An informal discussion of emergency nurses' current clinical practice: What's new and what works☆☆☆★

Article Outline

• Abstract
• Pediatric tips
  • Can you give me some tips about how to care for pediatric patients in the emergency department?
    • Answer:
• Violence in the emergency department
  • How can we make the emergency department a safer place for us to work and care for our patients?
    • Answer:
• References
• Copyright

Abstract 

J Emerg Nurs 2001;27:350-2.

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Pediatric tips 

Can you give me some tips about how to care for pediatric patients in the emergency department? 

Michelle Tracy, RN, MSN, CPN, from the University of Rochester Strong Children's Pediatric Emergency Department, recently gave me some very handy ideas. She told me that when she does a septic workup on a child, she obtains the urine first. She says that children always void when you attempt to draw blood or start an intravenous line, and thus placing the bag first usually guarantees success. If all you need is a dipped urine specimen and the child is still in diapers, she suggests putting 4 × 4 pieces of gauze in the diaper. When the child urinates, squeeze the urine from the gauze onto the urine dip strip and you can then take the reading.

Tracy has a trick for giving children liquid charcoal after they have ingested a toxic substance—she says to add a squirt of chocolate syrup to the charcoal, and they drink it right down. She also recommends using tablets and chocolate syrup when giving children steroids. She suggests crushing the tablets, mixing them with water, adding some chocolate syrup, and having the child drink the mixture. This concoction tastes much better than the liquid steroid mixture (Prelone). When a child needs to ingest contrast dye for a computed tomography scan, Tracy suggests that you try adding a sweetened soft drink mix (eg, Kool-Aid) to the chilled dye. She says the children drink this mixture much more easily than the dye alone. However, you should add only a small amount of diluent to the medicine so that you do not increase the quantity of the medicine by much—if children are given a large amount of medicine, they may not ingest all of it.

Another pediatric medicine administration tip is to beware of how you cut a suppository. The medicine portion is not necessarily distributed evenly throughout the suppository (a portion of the suppository may not include any medication), and you may cut off the entire dose. Check with the pharmacist or manufacturer about how to cut suppositories.

Add a squirt of chocolate syrup to the charcoal, and they drink it right down. She also recommends using tablets and chocolate syrup when giving children steroids. She suggests crushing the tablets, mixing them with water, adding some chocolate syrup, and having the child drink the mixture. This concoction tastes much better than the liquid steroid mixture (Prelone).

Tracy tells me that at her facility they do not allow children to suck pacifiers during an aerosol treatment, because the aerosol ends up trapped in the nasal hairs and they do not get the benefit of all of the medicine. Let the child scream a bit, Tracy says—it helps the medicine find its way into the lungs much more easily.

At a recent Emergency Nursing Pediatric Course, someone mentioned another pediatric tip that I found helpful. When a child needs a nebulizer treatment, have the parent or caregiver hold the child. Tape the tubing inside the blanket, facing upward toward the child's face. While the parent/caregiver is holding the child with the blanket wrapped about them, the treatment is blowing up at the child. They receive the benefit of the treatment and the comfort of their caregiver and blanket at the same time.

If you are starting an intravenous infusion on a baby and cannot find a vein, try using an otoscope. Shine the otoscope under one of the baby's limbs—the bright light helps to illuminate those tiny veins. Tracy told me that at her facility they use an aardvark (ie, a fiberoptic light used to illuminate tiny veins in the neonatal intensive care unit) to illuminate the veins, but that the otoscope does a great job in the emergency department.

Children always void when you attempt to draw blood or start an intravenous line, and thus placing the bag first usually guarantees success. If all you need is a dipped urine specimen and the child is still in diapers, she suggests putting 4 × 4 pieces of gauze in the diaper. When the child urinates, squeeze the urine from the gauze onto the urine dip strip and you can then take the reading.

A treatment that you can pass on to parents of children with diaper rash is affectionately called “butt cream.” Tracy says that when children present with gastroenteritis and have sore, excoriated buttocks, they mix up a batch of this cream to send home with the child. She uses a tube of zinc oxide (2 oz) or Desitin ointment and mixes it with 5 packets of A and D Ointment (5/32 oz) and 5 packets of Polysporin Ointment (1/32 oz) in a sterile urine container. The mixture protects the skin against moisture, is soothing, and has the added benefit of providing vitamins and antibiotic therapy for faster healing. Mothers can obtain all of these ingredients at their local drug store.

Finally, according to ENA's Emergency Nursing Pediatric Course manual, buffering lidocaine hydrochloride with 1 part sodium bicarbonate to 10 parts lidocaine hydrochloride 1% decreases the pain of an injection. This procedure is simple to implement when a topical skin anesthetic (eg, lidocaine hydrochloride, epinephrine hydrochloride, and tetracaine hydrochloride) is used, and the pain of the injection is decreased even further.¹

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Violence in the emergency department 

How can we make the emergency department a safer place for us to work and care for our patients? 

ENA has a position paper on violence in the emergency care setting² that emergency nurses can access on the ENA Web site at www.ena.org . Sergeant David Adler, EMT-P, of the Philadelphia Housing Police Department, also has some common-sense tips to offer. He specializes in tactical EMS and domestic terrorism and practices with the Burholme First Aid Corps. Adler suggests meeting with hospital administrators, because they are the ones who eventually will be implementing the solutions. He says that nurses should address their concerns to the administrators and let them know that many security measures can be put into place discreetly while still protecting the staff.

Having a uniformed police officer assigned to the emergency department is ideal. Many university hospitals maintain their own fully empowered police forces and regularly assign officers to the hospital.

Training is one area in which measures can be implemented. Nursing staff can receive training in how to manage violent persons, including early identification of signs of an impending attack, how to verbally de-escalate a situation, and, if all else fails, some simple self-defense techniques that can be used in the event of a sudden assault. Several states have penalties for assaulting nurses, but they apply only if you prosecute your attacker. If you are assaulted and press charges, this decision should be supported by the hospital administration. Whether you press charges or not, the incident needs to be reported and fully documented.

Adler told me that specially trained and armed security personnel should screen patients and visitors for weapons. Security should also be alert for signs of alcohol and drug use, which are often associated with violent outbursts. Having a uniformed police officer assigned to the emergency department is ideal. Many university hospitals maintain their own fully empowered police forces and regularly assign officers to the hospital. If you work in a private hospital, talk to your local police department to see if they are willing to dedicate an officer to the hospital.

My hospital (St Mary's in Waterbury, Conn) has a red phone in triage and at the nurses' station that is directly linked to the police department. We pick up the phone in an emergency and do not have to dial because it is directly connected to the police department. This system works well because the police department is only one block away and officers can be at our door in seconds from the time we pick up the phone.

According to Adler, our first line of defense should be the entrance to our departments. If we can limit access to our emergency departments, we can increase security. Having dedicated personnel enforce the visitor restrictions helps to limit access. Restricting access is always very difficult, but we can add protection with the use of metal detectors, package scanning, and inspection. Adler says that patients brought in by EMS should also be checked, because the prehospital environment is uncontrolled and unpredictable. EMS personnel may have missed something, and we should always reinspect the patient. Adler also states that having a locked door or a door that is accessible only by badge entry limits unauthorized access from within the hospital and helps to increase a department's security.

Safety in the workplace is a right, says Adler, not a privilege. For more information, you can contact David Adler at David.Adler@pha.phila.gov.

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References 

1. Emergency Nurses Association . Emergency Nursing Pediatric Course. 2nd ed. Park Ridge (IL): : The Association; 1998;
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2. Emergency Nurses Association . Violence in the emergency care setting (position statement). Park Ridge (IL): : The Association; 1999;
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