1. Fever
"The Patient has a fever."
- Does the patient have a known source for the fever? If not, go examine the patient and look for a source.
-After evaluating the patient, ask yourself which studies might be helpful in identifying the source (CXR, UA, throat swab, blood Cx, sputum Cx, urine Cx, LP).
- Is this a patient in whom you should start empiric antibiotics after drawing cultures (i.e. neutropenic, sickle cell, etc.).
- If the patient already has a known source and you decide no new studies are warranted, you may give tylenol or ibuprofen based on weight. Always consider whether a patient's medical condition might prohibit either of those meds, though (renal failure, thrombocytopenia, hepatic issues). Remember that neutropenic patients should not receive suppositories.
2. IV line
"The IV came out."
- Does the patient really need the IV replaced? The goal is always to minimize unnecessary painful procedures. Is the patient receiving any meds that can only be given IV or is the patient now clinically at the point where it would be OK to change to PO (or IM) meds.
- Does the patient need the IV fluids or TPN that were running through the IV? Is the patient NPO for some reason? If not, how is their current PO intake? How has the urine output been? Are they still dehydrated?
- Is the patient unstable, and therefore might need an IV access acutely (i.e. at risk for seizures, resp. distress, etc.).
-If IV access is indicated, don't be intimidated by challenges from nursing. Ask for their advice, and explain your reasoning.
3. Breathing Treatments
"Can the patient's breathing treatments be spaced?"
- Go and listen to the patient just before the next treatment is due, and look any signs of increased work of breathing.
- How are the SATs?
- If the patient sounds good and is comfortable, the treatments may be spaced.
- See how the patient is doing on the new schedule.
4. Blood in stool or emesis
"Patient's stool/vomit is blood tinged."
- Did they eat anything red? See if indeed gastroccult/hemoccult positive.
- Does the patient have any reason to explain the blood (i.e. NG tube recently placed, recent nosebleed, anal fissure, etc.)?
- If it appears to be an isolated incident, the patient is clinically stable, feels well, and the amount of emesis or blood was small, it is usually safe to watch the patient carefully without immediate intervention.
- Be sure to followup on this complaint often. If it continues or worsens, it can turn into something (e.g., briskly bleeding AVM) serious quickly. Let your upper level resident know.
5. Decreased urine output
"I just finished adding up the urine output last shift, and it's low."
- A well hydrated pediatric patient should make at least 1-2cc/kg/hr.
- What are the vital signs? Is the patient dehydrated and in need of fluid? What was the intake? Any recent BMP/labs? Is this a new issue?
- Go see the patient. Does the patient have any clinical signs of dehydration (tachcardia, dry mouth, sunken fontanel, decreased tear production)? If so, give PO or IV fluids. If not, is the patient edematous, and in need of diuretics? Is the patient already on diuretics, and what is the dose?
- Could the patient have a mechanical obstruction to urine output such as a malfunctioning Foley or recent catheterization making urinating painful?
-Ask the parents if there was any urine the nurse didn't know about.
6. Feeding problems
"Patient is not tolerating feeds (PO, NG, or GT)."
- Is this an infant in whom difficulty with feeds is a sign of something else (i.e. sepsis, meningitis, necrotising enterocolitis, obstruction etc.)?
- Based on these considerations, is simply holding PO feeds and giving IV fluids appropriate, or is further evaluation necessary?
- Consider abdominal imaging, electrolytes, CBC, cultures. - If this could be a surgical issue, get surgery involved early.
- Monitor vital signs and patient closely.
7. Change in Mental Status
"Patient seems to be acting differently than before."
- Do a bedside accucheck, and feed or give dextrose if needed.
- Consider sending BMP, mg, phos, CBC. and ABG STAT.
- Does the child have an underlying neuro condition (seizures, tumor, shunt, etc.). If so, could the noted change in mental status be related to the known underlying disorder?
- Consider CT head, esp if focal neuro deficit.
- Call neurosurgery if patient is a neurosurgery patient.
- Could one of the child's medications be affecting their mental status?
- Make sure airway is protected and provide support if needed (ABCs...)
- If airway is at risk or aspiration concerns, make patient NPO.
8. Pain
"Patient is in pain...what do you want to do?
- Is this a new pain or an under-treated old pain? If this is a new pain or the pain has changed in character, work up the pain as appropriate. If this is an undertreated old pain, re-evaluate the patient's pain meds.
- Can the patient safely receive more pain meds or more frequent dosing?
- Is anxiety contributing to the pain, and if so, if it being treated?
- If you are at all uncomfortable with changing the patient's pain meds, ask for help (resident, pharmacist, attending).
- Remember that the most common side effect of pain meds is respiratory depression. Also, monitor for constipation. Also, never underestimate the value of nonmedical therapies (change in position, toys, etc.).
9. Difficulty breathing
"Patient is breathing heavy."
- Go see the child.
- What are the vital signs and SATs?
- Does the child have decreased air movement or wheezing and needs albuterol?
- Does the child have crackles and need either a diuretic to treat pulmonary edema or antibiotics to treat pneumonia?
- Get a portable CXR and STAT ABG measurement if indicated.
-Provide supplemental oxygen.
- If you cannot easily get the child comfortable, consider transfer to the PICU. Remember that, in children, cardiopulmonary arrest is usually due to respiratory arrest, and these children can go downhill quickly.
10. Parents have questions
"Patient's family wants to speak to a doctor."
- Parents invariably have questions at night when you are cross-covering, and you may not know that patient's story as well as you know your own patients'.
- Ask the nurse if he/she knows what the parent's specific questions are. Then you can be prepared when you enter the room.
- Review the chart to familiarize yourself with the patient.
- If you do not know the answer to the parents' question, tell them you will find out from the primary team in the morning, and get back to them as soon as possible. Make sure you actually follow up!
- Remember, update the parents of your primary patients often, so that you will not put your colleagues in this position when they are on call.