Scope of practice in the ER

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Sorry this is long and rambling.

I changed positions and now work in the ER. For the most part I like it and I'm happy to be utilizing my Nursing skills but I'm a little concerned with what's in my scope of practice as an RN. Everyone down here is really gun ho, great trauma team, really eager to get a tough or interesting patient. We handle detox, psych, icu etc. I'm a good worker, well liked and adapting well to the environment except for one thing, I hate Peds cases.

The patient I will always try to shy away from are the pediatric cases, especially the newborns. I don't have kids of my own and I'm not comfortable with a lot of the things they expect me too do with them. I'm fine if it's fever or a cough, stitches and trauma .. no problem, unruly Parents... no problem. I'm in a teaching hospital and we all have to learn but they expect the nursing staff to place iv's , cath

neonates, hold kids down in xray and run barrages of tests that are unnecessary ( routine full ct scans on newborns, infants with no trauma) .

I questioned a Dr about the radiation during a ct of 1 week old baby and he flipped out on me. So when I get a serious Peds case I'm a wreck for the poor little thing. My last facility was in another state, they had real Pediatricians and Pediatric Nurses in their ER, so I never had to deal with anyone younger than 4 or 5.

What I want to know is as a Nurse who works in the ER what is my scope of practice, my facility tells me I am responsible for ages 1second old to 1000 years old, but I'm having a hard time believing a lot of what Management says. Am I responsible for peds too or should the Residents be in charge of cathing, ivs holding down kids in the Xray machines?

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If you work in an ER.. A recently discharged newborn that rolls in could be your patient. Yes, you are expected to know how to care for that age range. 1 minute to 1,000 is not just some bs management is trying to feed you.

Think of it this way.. Your unruly, psychotic pt that is unstable that needs an rn to accompany them to ct.. Are you going to say 'shouldn't the resident be doing that?'.

Please don't take this the wrong way, but it seems you have an issue with that age range because you haven't had a comfortable exposure to that age. I think you need to find a way to gain more education/experience with the youngsters.

As long as you're working in an ER, your scope and license depends on competent care. If you don't know what you're doing with those patients, please say so to your staff. That's not a 'I hate caring for kids don't give me them' but more of a I need help with these wee ones because I struggle delivering care.

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Specializes in Emergency & Trauma/Adult ICU.
What I want to know is as a Nurse who works in the ER what is my scope of practice, my facility tells me I am responsible for ages 1second old to 1000 years old, but I'm having a hard time believing a lot of what Management says. Am I responsible for peds too or should the Residents be in charge of cathing, ivs holding down kids in the Xray machines?

Licensed nurses care for patients of all ages -- there is no different licensure or different scope of practice for varying age groups or specific patient populations. Urinary catheterization, vascular access, and assisting with diagnostic testing/procedures are definitely typical nursing activities, regardless of the age of the patient.

And you've chosen to work in the emergency department, which as a rule - by definition - sees patients of all ages, all medical histories, all backgrounds, and all disease processes.

You are not the first ED nurse to be uncomfortable with peds ... particularly infants. But this is where you work. So you could continue to avoid pedi patients ... not gain additional experience, familiarity and comfort ... and worry about that day when you're going to HAVE to take a pedi patient who is going to need your skills and your care. Or, as suggested in the post above, you can make it a point to seek out pedi patients and gain that experience so that your care improves.

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Specializes in Emergency/ICU.

Fiona,

I know how you feel. If more parents took their babies to their pediatrician instead of the ED, the little ones wouldn't be exposed to the urinary caths, IV sticks, and rarely, CTs. Unfortunately, many parents don't understand this and use the ED as their peds office. The MDs hands are tied then, because it will become "why didn't you run xyz test - you were in the ED!" if something goes wrong later. I don't mind working on them when they are really sick, but the ones with congestion and fever x 4 hours and no other symptoms and no antipyretics bother me because you know they are going to go home after all the procedures.

The other scary thing about working with infants is how quickly they can crash - hence all the caution regarding them. Yes, we nurses do all these procedures in our ED and it's something you eventually get used to.

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What I want to know is as a Nurse who works in the ER what is my scope of practice, my facility tells me I am responsible for ages 1second old to 1000 years old, but I'm having a hard time believing a lot of what Management says. Am I responsible for peds too or should the Residents be in charge of cathing, ivs holding down kids in the Xray machines?

I hate to tell you, but you're expected to care for patients that are -1 second old, i.e. still in the womb.

That's the beauty of being an ED nurse, is we take care of people from cradle to grave.

When I find myself uncomfortable with a specific patient population, I take that as a challenge to learn more and become more competent with those patients. Sometimes that means asking for help if I'm not sure about something. Is that an option for you?

Our docs follow a protocol similar to this when determining whether or not to CT a kiddo:

http://www.mayoclinic.org/mcitems/mc1800-mc1899/mc1887-96.pdf

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Specializes in ED.

I too hate taking peds cases, especially when there is a pediatric hospital in the area. But the reality is that these patients to present to our ED and they have to be taken care of. I have gotten some what more comfortable, but having to stick a newborn to gain IV access still makes me cringe. My suggestion is to look for and ENPC course and sign up. It helped me a lot in my practice. Remember, knowledge is power.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

There was time I hated Peds cases...the made me nervous. It is the ED nurses job to be a master of all trades. Take this as a learning experience....remember that you are going to remember the babies discomfort much longer than they ever will. It is your scope of practice and non academic ED's all over the US see all ages all the time.

Get the ENPC course book and read it. Pediatrics is a specialty 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 amt 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 peds triage standard that should be used by all eds.

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/...c%20triage.pdf

[TABLE=class: cms_table]

[TR]

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

[TD=width: 23%, bgcolor: #ffffff, align: left]respirations[/TD]

[TD=width: 24%, bgcolor: #ffffff, 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://academics.ochsner.org/uploade...0PEWS%20v2.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/co...m_pews_tch.pdf

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Specializes in ER.

I felt the same way, so I took NRP and PALS, then started studying for the CPEN and passed then took ENPC. all of these are pediatric certs. it made me feel less insecure, however I still get nervous with the truly sick Kiddos. I think its normal.

Hope this helps/

Traci

PS I would start with ENPC if I had to do it over its a whole kid course

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Specializes in Emergency.

Esme pretty much nailed it. Loud baby, good baby & what do mom/dad think, baby acting/doing what is normal?

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Thank you everyone, I approached my ADN and NS Manager to clarify a few things, they were more than helpful but shocked when I admitted I was a wreck with the kids. We have a free clinic in my hospital I'm going to work a few days there to get more comfortable! We also went over policy and procedures with pediatric cases and now I have a better grasp on what I can do and what has to handed off to the MD . Tomorrow starts a 12 hour shift with the clinic, I'm packing a crucifix, holy water and a good peds book!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Good for you...I am serious buy the ENPC book it will help you tremendously!

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Specializes in ER, IICU, PCU, PACU, EMS.

Good for you for facing your fears! I never liked pediatric patients and did my best to expose myself as much as possible until I felt comfortable with them. You are doing yourself and your future peds patients a great service by getting in there. Good luck and I'm sure you'll get into your comfort zone with them.

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