Peds ED from Adult med surg

Esme12, ASN, BSN, RN · Jun 22, 2014

Congrats on the job!

The emergency department is a completely different animal. A Peds ED even more do. Your margin for error is much smaller in a pediatric population.

Get the enpc course book and read it. Pediatrics is a speciality all it's own. Their airways are different....smaller and structurally....they can eat and breathe. Remember that 1mm of swelling on an adult airway that is 5mm wide is completely than 1mm of swelling on a 1mm airway.

Vital signs are not a predictor of how sick a kid is for they can compensate forever and by the time they reflect it in their vitals....they are in critical trouble. The cap refill/urine output is a great indicator on the younger pedi population as an indicator of distress and end organ perfusion.

So when did they last pee and how many wet diapers in x amy of time is huge!!!! Using accessory muscle is a huge sign of distress.

They need fluid, o2, and keep them warm. a crying and screaming kid is a stable kid....it's the quiet ones that will/should scare you. if the child has a congenital/chronic illness listen to the parent.....they have done this before and can help you.

Rhythms for kids....slow, fast, and absent. Familiarize yourself with the normal vital signs for the age group!

Infants....was the baby full term, what was birth weight, weigh all babies regardless of what the parents say...emphasize how important it is as that is how the medicines are given. Small mistakes have huge consequences for the pedi population. If they are small so should the dose be as all doses are weight based.

The enpc (emergency nursing peds course) has a terrific pets triage standard that should be used by all ED's.

ciiamppedds: c is chief complaint, i is immunizations, i is isolation (has the child been exposed to any communicable diseases), a is allergies, m is medications, p is past medical history, p is parents impression of the child's condition, e is the event surrounding the illness or injury, d is diet, d is diapers (voids) and s is signs and symptoms

great power point triage assessment

http://webmedia.unmc.edu/bioprepare/2010symposia/goesch-pediatric%20triage.pdf

[TABLE]

[TR]

[TD=align: left]age group[/TD]

[TD=align: left]respirations[/TD]

[TD=align: left]heart rate[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]systolic blood pressure[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]newborn[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]30-50[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]120-160[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]50-70[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]infant (1-12 mo)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]20-30[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]80-140[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]70-100[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]toddler (1-3 y)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]20-30[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]80-130[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]80-110[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]preschooler (3-5 y)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]20-30[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]80-120[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]80-110[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]school age (6-12y)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]18-25[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]70-110[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]85-120[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]adolescent (13y +)[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]12-20[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left]55-110[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]100-120[/TD]

[/TR]

[TR]

[TD=width: 27%, bgcolor: #ffffff, align: left]adult[/TD]

[TD=width: 23%, bgcolor: #ffffff, align: left]16-20[/TD]

[TD=width: 24%, bgcolor: #ffffff, align: left] 70-100[/TD]

[TD=width: 26%, bgcolor: #ffffff, align: left]

[/TR]

[/TABLE]

triage course - nursing continuing education (ce) - nurse ce - ceufast.com

pews.....the pediatric early warning (pew) score system can help nurses assess pediatric patients objectively using vital signs in the pediatric intensive care unit. the scoring system takes into account the child's behavior, as well as cardiovascular and respiratory symptoms.

http://www.mc.vanderbilt.edu/documents/sss2/files/VCHPEWS_11_12.pdf

ahrq innovations exchange | pediatric early warning (pew) score system

this is another great assessment tool for assessment short and sweet but informative.

http://www.ucdenver.edu/academics/colleges/nursing/documents/pdf/sim_pews_tch.pdf

BP is the LAST indicator of a child in trouble. If it's dropping then you'd better intervene and quickly!!!! Kids rarely cardiac arrest (unless they have some congenital issue but even then it's usually something else). They will respiratory arrest.

The moral of this story is that assessment of the respiratory status of a sick child is absolutely critical in preventing a disaster. Slight retractions, while never normal, means watch closely but don't panic yet. Retractions with nasal flaring means bring the emergency respiratory equipment in or near the room. Grunting is an ominous sign of impending respiratory failure which can quickly be followed by cardiac failure.

Fix the respiratory issue and you will likely head off the cardiac issue. Broselow tapes are your friend. You cannot adequately monitor an infant swaddled in blankets. Get an over bed warmer and unwrap the baby. Don't be afraid of scalp veins in infants under 12 months. They are easy to get in an emergency and while they freak the parents out the child usually doesn't care.

Esme12, ASN, BSN, RN · Jun 22, 2014

Parents welcome....sitting in a in a chair, without wheels, only. Parents like Gomers will go to ground.

(I couldn't resist "The House of GOD" reference)

If they have tears have no fears.....If the pacifier's wet they're all set. :lol2:

Learn nursery rhymes and learn the popular kids shows.... NOW!

They are going to cry from the moment you begin to hold them...forage on! YOu and the parents will remember it much longer than they will.

Beads will find places where no bead has gone before...... :eek:

The art of calming a parent that although their child is bleeding and it's important to everyone.....the child will survive the injury.:hug:

OP you are already doing what you should....educate yourself. :yeah:

PedsED-RN · Jul 27, 2014

My first job was and adult med/surf ortho/neuro unit, while waitin for an open position at our Children's hospital. First open position was in the ED so I figure I would give it a shot. Almost 7 yrs later, can't imagine working anywhere else, I love it. Read what you can. When I started, I would make sure to stay in the room when the provider was in there, (especially the ones that are good teachers), to get an idea of their rationales and whatnot. Over time, familiarize yourself with your frequent complaints, and work on your discharge teaching. I found that to be very helpful. Know what info the parents need to feel comfortable cring for their kid at home, what to watch for, etc. parents are scared to death of fevers, and for the most part, it is not necessary. Learn how to explain fever, it's purpose, etc. I don't know how many times I go through my fever schpeal many times each shift. =)

it it definitely is going to be a different animal than adult inpatient, but if you are interested, you will probably love it. =) just learn a much as you can, and don't feel bad for not knowing everything immediately. It will all come with time! You will likely be required to take ENPC. And TNCC at some point, ENPC will be a great course. I teach that, and it is helpful for newer ED nurses. If you ever have questions, feel free to message me! Good luck on the new adventure! =)

Kidrn71 · Aug 7, 2014

I have worked PEDS ED for 8 years, left, and totally missed it. Going Back at the end of month. I hope all is going well with your knew position.

PG2018 · Aug 11, 2014

Thank you for some of the comments even if this isn't my post!

I've been in an adult only population for the last year and probably never had more than eight child patients prior to that. I've never even taken PALS - even when I was a paramedic, but I've got PALS and NRP coming up soon.

I knew respiratory function was critical but didn't really relate capillary refill and urinary output as being critical metrics although now that it's been mentioned I understand why.

I'll be working in an ER until I get my psych NP at the end of the school year. I love it because it's taking me back to my roots (and I feel you're doing something useful/meaningful in the ER), but I've been wondering about kids. I've already had a few belly pains (that turned out to be nothing) and some dehydrated adolescents from football practice.

Anyway, thanks again.

Kalipso · Aug 18, 2014

I went from adults only to adult/ped ER. Kids scared the poop out of me when I started. At first I felt like the things I had time to think through before action with adults are way different in kids. Like a little bit of wheezing in a kid makes them a much higher priority than I initially could wrap my head around. Allergic reactions, while serious in all age groups, must more concerning at an earlier time in kids than adults....like I would watch an adult with a new sudden onset rash but feel comfortable just giving some Benadryl and hooking them up to the O2 monitor until they could see the doctor, with a kid it is more serious....mostly for the airway potential but the doctors always seemed to slam them with way more drugs than I expected when I first started caring for peds. I had the hardest time with the patients who couldn't talk....I found assessment very hard to do at first. The reason is because it involves a whole lot more touching than it did with adults. Example: Adult patient comes in to the ER and says his elbow hurts. Most of the time you can ask out it happened, exactly where it hurts, ask them to show how much ROM they can preform THEN you find pulses and cap refill. A 20 month old comes in and the mother is telling you she heard the kids playing in the kitchen and then the next thing you know little Johnny was crying, after the initial cry was over she has noticed for the last few hours that Johnny doesn't really want to use his left arm as much. You don't see any bruising or swelling or obvious deformity, so how do you get the answers to the rest of your questions. Well you start with the good arm and you palpate the shoulder, elbow, wrist, passive ROM to the shoulder, elbow, and wrist. Then go to the hurt arm and do the same thing. If the child has been crying since it saw you then you have to take your pain indicators as to when the child's cry becomes more intense and the kid pulls away from you in pain. That took some time to figure out... plus you have to explain to mom why you are purposely making her beautiful, wonderful, center of the world, kid cry by moving the arm that she just told you she thinks is hurt. Start IVs mostly in the AC or the hand and for the most part it will take two of you to do it even if you use a numbing patch....which was just weird for me at first...felt like I needed to much help but really that is just best practice. Oh, and the most disturbing thing I learned was how to give meds to a small child that spits them back up. You hold them down then hold their nose so they have to swallow the medicine to breath. It works very well, but it is a little disturbing to watch. Try explaining that to an over protective parent! I can say I really enjoy peds now after 3 years, but I love being in an ER where I can do both!