Pediatrics Question

guest239592 · Jan 3, 2009

I'm only a student replying here and not replying from experience, but from what I've learned getting the parents involved and using comfort holding seems to be the new thing. For IV insertion position the child on the parent's lap with legs danggling across their thighs so they can kick easily without moving the arm. If the child does not want to watch, parent places one arm over the child's midsection to stabilize them, and the other hand on their forehead with head facing away. The arm is placed on the table for nurse to insert the IV. If another team member is needed, they can distract the child with a book, stuffed animal (based on child's development age) or to immoblize the arm. As far as you, and again not speaking from experience since I'm a student, but what I would do if I was in that situation is focus on the task at hand. Let mom or dad (or another nurse or volunteer if parent is not available) calm the child and worry about that. You should focus in on your skill and that alone. Try your best to drown out the noise focus on your hand and that vein. Use guided imagery if you need to to imagine a successful stick with the needle going into the vein the first time. Those are my thoughts, hope it helps

cjcsoon2bnp, MSN, RN, NP · Jan 3, 2009

I'm only a student replying here and not replying from experience, but from what I've learned getting the parents involved and using comfort holding seems to be the new thing. For IV insertion position the child on the parent's lap with legs danggling across their thighs so they can kick easily without moving the arm. If the child does not want to watch, parent places one arm over the child's midsection to stabilize them, and the other hand on their forehead with head facing away. The arm is placed on the table for nurse to insert the IV. If another team member is needed, they can distract the child with a book, stuffed animal (based on child's development age) or to immobilize the arm. As far as you, and again not speaking from experience since I'm a student, but what I would do if I was in that situation is focus on the task at hand. Let mom or dad (or another nurse or volunteer if parent is not available) calm the child and worry about that. You should focus in on your skill and that alone. Try your best to drown out the noise focus on your hand and that vein. Use guided imagery if you need to to imagine a successful stick with the needle going into the vein the first time. Those are my thoughts, hope it helps.

I'm another student replying to this but as someone who was a phlebotomist when we had to draw blood from children this technique that GodfatherSN mentioned is what we used to get blood. In my opinion, drawing blood from children is more difficult then drawing blood from adults (even without the distracters) just because I found it harder to get their veins and I was so worried about hurting them that it would cause me to miss. I think its getting over that mindset which helped me when it comes to drawing blood from children. That's just speaking from my experience, hopefully it can help you.

!Chris :specs:

getoverit, BSN, RN, EMT-P · Jan 3, 2009

Hi Lily,

I don't know where you work, if it's a peds clinic, ER or what. So I'm not sure if you're needing to start IVs emergently or not. And I'm sure a peds nurse will be along here soon and give you some good advice; but for what it's worth, I've started a whole lot of IVs on kids (90% were pretty urgent).

The veins are smaller and like you mentioned the crying, etc can psyche you out and distract you. If the kid is stable and old enough to understand what you're saying, I always tell them "I can do this real fast in a way that's going to hurt a little bit for just a second if you hold still, but if you move around it's going to make it hurt worse and longer." I also tell them the instant that it's over so they can relax.

I think the distraction thing for them doesn't work much, because they KNOW when they're stuck and nothing really takes their mind off it. Not many kids want to watch you, or look at a book or a stuffed animal...once the needle hits them, you have to be ready for them to squirm. that's why speed and firmly immobilizing your site are two keys to a good stick. If they're stable and the parents are in the room, to be honest I usually ask them to step out for a second or help hold the child down. I wouldn't want the child on the parent's lap. the drawback is that whoever has the needle also needs to be firmly immobilizing the site. because if you don't, there's just too many hands in the way. Unless you're using the saphenous vein for some reason, which is fairly large and I've used in a pinch (e.g. trauma, hemorrhage, cardiac arrest etc.)

Also just like any IV start, the more fishing you do and slowly poking around: the more difficulty it seems to bring. Just do it in one, quick stick and get it over with as fast as you can. and it may sound dumb, but just ignore the screaming and crying because if you ever have a kid that doesn't holler and wail, then you'll have a good story to tell people later!! Just think about the vein and keeping the child still.

I hope this may help somewhat and if a peds nurse comes along and tells you something totally opposite from this, then ignore me and go with them! Good luck!

kessadawn, BSN, RN · Jan 3, 2009

i'm only a student replying here and not replying from experience, but from what i've learned getting the parents involved and using comfort holding seems to be the new thing. for iv insertion position the child on the parent's lap with legs danggling across their thighs so they can kick easily without moving the arm. if the child does not want to watch, parent places one arm over the child's midsection to stabilize them, and the other hand on their forehead with head facing away. the arm is placed on the table for nurse to insert the iv. if another team member is needed, they can distract the child with a book, stuffed animal (based on child's development age) or to immoblize the arm. as far as you, and again not speaking from experience since i'm a student, but what i would do if i was in that situation is focus on the task at hand. let mom or dad (or another nurse or volunteer if parent is not available) calm the child and worry about that. you should focus in on your skill and that alone. try your best to drown out the noise focus on your hand and that vein. use guided imagery if you need to to imagine a successful stick with the needle going into the vein the first time. those are my thoughts, hope it helps

i am a pediatric icu nurse, and kid ivs are something that takes practice. the veins are smaller, and the patient is much less apt to be agreeable to what you're doing. my best advice is do it and get it done. you can't talk a 5 year old into anything when he sees that little 24 gauge as a jousting spear, because that's how 5 year olds roll. parents can be a help or a hinderence, imo. if mom is able to stay cool for the procedure, by all means have her stay. if she's falling apart worse than your patient, have her step out. i never place a patient in a lap for iv starts. you can't put your trust in a parent who really is just as stressed as their kid, even if they don't show it. they should be supine on the exam table/bed, and no matter how old they are, cover those legs and never let them kick freely, the chubbiest toddler can reach above their head with his toes and screw up your iv start. the calmest teen will freak out and try to run. any kid under the age of 5 could probably be papoosed with a blanket to protect themselves and you. as for your nervousness, all i can say is that it will pass with more experience in pediatric iv starts, just stay on focus, papoose that kid, pop that iv in, and go on with your bad self, you'll do great! hope that helps!

RNMeg · Jan 3, 2009

Another student weighing in here..the ICU nurse above touched on the technique we used in clinicals last semester. We always "burrito wrapped" the little ones, to keep their legs and unused arm close to their body. The swaddling really seemed to relax them, also. I was taught never to let the parents hold the kids, too, because then they associate the pain/trauma with their parents and might fear their parents instead of us.

back2bRN · Jan 3, 2009

Totally agree with kessadawn. Kids are challenging to start IV's and get labs on. I tell them matter of fact, try to get them to voluntarily stay still (depending on developmental maturity), get all my supplies ready, tell them that so and so will help them stay still so it doesn't hurt more and then just do it. Parents, in or out I give them the choice and sometimes will ask them to leave depending on their demeanor and how the interaction is with the child. Swaddling really works . Also if there is time (or I anticipate a iv) I wrap their arms with a warm blanket to help the veins pop. There are times when mom or dad will have to hold, but I haven't found that to be too bad, they also comfort so I am the "bad "guy. I too have found lying them on the bed/strecher to be the best, parents' lap, I'm not sure about that.

FlyingScot, RN · Jan 3, 2009

The other thing to remember is we tend to focus on telling them what NOT to do (ie. move). I've had great success with children as young as three when I tell them what they CAN do when the "owie" comes. So I tell them "you can scream and yell and even call me bad names which mommy can't get mad at you for". It works wonders because let's face it this HURTS and they need to know how they can respond. I also completely agree with using a papoose or a sheet as a snug restraint. I call the papoose board a "special bed to help you hold still" and I always put the child on it so mommy isn't the bad guy. But mommy gets to take them off (rescue) the board. Using a restraint device also minimizes the number of strangers required to hold the patient down. I generally need only one helper to position the extremity and that's all. They are introduced as "my friend who is going to help you remember not to move". Imagine if you were three and all of a sudden 4 strange grown ups came in and held you tightly down on a bed. I'd panic too! I had an adorable but rascally little guy once (3 year old) and I explained to him what was going on and that if he held still I'd probably get the owie over with just one poke but if he moved it would take a lot more pokes and then told him what I quoted to you earlier. I got him positioned and he stuck his little arm out and said "I'm weady" then proceeded to in the most dramatic voice I can imagine moaned out "somebody heeeeeelp me!) but darn it he didn't move a muscle! I honestly believe much of the success in pediatric IVs is the nurses approach to the child. Also remember that the crying actually helps you because it makes their veins pop out and a crying child is really a good sign. It's the quiet ones you have to worry about.

cjcsoon2bnp, MSN, RN, NP · Jan 4, 2009

I honestly believe much of the success in pediatric IVs is the nurses approach to the child. Also remember that the crying actually helps you because it makes their veins pop out and a crying child is really a good sign. It's the quiet ones you have to worry about.

I think thats a really good point. I will say one thing that freaked me out the first few times I did it was when I drew blood from diabetic children (ones who have had diabetes for a while) and how quiet many of them are compared to other children because they have their blood drawn more often then most children. Don't get me wrong I love it when they don't scream or try to bite me or something but it is a little strange at first to have a child not even make a sound or flinch when you stick them with a needle. Poor kids

!Chris :specs:

Pediatric Critical Care Columnist · Jan 4, 2009

I've moved this thread to the Pediatric Nursing Forum for more replies.

workingforskies · Jan 8, 2009

I have been a pediatric nurse for almost 10 years now, mostly in ER’s.

Some pediatric IV start tips.

-Gather all your equipment and have everything set up on a tray BEFORE you enter the room. Setting up in the room only increases the anxiety time.

-Have the child supine on a bed. Never let them be held on a lap. If for no other reason than for safety. It takes away the up and down movement of a pinned down an extremity.

-To me, a screaming child is a breathing child so it does not bother me at all. (At least that is how I rationalize it.)

-Have a co-worker help you hold down/pin down the child. I still have a slightly broken tooth from getting kicked by a 5 year old whose mom was ‘holding’.

-If the child is 4 or under, don’t bother to try to get them to cooperate by explaining. As soon as they see the needle and realize what is about to happen, all bets will be off.

-DON’T blind stick. If you see a vein and you think you can do it, go for it. But if you are not reasonably sure, get someone else to do it. In time, as you become more experienced, you will gain the confidence and the skills to be proficient. (And FYI, it usually takes a couple of years to become really good at that.)

-There is nothing wrong with allowing parents to be in the room. But if they are going crazier than the child, there is nothing wrong with asking them to leave.

-The biggest mistake I see with newer nurses missing pediatric IV’s is when they go through the vein. Go slow. Once you get blood return, advance a little bit further, if you still have blood return then start to advance the catheter only.

-If you have any doubt about the integrity of a PIV, take it out and start a new one.

FlyingScot, RN · Jan 8, 2009

-If the child is 4 or under, don’t bother to try to get them to cooperate by explaining. As soon as they see the needle and realize what is about to happen, all bets will be off.

I'm gonna have to disagree with you on this one (see my previous post). Yes they cry but I have had great success with even some three year olds holding their arms still with a little explanation and a friend to help "remind" them. Now two year olds and generally ill-behaved kids are a completely different story. I've even heard some who could barely talk drop the f-bomb on me. Yikes!