. TenderGrips, those little round stickies for securing nasal cannulae, work really well for NGs too, one on the cheek close to the nose, another just in front of the ear and a third one on the side of the neck.) Catheterizing female infants is a skill that isn't in everyone's bag of tricks, so tips on making that easier might be useful too. Chest assessments on little chests can be challenging, so audio of normal breath sounds in the older infant could be a good thing. There are a lot of little tricks and tips that can make caring for peds patients easier and less stressful for the nurse, but the biggest hurdle is getting them to trust you.

kristenncrn · Apr 13, 2008

Great ideas above, I think!

Also, what about how to assess when you can't ask questions? Pain assessments for children are very different than adults, I've found. Neuro assessments too.

Pediatric Critical Care Columnist · Apr 14, 2008

Pain assessments can be challenging for sure. First look at the child. Are they relaxed or tense? Is their face relaxed or stiff-looking? Are they moving around or lying still and quiet? Are they making any noise, and what does it sound like? Next, do a quick set of vitals. Do they appear to shrink when you approach them? Are they tachycardic, tachypneic, grunty and hypertensive, or are their vitals within normal limits? Kids with chronic pain may have none of these signs except the reluctance to move around much.

Neuro assessments are different from adults but not that difficult to integrate. Infants have open fontanelles and that's the first thing I assess. If it's soft, mildly pulsatile and level, no problem. If it's full and tense, or bulging, that's bad. The neonate will also have cranial sutures that will separate if they have increased ICP. Pupils are no different in children... equal, round, reactive to light and accommodation... check. Slight deviations in gaze are normal in very young children, but sunsetting is NEVER normal. They may or may not open their eyes spontaneously or to touch, but they will often squint when you touch their lids. Does the baby move when you touch her? Is the movement appropriate for her age? There should be a normal amount of movement in response to noise and touch, and there should be some response to parents' voices. Muscle tone should be assessed as well. Flaccidity and high tone are both abnormal. Temperature regulation in the infant is often immature but the toddler and on up should be able to maintain their temperatures with just light covering. The sound of their cry is also an indicator. If the cry is shrill and irritable, it's bad.

Anything else?

kristenncrn · Apr 14, 2008

Sidenote: Jan, I wish I worked where you worked. Seriously. And I hope you are a preceptor and mentor!!

The only other thing that I've noticed is sleep, play and parents.

Sleep - some kids sleep through enormous pain. That really is true. Younger kids especially. So you have to be especially detail oriented on clinical signs to make an accurate assessment. Same thing with playing. I've seen kids with sickle cell play video games while their pain is 10/10... and their clinical signs and labs actually agree with their self-assessment. Kids cope in incredible ways.

And then that parents (if they are involved) can usually tell you if something is going on with your kid. I've seen a parent "predict" a subdural bleed in a trauma patient about to be discharged (and the mom wasn't in health care or anything.) For me, it has always served me well to listen to the parents.

I love peds!

Pediatric Critical Care Columnist · Apr 15, 2008

Sidenote: Jan, I wish I worked where you worked. Seriously.

Umm... why?? There are days when I really wish I didn't! It can be a total zoo.

And I hope you are a preceptor and mentor!!

I am. I have an orientee with me right now, and newer staff always come to me with questions they think are too stupid to ask anybody else... because I never make them feel stupid.

Sleep - some kids sleep through enormous pain. That really is true. Younger kids especially. So you have to be especially detail oriented on clinical signs to make an accurate assessment. Same thing with playing. I've seen kids with sickle cell play video games while their pain is 10/10... and their clinical signs and labs actually agree with their self-assessment. Kids cope in incredible ways.

This is too true. You wouldn't think they'd be able to sleep when they hurt, but I know for myself, after I've had surgery I can always fall sleep. Until I have to move. And play is a great distractor. It gives them something they enjoy to concentrate on.

And then that parents (if they are involved) can usually tell you if something is going on with your kid. I've seen a parent "predict" a subdural bleed in a trauma patient about to be discharged (and the mom wasn't in health care or anything.) For me, it has always served me well to listen to the parents.

How coudl I have forgotten to mention the peds nurse's best and most available resource... the parents. They're the ultimate experts in that kid. They know what's right and when something's wrong. They might not know what's wrong but they know something is, and the signs are usually so subtle that the nurse is completely unaware. Great points!