Category Archives: Pediatric Intensive Care Nursing

Next Career, No Body Fluids

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XXXL Pajama Pants pencil and pastel by jparadisi 2012

“Next career, no body fluids.”

That’s what I tell myself.

I admire hospital management their ability to wear cute dresses and pumps to work or, if they are male, slacks and sweaters. Oh, and jewelry: modestly dangling earrings and longish necklaces. I knew the most talented and charming surgeon who got away with it too, mostly because she’s so damn good at what she does. I once saw her come from the OR wearing green surgical scrubs, a string of black pearls around her neck, and pumps covered in paper surgery booties. I was so impressed I splurged on a string of black pearls for myself, and wore them to work with green surgical scrubs too. Imitation truly is the best form of flattery.

I digress.

I don’t wear cute dresses, few necklaces, or modestly dangling earrings to work because I do direct patient care.  A pediatric nurse quickly learns dangling jewelry is a handhold for infants and children to grab, snapping them or ripping an earlobe. Adult patients suffering dementia put a nurse and his or her jewelry at risk too, and long necklaces tangle into stethoscopes.

The other day, in the adult ambulatory clinic, I started an IV. Unexpectedly, a gush of blood erupted, running warm down my pant leg as if it were the slope of a volcano. I couldn’t get my leg out of the way because I was trying to keep up a calm facade for my patient (“Everything is just fine, just fine.”) while frantically taping the IV in a successful effort to maintain it. When I saw the blood on my pant leg, it looked like I had stabbed myself.

I remembered the last time my clothes were soiled this badly at work. I was a new PICU nurse and a child threw up ALL OVER my pink scrubs.  A nursing supervisor acquired clean scrubs from the OR dressing room for me, and I finished my shift.

I work in an outpatient setting now. There are no kindly nursing supervisors willing to go to the OR for fresh scrubs. I had to think of something else.

In ambulatory care, patients wear their own clothes. Our linen closet is not stocked with an array of gowns or pajama bottoms; however, I managed to find a pair of XXXL pale blue drawstring pajama bottoms stuffed behind the fitted bed sheets. They were so gi-normous, I had to hike and tie the drawstring waist at my bust line. The pant legs were three times wider than both my legs put together. You can imagine how ridiculous I looked (if you can’t, I drew a picture for you above) even with a white lab coat buttoned over the ensemble to hide it. My coworkers were busy, and unaware of my dilemma. When one noticed, all she could say was, “Uh oh.”

Clearly, I needed another plan. Fortuitously, David had the day off, and was near where I work. I called for help, and he brought a pair of pants for me from home. I changed, and resumed patient care.

Apparently, I need a preparedness plan for my clothing at work. Do any ambulatory care nurses have one?

Next career, no body fluids.

Keeping Toddlers Safe in an Adult Only Home

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Scarletti Confetti pencil and markers on paper 2011 by J.Paradisi

With the onset of late summer hot weather many local children are falling through the screens of open windows. (Another frequent danger to children during hot weather is drowning.  AJN editor-in-chief, Shawn Kennedy posted an excellent article on that subject for Off The Charts).

When I was a Pediatric nurse, the falling diagnosis was nicknamed failure to fly, but only if the child was admitted for nothing more serious than observation and a few bruises. Often the injuries are life threatening or worse, and in truth such an accident is no laughing matter. Perhaps this is why Sesame Street has never featured an episode titled Things That Don’t Fly, in which I imagine Elmo singing a list of things that don’t fly: rocks, books, and YOU!

Okay, that’s not funny either; it’s a poor attempt at humor stemming from recent anxiety while babysitting my favorite toddler, the sister of my favorite twelve year old. A decade has passed since I’ve babysat a toddler, and I worried over her potential for injury while in my care. I’m a nurse, and a former Pediatric Intensive Care nurse at that. It’s a lot of pressure. Of all the people in the world, she should be safe with me, but from the moment she entered my home I realized how dangerous the adult environment David and I share is for an active toddler, even after efforts of childproofing, which included taking all of our CDs out of their towering storage rack and laying it on its side so she couldn’t pull it down on herself, locking under the sink cabinets, installing socket covers, and removing from reach all small, swallowable objects. The balcony door was fastened the entire visit, and she was not allowed on the balcony, even with adult supervision. All windows were closed and locked. There would be no failure to fly on my shift.

Here’s some other tips gleaned from over fifteen years in pediatrics, the news, and personal experience. In no way is this list complete or infallible:

Grandma, What’s in Your Purse? I have no idea how many accidental poisonings occur because a small child finds prescription pills in an unattended handbag. It’s so common that I have removed my little bottle of ibuprofen, used for headaches at work, from my purse. It’s inconvenient; sometimes I have to mooch from my coworkers or walk over to the hospital pharmacy and purchase ibuprofen when a headache comes on at work, but that’s how it is.

 ABSOLUTELY KNOW WHERE THE CHILD IS BEFORE STARTING THE CAR’S ENGINE. This applies when there is more than one adult with the child. Too many children are run over by a car while it’s backed out of a garage or driveway. The driver of the car and the adult in the house each assumed the child was with the other. When I was fifteen years old in Drivers’ Ed, the instructor taught us to walk behind the car to see what might lurk there before getting into the driver’s seat. This is an especially good idea when small children are near.

Never Leave The Child Unattended With The Family Dog. Dogs that are not accustomed to children are unpredictable around them. Dogs that are accustomed to small children are unpredictable around them. I once heard a story of a loyal dog uncharacteristically attacking the family’s toddler. The family was so shocked that after the dog was put down, they had an autopsy performed and found the dog had a painful ear infection. When the toddler touched her ear, the dog attacked him in pain. A very sad story. Protect both the child and the pet by never leaving them together unattended.

Secure That Big Ass TV. Towers of CDs aren’t the only things children old enough to crawl can pull down on themselves. TV’s that are not secure on their bases or bases that are the least bit wobbly put children into ICU’s with crushing injuries every year.

Do Not Assume Any Device Installed For The Child’s Protection Will Work. I’ve seen children who got under impossibly heavy hot tub covers and drowned. Baby gates fail and lead to falls. Years ago, I put my daughter’s baby acetaminophen on top of our refrigerator, safely out of reach when she was small. When she became a teenager, she informed me that as a child, she had climbed the kitchen drawers onto the counter and ate one or two orange flavored acetaminophen at a time while I took a shower, demoralizing me the way only a teenager can demoralize a parent.

The Best Protection for Children is Your Presence. Let the housework and phone calls wait. You are not the kid’s parent, so you’ll have time to clean up after they leave. Getting to know these little people is one of life’s most satisfying experiences. This is your opportunity to influence a developing new life in a positive way. There is nothing in the world more important than their safety and your peace of mind. Enjoy it while it lasts. They grow up so fast.

Pain is The 5th Vital Sign, Who Has Control?

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Photograph courtesy of Adriana Paradisi, 2011

Recently, two nurses in my blogging community wrote about patients in pain. Joni Watson at Nursetopia posted a link to horrific videos of patients suffering in pain without proper medication, and J. Doe at Those Emergency Blues urges nurses to provide post-op patients with education along with that vial of pain medication at discharge.

Patients who are not in control of their own pain medication often suffer in pain. Here’s a composite story from my Pediatric Intensive Care experience:

I am taking report on a child less than 24 hours post-op open-heart surgery. The night nurse, who is fairly new, tells me that the only pain medication given on her shift was acetaminophen, although the surgeon ordered narcotics too. I say, “WHAT?” The night shift nurse explains she offered narcotics, but the patient’s mother, who was up all night at the bedside, refused them. Like I said, I am familiar with this routine. I have a script for it. I ask the night shift nurse to follow me into the patient’s room so she can learn it too.

In the room, I see a small child sitting rigidly in a hospital bed. An untouched breakfast tray rests across her lap on the bedside table. Above her, the green tracings of the monitor displays tachycardia (heart rate is high). The central venous pressure (CVP) and blood pressure are also high. Barney the Purple Dinosaur is singing about friendship on the blaring TV, and I feel a headache coming on. Mom at the bedside, looks like she hasn’t slept for weeks, and is clearly exhausted. I say “Good morning,” and introduce myself. I say, “So, your daughter’s surgery went very well. How do you think she is doing today, right now?”

The Mom tells me her daughter seems very quiet, and isn’t eating breakfast, which is unusual. I say “Hmmm,” then point out that all of the numbers on the monitor are high, and to me, it looks like her daughter might be painful. “By the way, the night shift nurse mentioned that you prefer your daughter receive only acetaminophen, and she hasn’t had any narcotics. Is there a reason you don’t want her to receive narcotics?”

I am not surprised to find out that someone in the mother’s family recently died of cancer, or another long disease process and at end of life was on a narcotic drip.

The mother equates narcotics with death, and is illogically protecting her daughter by preventing narcotic administration. The patient is too young to speak for herself. I educate the mom on the difference between post-op analgesia and end of life pain control. She allows me to give a little narcotic to her child, and soon the kid is eating breakfast and singing along with Barney. Her vital signs are normal, and the surgeon is very happy with her progress.

Now I work in an ambulatory oncology clinic, and I see another variation of this patient who is not in control of his or her own pain medication administration. Typically, this patient has rapid disease progression, and almost always tumor metastasis to the spine. They are easily identified by their need of mobility assistance, and are painful even lying in bed. They tend to talk to you with their eyes closed. They are too sick to speak for themselves.

A family member always accompanies them, and that person knows the name of all the prescribed medications, the doses, and when they were last given. They give a detailed report of the patient’s diet, stools, and urinary output. The patient is clean, and dressed in clean clothes. They are obviously loved.

I assess for the fifth vital sign: pain. Their body language prepares me for a high number, and I am not surprised when they report an 8 out of 10, or greater. I see on the home medication list that the oncologist has prescribed both long acting pain medication and a short acting one for breakthrough pain.

I ask both the patient and the caregiver when the patient last had pain medication. The caregiver answers, “Last night.” I ask why the patient didn’t have a dose in the morning before this appointment. The answer is something like, “He needs to walk more.” “He doesn’t eat enough when he takes pain meds.” “I didn’t think he needed it,” and a long list more. Apparently, this is a very common problem confronting hospice nurses, and Medscape has a very good article on the topic.

It is my experience when encountering this caregiver and pointing out that their loved one is in pain that they start to cry. They almost always have the vial of long acting pain medication in their purse or pocket. I get an order from the oncologist, and together, the caregiver and I treat our patient for pain.

I explain that the bone pain will not go away; it will worsen. Our patient will need more pain medication, not less.  Then we discuss loss and grief, and how painful they are. The caregiver sees their loved one floating away on a cloud of analgesics, and illogically thinks that withholding narcotics will keep them here longer. I can’t fix this for them. It’s going to happen. I provide a safe environment to talk about grief. I urge them to be brave and declare their love by treating pain. I arrange the appropriate support to protect the patient at home.

And I say a little prayer for all of us.

How I Became a Nurse Part III: It’s An Ongoing Process

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The Christening Gown (From Cradle to Grave: The Color White) by jparadisi

One shift, Roz and I worked alone. That night, there were only two patients in the pediatric intensive care unit. Roz was charge nurse. I sat at the console charting, with the hypnotic QRS tracings of sinus rhythm in the background. Roz charted at another desk by the door. The door opened and a man I’d never seen before entered. He walked past Roz, to me. He identified himself as the pediatrician for Roz’s patient, and asked who was the charge nurse.

“Roz is in charge. She’s taking care of your patient.”

He continued addressing his questions to me. “How’s my patient? What’s his blood pressure?” “I don’t know,” I reinforced, “Roz is your patient’s nurse, and she has his chart. She can answer your questions.” I looked quizzically to Roz, who briefly looked up, then put her head down, intent on charting. The doctor continued. “I want to know the I and O. Is the patient getting enough pain medication? Are his parents around?” I didn’t get it. I remained confused until Roz walked over and handed me the chart. Suddenly, I understood. My anger flared then turned into a cold lump in my stomach. I had to control my voice as I answered his questions from the chart.

Roz nursed circles around me. I owed it to her that I was in the PICU and this physician wouldn’t talk to her because of the color of her skin. I only spoke to him because of his patient, a child. He scribbled some orders, gave me the chart, and left. I felt traumatized by his overt racism, and because he directed it towards Roz, my friend. The cold lump in my belly morphed into nausea.

“Roz, I’m so sorry. He’s an ass.” Her eyes betrayed her feelings, but her words were calm.  “Jules, I don’t blame white people for this. That fool is an ornery, nasty soul no matter what color his skin is.”

Decades later, Dr. Racist remains a painful memory. Dr. Racist was never seen again in the PICU. He was a blip on our screen, nothing more. His disappearance prevented Roz and I from doing more than complain to management.

Becoming a nurse is an ongoing process. Certainly, a nurse’s expertise grows through attainment of knowledge and skills, but it is more than that. Becoming a nurse also includes learning when to speak up and when to let something roll off your shoulders. Like everything else she taught me, Roz was better skilled at this than I. I am not a qualified authority on racism in nursing, but the National Black Nurses Association, and minoritynurse.com are two educational resources by people who are.

My treatment by Sister Sebastian was workplace bullying. What happened to Roz is workplace bullying taken to its sinister extreme. It is so universal that the successful TV comedy series The Office uses it for its premise. However, when nurses experience workplace bullying, we are usually in the midst of work requiring responsibility for the safety of others. It’s hard to stand up to rude or disruptive comments when your patient’s condition is rapidly deteriorating or you are in a patient care area. Bullies know this, and use it to their advantage. I think this is what makes workplace bullying particularly demoralizing for nurses:  often, we must choose between defending ourselves and protecting our patients.

I have one strategy, developed over the years, which I find effective. When I overhear a coworker berated by another in either language or tone of voice, I go stand next to that person. Usually my quiet presence is enough to cause the offending person to stop. Occasionally it is not, and the offender asks, “What do you want? Why are you here?” I reply, “I’m just wondering if everything is okay over here. Do you realize everyone can hear you?” So far, this has always stopped the abuse. It’s particularly effective if more than one nurse stands by.

Becoming a nurse is an ongoing process. I am still learning.

How I Became a Nurse Part II: Gatekeepers

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Gate Keepers by jparadisi 2011

“Jules, you need to quit wasting your talents working with Sister Sebastian up there on the Pediatric unit. I want you transfer to Pediatric Intensive Care so I can train you. You’re a natural,” said Roz, when we finished our shift.

Roz found a way for me to float to PICU at least once a week. Soon, I was caring for stable patients with her backup. It was complex work, and I had a lot to learn. I loved it. I wondered what it would take to become staff. Roz encouraged me to ask Barbara, who managed both pediatrics and the PICU.

Barbara worked her way into nursing administration first as a pediatric RN and then in PICU. She and Roz had worked side by side in both units before Barbara became manager. They were friends. Roz and I sat in her office, discussing my transfer.

“Roz can’t say enough good things about your nursing, Juli. I’m happy to hear you’re doing well and I’m grateful for your help in the PICU. I think you will make an excellent PICU nurse, however, I’m reluctant to transfer you there so soon after graduation. You’ve been a nurse for less than six months, and I’m afraid that getting in over your head is a real possibility. I will feel more comfortable with the idea after you gain more experience. I don’t mean to discourage you, but for now the answer is no. Let‘s talk about it again after you‘ve been here a year.”

I was already in over my head on the pediatric unit, but I understood Barbara’s concerns. Since I floated so often, I knew it wouldn’t be long before she changed her mind. I decided not to push for the transfer at present.

What I didn’t count on was interference from Sister Sebastian. One evening I checked in on Peds before floating to PICU when once again she stopped me at the nurse’s desk.  “I see they scheduled you in the PICU tonight, however, it is not fair for them to have favorites. You cannot always be the nurse who goes down there. I am keeping you here tonight and I have sent Leah down to them instead. I have told Roz no.” Her wimpled face radiated with satisfaction as she spoke. She found pleasure in the self-assigned role of gate keeper. Her personal disappointments compelled her to block the way of others pursuing happiness. Now I know life is full of such people.

I wanted to argue with her that the other Peds nurses hated floating to PICU, but I knew it wouldn’t help. I took report on my assignment, realizing I was going to stay a Peds nurse for a very long time. During my break in the staff lounge, Roz called from PICU. “This isn’t the end of it,” she said.

Three days later, Barbara called me back to her office. Roz was already there, seated. Barbara started the conversation.

“Juli, Roz requests I transfer you to PICU. I have already explained my concerns. I still feel the same, but Roz has agreed that if I transfer you, she will take responsibility for your training in the PICU. She has committed to working the same schedule as you every shift for a year, to make sure that both you and your patients are safe. Do you still want to transfer?

I couldn’t believe Roz would commit herself like that for me. I agreed to the transfer, resolute that she would not regret her choice. Years later, after mentoring many new nurses myself, I fully understand Roz’s gift.  Her generosity is more overwhelming than the nursing unit she rescued me from. Life should be full of such people.

I thrived as a nurse in the PICU. I learned rapidly in the fast paced environment. Roz gave me a Pediatric Intensive Care Nursing textbook. I studied it at home and on breaks.

Roz was well respected by the PICU intensivist. Eventually, he trusted my nursing judgment nearly as much as hers. I was proud when he nicknamed us “The A Team.” I was going to stay in nursing after all.

Next week: How I Became a Nurse Part III

How I Became a Nurse Part I-It Could Not Have Begun Worse

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The White That Binds (Pinning Ceremony) by jparadisi 2010

It could not have begun worse. I was not prepared for the difficult transition from student nurse to a full-time professional. My first job was working 12-hour night shifts in a high acuity pediatric unit. No one explained that during my two-week orientation I would work days, 7:00 am to 7:30 pm, not nights. The head nurse, Sister Sebastian, failed to see the humor in this misunderstanding, and sent me home when I showed up twelve hours late on my first day. She never liked me, and I was afraid of her.

The unit used a team-leading model, which meant two Registered Nurses managed 30+ sick children with two Licensed Vocational Nurses, if available, and a few Certified Nurses’ Aides. The LVNs could not start IVs or give IV medications. The CNAs took vital signs, and bathed and weighed the patients. The RN’s assessed each patient and new admission, started IVs, drew labs, hung IV medications, and resolved problems. Significant changes in a patient’s condition were phoned to their pediatrician ASAP, unless it could wait until morning. It was expected the RN knew the difference. If she was wrong there was a morning confrontation with Sister Sebastian.

After two weeks of orientation, I had patients, LVNs, and CNAs to manage. Six weeks later, I was occasionally charge nurse. The charge nurse took a full assignment. Ignorantly, I assumed these were realistic expectations for an inexperienced nurse. I worked hard to succeed, but failed miserably. When I made mistakes, Sister Sebastian glared at me during change of shift report. It was overwhelming. Often I would cry at home after shifts. Four months into it, I considered quitting nursing. Then I met Roz from the Pediatric Intensive Care Unit.

The PICU was experiencing a long period of low census. So Roz floated to Pediatrics and helped our chronically understaffed night shift. That first night, we teamed together to do patient care.  Roz was compassionate with patients, and highly skilled. She put them and their parents at ease with humor and a calm demeanor. She carried out several nursing tasks while thoroughly assessing a patient at the same time. I felt the rhythm. We worked together many shifts.

Roz changed my perception of nursing. She did everything my nursing instructors called unprofessional: she laughed a lot and loudly. She made irreverent jokes. She told stories on doctors and other nurses. She talked back to Sister Sebastian and advised me to do the same. We became friends.

Time passed. I arrived for work one night and as I approached the nurse’s desk, Sister Sebastian blocked my way, arms crossed in front of her chest. She said, “We don’t have enough patients tonight for you to work here. I was going to call you to stay home. However, the PICU is busy and they need a nurse to float. Roz asked for you. Try not to kill anyone there,” or something to that effect.

This surprised me. I appreciated Roz’s confidence, but I wasn’t sure I wouldn’t accidently kill somebody down there either. Most of the children were on ventilators, which I had only limited experience of in school. The PICU nurses managed complex IV drips. I was nervous, but believed Roz wouldn’t let me get into trouble. So I reported to the PICU.

The hospital housed a small, but high-powered PICU. As part of a Level Three Trauma Center, they treated every kind of pediatric emergency. All their beds were full this shift and most of the patients were unstable. Rather than giving me a patient to struggle with on my own, Roz assigned us together managing two unstable patients. Her strategy had me helping her with assessments, taking vitals signs, and giving the medications I was familiar with, while teaching me how to draw blood from the central and arterial lines for lab tests. She reinforced my suctioning skills with the ventilated patients. We shared charting in the nurse’s notes.

I loved intensive care nursing! Rather than scattering my attention on a floor full of patients, I found my strength was focusing on the intricate details of one or two critically ill patients. Following nursing tasks through to create a care plan I could assess and adjust rapidly suited me.  This kind of nursing made sense. Of course, I relied heavily on Roz, but by the end of the shift, I knew that PICU nursing was for me.

But how would I get to stay there?