Where are the Pediatric Nurses at This Site?

[Edson!]

Was just wondering. Any pediatric intensive care nurses--or the like?

[veggirl57]

I am getting ready to take a new job at a ped's office and would love some hints from peds nurse as to how to be successful in this new role. I have 20 years experience with the elderly but ZERO with peds except for having my own children who are now grown... any advice/suggestions/things NOT to do?

[Edson!]

I am getting ready to take a new job at a ped's office and would love some hints from peds nurse as to how to be successful in this new role. I have 20 years experience with the elderly but ZERO with peds except for having my own children who are now grown... any advice/suggestions/things NOT to do?

To me it seems it would have been helpful to have acute or critical care experience in pediatrics first.

Basically you have to re-learn some things--not all but some significant things--and maybe not to the degree that you would have to learn them if working in an acute care or critical care setting for pediatrics--b/c basically the kids in the peds office will usually not be anywhere close to as sick as what you'd see in the acute/critical areas.

Don't double check anything you give--seriously TRIPLE and QUADRUPPLE check ANYTHING YOU GIVE. Seriously. Follow that rule religiously--even if someone suggests otherwise to you.
Remember, you haven't worked acute/critical pediatrics--you haven't had the "pleasure" of seeing what can going on in literally minutes or seconds. When I tell you that things can turn on a dime with kids, I am NOT kidding! And this is ten times truer for neonates and infants. Never, ever take anything you give to them or any child for granted.

Find the most overall experienced pediatric nurse there--ideallly one that has indeed worked in acute or cc settings as well as in the medical office setting. Size him or her up politely. Watch and observe.
Get a current pediatric manual for primary care pediatrics as well as one that may include acute, emergency, and critical care--though the depth and breadth of teh later areas will probably be beyond what you would need to know to practice. The way I look at it, it can't hurt to have it around and learn from it. But you will be mostly concerned with primary care pediatrics; so the bulk of your learning will need to be in this area. But it is good to be aware of common things to looks for that may lead to greater trouble for the peds population.

Be aware that primarily, though not always, but overall, kids run into trouble foremost due to respiratory issues and troubles, and it is often the main reason for them coding.

Regadless of whether they tell you you need it or not, take the $200 and whatever bucks and sign-up for the two-day PALS. No, it is not comprehensive, but it is something. And you will have to get the materials ahead of time, and they can be helpful.

Find, even if it is online, a reputable pediatric mentor RN. Ask if you can volunteer in a local Children's Hospital or at least a hospital with a busy enough peds department.

What adults can tolerate b/c of metabolic differences and such, children often cannot, and if they do, they usually don't tolerate such things as long. They may rebound quicker depending on a number of things as compared with the adults, but they can tend to circle the bowl before there is often enough time to figure out what may be going on. Often adults have a physiological lead-in time before they go into crash mode. If a pediatric player has this, and in my experience, the younger the less this lead-time is, it is no where near what you would often see with an adult patient. It does move very quickly and like a shooting star, if you are not looking up, you will miss it. The last shooting star I watched took less than 2 seconds for visualization from by patio. Really, one-one thousand, two one thousand, and then gone! It was amazing but if I wasn't looking up at that particular point at that particular time, I would have totallly missed it.

You get my point. I am not trying to scare you, and really most of the peds patients you see will generally be relatively healthy or well and need check ups, and the sick stuff will be the general sick junk--but there will be exceptions, and if you don't have any baseline from which to appreciate these exceptions, well, it puts you and your patients at a disadvantage. So stick with the brightest, most experienced, and the best for a mentor in the office, get helpful materials and reputable, experienced peds mentors, and check, check, and then check again everything and anything you give to a kids--no matter what. Once you give it, you can't take it back.

Additionally, review some principles in developmental psychology. Kids at different stages of psychosocial as well as physiological development have varying needs--and we have to gear our approach accordingly.

Hope this is helpful.

[fsheruvmen]

Hey Edison,

I've been thinking about going into pediatrics, more specifically pediatric hospice. I knew I wanted to go into hospice once I graduated nursing school 3 years ago, but right before I graduated, a professor asked me to consider pediatric hospice. The thought was in the back of my mind ever since.

Do you have any tips or insight into this?

[Edson!]

Strange, I made a duplicate post--probably when I edited.

[Edson!]

Hey Edison,

I've been thinking about going into pediatrics, more specifically pediatric hospice. I knew I wanted to go into hospice once I graduated nursing school 3 years ago, but right before I graduated, a professor asked me to consider pediatric hospice. The thought was in the back of my mind ever since.

Do you have any tips or insight into this?

Well most of my experiences in peds relate to ICU, CICU, or NICU. The death rate can be high at times in these areas and low at others. A lot of times, you don't what you are going to get. And of course with kids, they can seem relatively stable one minute and then plummet in the next.

Emergency Dpts can see a fair number of death to kids d/t trauma, accidents, abuse, fire, and various causes of respiratory distress. But these are so critical and fast and unexpected.

It may be helpful if you worked as a RN in a children's hospital in oncology. We've come a long way with cancer; but still, "Cancer is the third leading cause of death among children age 1 to 4, and the second leading cause of death among children age 5 to 14 (Minino and Smith, 2001)" * Overall, I believe leukemias, various brain and CNS cancers, and lymphomas are still the big three general cancer killers in children. Of course I am sure there is more current data on this that can be referenced.

In one area of subspecialty I worked, our transplanted kids--heart and lung in particular--had regular complications--making them long-term players--constantly in and out of the hospital--and a fair number of transplant patients are at risk for cancer b/c of the dialing down w/ meds on their immune systems. So this group can make up long-term kinds of patients that may or may not use hospice.

In general, I've found that parents will go as far as they possibly can to fight for continued treatment, even in the worse prognostic scenarios. It seems understandable, given that the patients are children and the parents and often the children as well have a really tough time coping.

It is only more recently that there seems to be a greater openness toward using hospice more broadly in the adult population; since not too long ago, and even still among many, people have looked at hospice as the total end of the road; that is just not the case anymore. You can be in hospice for a while, find an up-turn, and be out of it.

Trying to communicate this to families of adults is tough enough. I think we have a way to go in getting parents and others in the peds community to realize that use of hospice to a greater extent--that it does not mean the end necessarily.

I'd recommend getting some experience in peds in a children's hospital or a hospital with a strong pediatric department--perhaps oncology, and then looking into working in hospice in general--not just kids but adults too.

Hospice has had some dynamic changes in more recent years. There's a lot of education needed in the general population on it. And another part of the problem is in educating some insurance companies on this as well.

But really I am NOT a hospice nurse. Hospice nurses are the experts with whom you should talk.
Check out the Hospice and Palliative Nursing Association and then network with experts and members in a local chapter.

http://www.hpna.org/


*http://www.nap.edu/openbook.php?record_id=10767&page=20

[fsheruvmen]

Thanks for the reply. I am a hospice nurse right now. Unfortunately the company I work for doesn't take pediatric patients, so I don't know how it is to deal with children who are dying. I guess one question you might be able to answer is, I'm a guy, thinking of going into pediatrics. During my peds clinicals, I was actually reassigned from a little girl because her mother didn't want a guy to be caring for her, especially alone behind a curtain. Do you come across this often with other male nurses?

[Edson!]

Thanks for the reply. I am a hospice nurse right now. Unfortunately the company I work for doesn't take pediatric patients, so I don't know how it is to deal with children who are dying. I guess one question you might be able to answer is, I'm a guy, thinking of going into pediatrics. During my peds clinicals, I was actually reassigned from a little girl because her mother didn't want a guy to be caring for her, especially alone behind a curtain. Do you come across this often with other male nurses?

In the ped intensive care areas I work/have worked, this really isn't an issue--even with the teenage girl-pts. Maybe it is b/c they are university type settings--teaching places--and there are lots of men and women docs, pharmacy, social workers, nurses, fellows, etc. Another job I work at has men in clinical and clinical/supervisory roles, and it really doesn't seem to be a problem.

Cut yourself a break. Some of what you are talking about may have to do with the fact that you were a student at the time.

If you are confident, they will be confident. It's a kind of humble, yet flexible kind of confidence you have to have in peds with parents. Often enough they can have big control needs with regard to their children--especially at times when things seem to really be spinning out of control. I think there is a fair amount of the psych-factor in working in these areas--b/c you are treating the family--the whole unit really--not just the child. I can relate; b/c as a parent, I can deal with things going wrong with me; but it gets a bit crazier for me when it comes to my kids.


OTOH, other times you have parents that have other issues like drug abuse or some odd ball thing, and if they even show up to be with the kid it's a miracle. And then you have those parents that are part of the abuse/neglect problem--and they try to intimidate everyone--tend to see them more in the PICU and in ER trauma, etc. Some of them can be incredibly obnoxious, and it takes a special strong yet nonjudgmental, non-inflammatory approach in dealing with them. You may want to smack some sense and moral responsibility into them; but if you let them know it, often this will escalate the problem They can be tricky to deal with.

But for a fair number of more normal parents, there is this need to control everything with their kids, and that is tricky in another way.

People also underestimate the need to bone up on developmental/child psychology when they enter peds. Different age levels often require different approaches. And also some parents interact and discipline their kids differently then others. And then when the kid becomes acute and then chronically acutely ill, they may throw limit-setting out the window out of guilt.

I've seen this a lot with cardiac kids or transplant kids that become cardiac or transplant cripples. And a few times, surprisingly the nurses that were men sometimes didn't actually didn't see the importance of setting limits with some of the kids. It's a balancing act. But the ones that had kids of their own did. That's a hard thing too sometimes.

Some people in the field do not really see the need to set reasonable limits--b/c they are afraid of upsetting the parents or are afraid of not being more "customer-service" oriented--or at least looking that way to administration. Compromise can be a good thing in order to get safe and reasonable limits in place; but some are so afraid that conflict will ensue, they just roll over and don't look for another way around the problems. Then they want to know why the parents come back in so overwhelmed sometimes. They never helped teach them that it's OK to set limits--and that it actually helps the child as well as them and their family. The SWs can only do so much if nurses don't see the importance of their role in this.

One young school-aged congen. heart kid had severe pica, pretty much used it though as a means of manipulation and control; but to be fair there were other reasons, such as other neuropsychological issues. She'd eat everything in sight--including the tubing infusing meds into her, pulse ox probes, monitor leads, you name it. We asked them repeatedly to just make the kid one-on-one; since it was hard to effectively treat other critical babies when she was always endangering herself. But see that would have cost them more money. And then mom was so frustrated b/c she never set appropriate limits with her from early on, so when the child was in the hospital it was a break for her.

She was a sweet kids, just a bit of a serious problem child. What they also could have done was to get a patient-care tech or nurses aid or the like to sit with her--especially on the off-shifts. This kid never slept. They didn't do that either. At some other hospitals I worked at, this would have been done in a heartbeat--liability and just basic safety issues. You get children with congenital defects of one major organ, and sadly often enough, they also have other problems too.



I am very glad for all my experiences with peds; but I won't lie to you. It can get tricky at times. A lot of time, if you are strong in critical care and critical thinking and honing in on the illness and tx as is called for in these areas, that is the straight-up easy part--however the increased level of responsibility that goes along with it can make it demanding. Dealing with the psychosocial components with kids and families, however, can take a lot out of you at times. However, I'm glad for family-centered care. Overall, I find the kids do better with their parents close.

And so you know, although many states fingerprint for licensure, full state/federal background checks are required for peds jobs at all institutions--and each place wants their own BGC and FPs--not simply what was required for licensure. I've been fingerprinted so much b/c of working is such areas. It used to bother me, b/c of privacy and personal rights to biometrics; but I also understand the need for it. So I'm over it.

[Edson!]

The other thing with peds and critical care is that you will find you work in a fishbowl.
Just know if you are OK with that.

I personally find comfort in that; b/c when a kid goes bad, it can happen quickly and you want the right support with you right away. But it is an environment where everyone is usually looking over someone else's shoulder most of the time. I don't mind it. I tell myself the following:

"You are working in view of "the camera" and under a magnifying glass, so be on your toes at all times." I never want to get too comfortable where critically ill kids are concerned. I think a hyper-alert state, so long as it isn't crazy and annoying, is a good thing in this kind of environment.

My experience in comparing kids to adults is this. While you don't want to hurt and you only want to help all of them, you really have to be many times more careful with kids. They can just turn on your so fast. All you have to do is have it happen one time, and your eyes open up very wide to this. I can say I've never had bad outcomes with my kids. (Fortunately for me at least this didn't happen in codes on my shifts; but clearly there are some patients that come up in really bad shape, and so even if you kill yourself and they don't die on your shift, you know they probably will on the next. When kids did die on my shift, it was a matter of staff and a team talking to mom and dad and letting the kid go.) I think I've actually had more codes that ended in death on my shifts while working in adults than in peds; but that may be b/c in adults, the drag-out isn't nearly as long--and b/c they aren't going to call in an ECMO team and put the patient on an ECMO circuit anywhere as much, usually rarely in adults as compared with children. In adults, this would generally happen by way of taking the patient back into the OR--or maybe trying a balloon pump or sometimes doing some last ditch open chest procedures and maxing everything out.

I have seen some pretty crazy stuff w/ kids though--and have "enjoyed" many a shift-long code or frequent codes during the shift. God has been good to me. Thank God we could turn things around as we did. But again, some patients you keep alive all shift and put on ECMO and really they probably should be let go. It's harder to call with kids. So whatever you think could be done, you do it. I've just been sort of lucky most of the time to be on more of the start-up end of coding rather than totally no hope end.

Also, mostly a med error with an adult generally is not the same thing as it can be with a kids. The smaller/younger the pt, the less they can tolerate various shifts in anything. It's kind of scary at times; but I am glad I hold on to this fear to a reasonable degree. Like I said, I never want to become too comfortable or complacent.

I like a good adrenal jolt; but overall, I feel the point of having a kid in a critical care bed is to stabalize him/her and keep that pt stable and well-controlled. So anything I can do to avoid a code is the way I want to go. And really doing three or four 12 hours shifts in a row of coding patients on a routine basis is the beginning of burnout. Truly.

Be prepared; but do whatever you can to avoid tipping the scales toward codesville. That's my motto.

In contrast, in the ED, you may well not have that luxury. So in that regard the critical care unit is a luxury; b/c you have the luxury of more control compared to say, the ED.

Good luck to you. Don't worry about the male thing. I've worked with many men that were critical care nurses and peds nurses, and they were great to work with and did quite well in the field. If you are truly interested in it; I say go for it.

In critical care, we female nurses love having men as nurses on our side. I generally enjoy working with men, and there are many female CC RNs that feel the same way. I only get pissy w/ a nurse that's male if he becomes one of the petty girls and begins to play their silly games. In order to survive in a female-dominated profession or area, I've seen some men RNs do this.

I tend to respect the ones that rise above the nonsense and won't play such games--even below the surface where they think no one can see them. I usually see through it. When I see them do that, I kind of lose respect for them and then can't find the benefit of bringing more male influence into our profession. We have enough undermining, cut-throat, petty nonsense in the field already. IMHO nursing needs more strong, professional players on all levels--especially directly in the clinical areas. Mostly, I've always worked with with men and more diverse groups of people and have loved it. I think it is an inner city thing--working with people from all walks of life, all different ethnic groups and backgrounds. Keeps things interesting.

[Edson!]

fsheruvmen,

Just wanted to say I'm sorry for going on so. But overall I really enjoy working in CC peds.

[fsheruvmen]

Thanks Edson for all the info. I guess the good thing about pediatric hospice/palliative care is that you prepare the family for when what would be a code happens.

I saw an old friend of mine who was at pediatric oncology patient at the time and they placed her on a vent, reverse isolation, etc even though they knew there was multi-organ failure from the chemo. It was harder when they decided to enforce visiting hours and asked the family to leave for the night. I had to ask them to stop being a nurse and be a human, if they really wanted the last contact they girl had to be a latex glove, last voice be through a surgical mask, and last interaction with her parents be when they say goodbye because visiting hours are over.

I guess I'm just wondering, would I make a good pediatric hospice nurse. I mean the theory is there, just the practice I'm not sure about.

[Edson!]

Regarding your friend, well, pretty much all children's hospitals have gone the way of family-centered care since I'd say the mid 90's. Hositals that have pediatric dpts should be open to this as well. I really hate resistance to this. I think it should be adopted with hositalized adults as well, although I have seen generalized hospitals be a bit more open to that. When my father was dying with leukemia and in the hospital like 4 dozen times, I was not going anywhere--though sometimes my stepmother could be weird and make an issue. That is just a sort of odd and sad story, but anyway. . .


So FCC (family-centered care) acknowledges the need to have the primary people in the child's life there with them through it all, even during codes. They can be there through everything, save being directly in the OR surgeries or cardiac cath lab, for example. The philosophy and approach works to accomodate the reality that kids generally do better with their parent's around. I find that is just as true for most people. They often do and feel better with their S.O.'s or spouses or whomever around. (Of course it is limited. The whole family/extended family can't be there all the time. That's just common sense to me.) Some parents or people are problems, but overall, most are respectful to the policies and are good with their family members.

Parents should NOT be separated from their sick children, and sick children should not have to be extra stressed by being separated from them. Unless the parents are interfering with treatment or are truly disruptive, we as nurses and healthcare providers should welcome them.

You seem like a real advocate, so why in the world would you not make a good pediatric hospice nurse? Again, I'd just recommend that you get some pediatric experience. Try for obtaining a good variety of children at different developmental stages.

Also, the experience is important, b/c it's good to see that often kids are not nice when they are sick or have been sick for a while. I mean some people get this; but some of the really young people just out of high school and college-nursing school or people that have had limited experience with lots of kids get upset or take it personally or fear setting necessary limits. OTOH they might lack being a little more tolerant and understanding, at least initially. I find there are issues with balance many times. Some that is controllable, and other aspects of just aren't. Way it goes. Some kids are exceptional; but really sick, yet awake kids are NOT nice to be around. Sure if they are too critical, we put them on continuous IV sedation; but that is not all the time, nor should it be.

Where they are developmentally has a part in how they behave under stress and pain and discomfort and anxiety as well as other factors. Adults generally have learned some standard, socially acceptable coping mechanisms. Kids often don't know or really care about that; so they can be quite miserable. Even if you are talented in handling and connecting with kids, the internal coping is just not there for many of them. They can be difficult to re-direct or console when they feel terrible or just so darn tired of it all.

That's another good reason to have parents or their closest primary figures near them. Even then, they can't easily console them; but they have a better feel for their kids than strangers do, regardless of whether or not those strangers are professionals. Parents are often an excellent resource. The other side of that is they also get stressed, and someone has to help them get a break and give themselves permission to do so.

Some parents want to be there all the time, and while that can often be a good thing, there comes a time when they need help in seeing that being their 24/7 is wearing thin on them--or even the staff or child. They need permission or encouragement to take a break or go home for a while and care for their family or just get some rest. My daughter had surgery last year, and I didn't want to leave her either. Now had we had to stay longer, I do know that it's healthy for me to get a break. Parents can have a sense of ominipresence, omnipotence, or omniscience when it comes to kids. It's a false inner belief, yet it has to do with their ability to internally cope with the overwhelming nature of what's going on. Someone has to protect and control. Fundamentally, as parents they feel that is their job. Yet it fails to acknowledge a sense that you can love and support and even advocate for another without striving to be a god-like person--an all-knowing/all-presence mother bear over the cub. If the child sees some vulnerability at one point or another, they may not totally be overwhelmed by it. If they see it all the time, it may well shake the heck out of their hope and confidence--even if it hope for pain relief or comfort or secure. And parents don't get that by neglecting their own needs 24/7 day in and day out in a hospital room through every wild procedure, they will not be able to stay strong in the right way. But I have a certain developing philosophy on such things. As parents, we can't control everything; but we can stay strong so that we can support and love our children through things. So that means taking a break and taking care of ourselves. Nurses and physicians would also do well to learn this. It just seems that many parents just can't separate those things appropriately, IMHO.



Nurses are always juggling something, and it just seems to me there is a lot more emotional juggling when it comes to dealing with kids and families. That's just based on my experiences, which overall have been very good. At this point I can say that I've taken care of a good variety of pediatric patients with a variety of diagnoses and issues. It's good to get a mix. If I only took care of fresh post-ops, my experiences in dealing with various pediatric/family psychological dynamics and such would be more limited.



I wish you the best in this area. Many people in pediatrics would not like to primarily deal with kids at the end stages of diseases/illnesses and dying. I mean in the unit, well, if it a major center, it is unavoidable. Some children that come into such units are going to die, and it will not just be a rare anomally.
It tends to come and go in patterns. You'll go for a while and have fairly good outcomes with most of your patients, and then you have a string of pediatric losses. I'd say if you want more experience in dealing with this kind of thing, consider working in a major pediatric center in an intensive care unit or working in a pediatric oncology unit.

Let me know how you make out.

Please don't let gender be a factor at all. Some of the kids' most favorite nurses on the units I work are nurses that are men. (I really hate saying male nurse/s. Ugh. It annoys me to no end. No one says female nurse or female doctor versus male doctor. No one says male teacher or female teacher or male RT or female RT. I mean it's kind of ridiculous to me that people would set apart the term "MALE NURSE." It's irksome.)

In fact if time permitted, I'd rally to have that abolished from all conversation.

. . ."Oh So and So is a 'MALE' nurse." "Wow, HE IS? You're kidding me. I just thought that nurse had an endocrine problem and a small bustline."

[pillpill]

I'm studying for my high-risk neonatal nursing certification test in April.

I've worked in our level 2 nursery (and in well-baby) for eleven years after six years in adult intensive care nursing.

I have several coworkers that might be interested in chatting with you and other ped nurses.

I'll let them in on this site and any helpful hints I get for earning CE credits in our field.

Love all my fellow nurses!

Au revoir

[tiffi07]

Hello I am currently a nursing student who is stuck on working in the pediatrics area. However I have a huge paper that is due tomorrow and I have interview questions that I need to turn in. I need a Nurse in the pediatrics field or was in the peds field. The nurse who was going to do them for me left me hanging and would not answer my calls when I called the office to talk with her. If some one could help me out that would be great. I can either ask them over this or give you my yahoo messanger or something. Thank you and I hope that someone can help me out that would be great. Thanks again

[nursingreview]

i want to be a pediatric nurse. I used to care children