Piaget’s (1993) theory of cognitive development in children aged two to seven is linked to 4 stages, and that they may have trouble in distinguishing real from unreal. In this they lack the ability to generalise about things or to make deductions. Meaning that the child may not realise the need to complain formally about their pain in order to get relief from it. However, this is contested by Castiglia (1992) who suggests that there are 8 stages of these hypotheses and by the age of six, the child can relate to the pain resulting in the perception and response to previous similar stimuli.
Feelings
This was the first day of my second set of placements, and although the A&E staff knew the objectives of my purpose in the department, I had met with some resistance from the Emergency Practice Nurses (EPN’s) who opposed the idea of ECP’s and they had been reluctant to monitor/mentor me. Hawkins and Shohet (1989) identified this behaviour as destructive and that we should learn to manage these individuals and attempt to understand how they operate. Holloway and Whyte (1994) agreed with this concept, and the apparent behaviours were not the qualities expected from enablers (mentors). However, the Doctors in contrast were very supportive and interested that I should gain as much valuable experience as I could.
I felt unsettled, although I tried not to show it to Jamie or his mum. The fact that I had been a state registered paramedic (HPC) for thirteen years and had attended many paediatric 999 calls, and felt mostly comfortable in dealing with children, seemed along time ago. Benner (ref) might have suggested that there was a conflict of feelings due to being a student, and that I was struggling to comprehend why I felt so out of my depth, was probably the fact that I had to take over the responsibility of treatment instead of leaving it to the hospital staff. i.e. novice to expert. I was really unsettled with the idea of having to perform a procedure that I had very little experience of, on a child. Jamie was in fact the first child I had examined in my placements. Burnard (1994) suggests that some practitioners find the treatment of children to be somewhat difficult. This may be due to our (as adults) perception of the fact that they are smaller, and speak using differing language and expressions. However, it is important for the children to be given the opportunity to express themselves and they need a practitioner that is able to relate to them, in order to install a sense of trust and understanding of their needs. With this in mind, I think my main objective was not to upset Jamie and make him cry, so I had to make use of the skills I had gained as a mother. I knew how important it was to get down to the child’s level and to incorporate distraction techniques to good effect. I also knew the importance of not rushing and the initial interaction with Jamie would be vitally important to a successful outcome. (Pantell et al 1992). I also tried to find common ground to discuss, and soon found out he liked football and his favourite team was Arsenal.
Evaluation
I realised that it was not just Jamie I had to deal with but his mother as well (Pantell et al 1992), particularly as she was going to be present throughout. It was just as important to keep mum relaxed so she would not convey any negative anxious feelings to her son. This however, did not appear to be a major problem as mum and her son appeared to have a good rapport. I also understood the importance of addressing Jamie and not focus my attention to his parent (Pantell et al 1992), it was important for him to tell me the story of what had happened.
I completed my initial assessment of Jamie, which had consisted of his presenting condition, his history of his presenting condition, past medical history. I then attempted, with a degree of success, to put in plain words what I was going to do and that afterwards I would have to have a good look at his wound.
My overall impression of Jamie was that he was a well-behaved sensible child, that he might not get too upset at my attempts to review his wound. I asked Jamie to look up and count the flies on the ceiling, hoping this distraction (ref) would be long enough for me to inspect the wound and assess how deep it was and whether I could see the base of the laceration. The wound appeared to be approximately 2 cm long and I could easily see the base of it, and it had not bleed now for about half an hour. Looking puzzled, Jamie then exclaimed there were no flies in the room. Fortunately, my distraction had worked. I was now able to leave Jamie with his mother whilst I documented my clerking notes to enable me to present the case to the A & E Doctor.
Once I had presented this case to the A&E Doctor, he asked me what my treatment plan was. Due to the nature of the wound, and its position under the fleshy part of Jamie’s chin, he was quite happy with the fact I had just decided to steri-strip the wound and not gone down the route of gluing or suturing. The Doctor continued to ask me why I had decided to do this. I answered by telling him that the child was only 6 years old and the laceration was not too painful, but he was however, a little bit frightened, as he had no previous recollection of pain. (ref). I also told him I didn’t want to startle Jamie, as he would only remember the negative part of the hospital treatment. The Doctor then asked one of the ENP’s to help get the items ready for me to perform the steri-stripping as one of the problems was finding out where the materials were kept. The ENP clearly was not amused at having to do this, however, she did relent and I went with her to get the bits and pieces ready.
I managed to find an old football annual in the waiting area that might help to distract Jamie whilst I performed the steri-stripping. When I had collected everything and assured the ENP that I could cope ok, I re-entered the cubicle where Jamie and his mother was. As I handed over the book, he started to grin, and understanding his facial expression, eye contact and his relaxed posture leaning against mum, I soon began to relax with him. I bobbed down in front of Jamie who was now flicking through the pages of the book. As I unravelled the items required I explained to Mum what I was about to do. Jamie was not so keen to look for flies this time as he did not see any before and the book was distracting him too, so I got on and cleaned the laceration with a little difficultly because I couldn’t see it properly as Jamie was looking down. I asked him to just look up for a couple of seconds promising that he could look through the book in a moment, but he would have to be still and do it again in a moment so I could place the steri-strips in the exact places. At this stage his mum promised him a little treat, as he had been very good.
I felt elated as I placed the first strip squarely over the wound, more difficult than it appeared as my hands were shaking slightly. I started to relax when I had the last one completed. It looked quite neat and there was no residue of blood. I then asked Jamie how it felt. He said it was okay and shrugged his shoulders. Totally bored by the whole episode but still looking through the annual. I was very relieved and glad the incident was over, and what on earth I had been worried. I knew I was more than capable but it was one of the scariest moments in my career. In order to deal with more complex matters, that will arise in the future, I learnt so much through this simple encounter with Jamie.
Conclusion
Jamie was a 6-year-old boy, was brought in to the A & E Department where I assessed and examined him in my role as a student ECP. There were aspects of the consultation that I felt were good and bad but on reflection it was more successful than I anticipated it to be. The A & E Doctor praised me for my concise and accurate history taking skills and the conducting of a thorough physical examination of a child. Both the Doctor and myself went back to the cubicle to speak to Jamie and his mother to discharge Jamie with advice on what to expect in respect of his injury, and should they have any concerns, contact their General Practioner’s practice or return to the minor injury unit. Jamie and his mother thanked me and left the department to go home.
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