By Guest Blogger Rhonda Hertwig, BSN, MSN, PNP-C
If I could have a nickel for every time I heard “pediatrics scare me to dickens”, I might have enough to take in a movie. Yes, it is true because they can’t always tell you what’s going on, and while they do present with a unique set of clinical challenges, they are what you see. To be better equipped to handle these challenges, I want to share some pearls of wisdom. They are not arranged in any alphabetical way, rather as topics or threads that may be applicable to the various age groups. Why are children unique patients? The following are a mixed bag of tidbits that will carry you a long way.
Things to keep in mind when you are doing well child visits/anticipatory guidance/acute visits
We never can get enough acronyms to help us with our learning, right? This one I’ve had in my notes from way back and I do not have it referenced. While I did not develop this handy word-PERIL, I have brought it up to date(25 years ago since I scribbled it into my notes) to include recent research.
Perception: What do you notice about the parent’s perception of their child? If you haven’t already, get acquainted with the ACE(Adverse Childhood Experiences) Study – it will help with adult populations as well. Stress varies for each child. Some are more resilient.
Expectations: Perhaps they seem to overestimate their child’s developmental capability. Here is a good time to repeat that children are not small adults. And depending on those stressor factors, caregivers and children could be maxed out. Are they going to bed hungry? Are they having to be the “parent” to other siblings? Maybe mom or dad is a single caretaker.
Reactivity: What is the child’s temperament or personality? Parents become concerned about differences. As providers we can listen, review developmental assessment screens, provide reassurance when needed, and stress the positives.
Interaction: What are the results of the interaction between child and parent? Parenting can be lonely at times. Research has shown that the number one factor that will influence outcomes, is having a connection to someone. That applies to both the parent and the child. What is their support system?
Level of development: a reminder to always regard their developmental level. We all compare and contrast.
Surroundings: What is their environment like? We don’t know what is going on in the personal life of our families, but I can assure you it has its demographic challenges – think about what is going on in the school setting (are they going to bed hungry? Are they being bullied?)
Another example I shared with new parents; hold out your hand and discuss the five reasons your baby may be crying. Are they hungry – did they recently nurse well or take a bottle well? Check their diapers – are they wet or soiled? Have they had a busy time – considering they may be tired and need to sleep? They may just need some human touch and need to be cuddled. And lastly, consider they may be in some discomfort or be sick. This is where taking a temperature comes in and is an important marker. Just make sure the patient is not over bundled and is well hydrated for starters. Expect lots of anticipatory guidance, but do so in a respectful manner and one that encourages the strengths of the parent.
Whether we label it mental health or behavior health, you need to be ready for those concerns. I have to admit, it took me a little while to recognize that most of my adolescent visits were not for the “chief complaint” they were coming in for – they just needed a non-embarrassing reason to come in to talk/to hopefully connect with someone about a mental health concern. Ask “May I ask what concerns you may be having about school or home?” or “What thoughts have you had about a …? Above all, get comfortable about asking sensitive questions – most will not tell if we don’t ask and you may lose a critical opportunity.
We need to be able to meet the unique social and mental health needs of our children as social determinants continue to grow. Consider what is occurring across the world with the pandemic. Those already weak links/connections have been broken. Those families who were already vulnerable to the financial stressors and lack of health care, places them and their children at risk for domestic violence and child abuse. And consider those with special care needs at even higher risk.
A Developmental Screening:
The importance of knowing your “normal”, both in physiological and developmental differences. Vital signs are different for different ages. If I can recommend one book, that would be Touchpoints. Thinking of these like way points or behavior on a map – developmental growth behavior of a child that is predictable and serves as a teaching guide for our parents. You’ve probably heard the old adage as well – “children don’t arrive with instructions”. But they do, and with the help of our providers, we can guide and make our parents more confident and better caregivers. Taken from the book, the most important advice for the clinician to keep in mind is that “parents are the experts on their child’s behavior”. While it is an expected part of a well child visit, remember to ask permission before pouring out advise. And know that you only can truly focus on two main items. Ask a couple of open-ended questions, “What have you found helps your baby to settle at night?”. Understanding their cultural beliefs, level of health literacy, and stressors, will increase the likelihood that guidance will be carried out and be of great comfort to parents.
Examining the Pediatric patient:
As we may have the opportunity to observe the waiting room and perhaps the rooming of our patients, this is a chance to see the interaction of patient and caregiver, which will give you a head start on your exam. Remembering children are not small adults, they do have different diseases. Dermatology in particular, we all learn as some things are not black and white. My colleagues and I routinely asked another provider to step in for their opinion. Explain what you will be doing. Different ages will need distractions. Have an arsenal of easily washable small toys or books on hand. Toddlers will want to be in their parent’s lap. And a huge trick (works every time) is to not look them in the eye and perhaps simultaneously make a clicking noise with your tongue. They are very curious about that sound and it has worked for nearly all my ear exams! And while you can’t always see the TM due to a minute amount of wax, it has to be removed and will require some assistance to do so.
This takes me back to the 5 “rights” of medication to reduce error and potential harm – right patient, right medication, right dose (based on weight), the right time, and right route. Remember that drug treatment does have age-related differences in regards to absorption, distribution, metabolism, and elimination. Beyond these basics, always use the “teach back” method when counseling your parents. Have them repeat what you have discussed and give them a written copy of instructions.
When you hear that children don’t come with instruction books, that’s just not so! And despite all those helpful books that do tell all, we continue to have children – lol. As their provider, you will serve as confidant and encourager. If you find your career preference leaning toward Pediatrics, may I suggest a couple of books that I have used as “instruction books”. Between your textbooks and your apps on your phones, don’t forget you have other providers around – don’t hesitate to ask for a second opinion.
- Touchpoints-Birth to three, by T. Berry Brazelton & Joshua Sparrow.
- Harriett Lane: The Johns Hopkins Hospital Handbook.
- Pediatric Pearls: The Handbook of Practical Pediatrics, by B. Rosenstein & Patricia Fosarelli.
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Rhonda Hertwig is a recently retired Pediatric Nurse Practitioner (PNP) but still an RN working in several arenas (student med records for studies abroad; grant reviews; telehealth asthma coaching) while living in Western North Carolina. She has her BSN, MSN in Pediatric Nursing, and worked the last 16 years as a CPNP. She has a huge interest in school based nursing as well as advocacy work in the area of DMST.