What Does a Pediatric ICU Nurse Do?

If you’re considering working as a nurse in the Pediatric Intensive Care Unit (PICU) but are unsure about the responsibilities, you’ve come to the right place! In this post, we will explore the pediatric ICU patient population, mastering pediatric ICU nurse skills, common equipment and technology used in the PICU, medication administration, emergency preparedness, and much more.

Understanding the PICU Population

The age range in the PICU typically spans from a few weeks old to late adolescence, and the conditions treated can vary widely, from severe respiratory issues to complex post-operative care. The PICU stands apart due to the acuity and duration of care required, where you must be prepared to handle rapidly changing situations and provide highly specialized interventions.

Caring for pediatric patients in the PICU is fundamentally different from caring for adults. Children are not simply small adults; their bodies, minds, and emotions operate differently, and these differences profoundly impact how they respond to illness and treatment. Let’s explore what that means.

Children Are Not Small Adults

One of the most critical distinctions between pediatric and adult patients is how their bodies function and react to medical conditions. Here’s a practical example.

In adults, dehydration is often a slow process that develops over days, and adults generally can recognize early signs like thirst, dry mouth, or reduced urine output, allowing for early intervention. The body’s response is more gradual, and adults can usually compensate for mild dehydration by simply increasing fluid intake.

However, dehydration can occur much more rapidly in children, particularly infants and young children. For example, a child with gastroenteritis (stomach flu) who is vomiting and has diarrhea can become dangerously dehydrated in just a few hours. Their smaller body size means they have less fluid reserve, and they are less able to communicate or recognize symptoms early on. Additionally, children are more likely to refuse fluids when they feel unwell, worsening their condition quickly.

In the PICU, this means a child with dehydration might need aggressive fluid resuscitation much sooner than an adult would. Their electrolyte levels need to be closely monitored because imbalances can happen quickly and can be life-threatening. This rapid progression requires PICU nurses to be vigilant in assessing fluid status and responsive in initiating treatments that stabilize the child, often using IV fluids with precise electrolyte compositions tailored to the child’s needs.

A wise pediatric nurse told me that children compensate well for a long time and seem completely fine, but then when they start to go downhill, it’s fast.

Developmental Stages and Patient Participation

A child’s developmental stage dramatically influences how they perceive illness and participate in their care. A toddler, for example, might not understand why they need a painful procedure, leading to fear and resistance. They might need extra comfort, distractions like toys or videos, and simple explanations tailored to their level of understanding. 

On the other hand, a teenager might comprehend more about their condition and be involved in decision-making, but they also might struggle with the emotional aspects of being critically ill, needing both autonomy and support.

Excelling in the PICU means that you’re not only keenly aware of the physiological changes that occur when the body grows, but that you also know where they are in terms of mental and emotional development. This enables you to provide appropriate education and support. 

It’s Not Just About the Kid

While all areas of healthcare recognize the importance of involving families, the PICU is unique in that the child is the patient, but their parents or caregivers are the ones making decisions on their behalf. This dynamic means that as a PICU nurse, you are not just educating and caring for the child; you’re also guiding the family through the complexities of their child’s care.

You may have to explain a procedure or treatment to a frightened child in simple, comforting terms while simultaneously providing the parents with a detailed, technical explanation so they can make informed decisions. This dual role of educating both the child and the parents adds another layer of complexity to the PICU, as you must be able to communicate effectively with both audiences, often in highly stressful situations.

In many ways, it’s like having a whole family as your patient rather than an individual autonomous adult.

The child may not fully understand what’s happening, and their emotional response can heavily influence the family dynamic. The parents are often dealing with their own fears and anxieties, requiring you to offer not just medical information, but also emotional support and reassurance. Your role is to bridge the gap between the medical world and the family’s needs, ensuring that both the child and the caregivers feel informed, supported, and cared for throughout their time in the PICU.

Parents are understandably emotionally vulnerable when their child is critically ill, often feeling overwhelmed and frightened. As a PICU nurse, your ability to provide calm, warm, and compassionate care can make a world of difference, offering the reassurance they desperately need; conversely, being short or distant can exacerbate their fears, making an already difficult situation even harder to bear.

Simply put: PICU nurses have the power to help make a painful and difficult situation easier to bear, or make it much worse. 

Mastering PICU Nursing Skills

Mastering the skills required to excel in the Pediatric Intensive Care Unit (PICU) is essential for providing the highest level of care to critically ill children. Below, we explore the top diagnoses that commonly land a child in the PICU, essential nursing equipment, the unique aspects of pediatric medication administration, the mental health considerations for PICU patients, and the importance of emergency preparedness.

Top 10 Diagnoses That Land a Child in the PICU

During your nursing school education, you’ll learn about a lot of different diagnoses and situations that children face. However, not all of them will require treatment in a PICU. To excel as a PICU nurse, you have to know the top diagnoses that you will see. 

As a seasoned nurse educator, I highly recommend focusing on these first because they are need-to-know situations. (Let’s save nice-to-know for when our heads are above water!) While we could debate what the top 10 diagnoses for all PICU units look like, this is a general list of the most common ones. If you are at a specialty hospital, like St. Jude’s, this list would look quite different. 

Respiratory Failure: Often caused by conditions such as asthma, bronchiolitis, pneumonia, or acute respiratory distress syndrome (ARDS), requiring mechanical ventilation or other respiratory support.

Sepsis: A severe, systemic infection that can lead to multi-organ failure, necessitating aggressive antibiotic therapy and intensive monitoring.

Traumatic Brain Injury (TBI): Resulting from accidents or falls, TBI can lead to increased intracranial pressure and requires careful monitoring and intervention.

Congenital Heart Defects: Children with complex heart conditions often require surgery and post-operative care in the PICU to manage complications like arrhythmias or heart failure.

Post-Operative Care: Following major surgeries, such as neurosurgery or complex abdominal surgeries, children may need intensive care to stabilize and monitor their recovery.

Diabetic Ketoacidosis (DKA): A life-threatening complication of diabetes, where blood sugar levels become dangerously high, requiring insulin therapy and fluid replacement.

Severe Asthma Exacerbations: Children with uncontrolled asthma may experience life-threatening attacks that require intubation and intensive bronchodilator therapy.

Status Epilepticus: Prolonged or repeated seizures that do not respond to initial treatments, necessitating intensive monitoring and medication management.

Poisoning or Overdose: Accidental ingestion of toxic substances or medications that require close monitoring, antidotes, and supportive care.

Multi-System Trauma: Resulting from accidents, falls, or violence, these cases require coordinated care to manage injuries across multiple body systems.

Common PICU Nursing Equipment

A common nursing responsibility for any ICU-level nurse is safely using complex medical equipment to support your patient. Much of the equipment listed below is consistent with the adult population; however, they may have different considerations and settings to accommodate kids. 

Ventilators: Machines that provide mechanical breathing support to patients who cannot breathe adequately on their own.

Infusion Pumps: Devices that deliver precise amounts of medication or fluids over time, critical for managing pediatric doses.

Cardiac Monitors: Equipment that continuously tracks heart rate and rhythm, essential for detecting early signs of deterioration. This is likely a 5-lead telemetry set-up, hooked up to a bedside monitor, where the PICU nurse is always aware of what’s going on.

Intravenous (IV) Lines: Catheters are placed into veins for fluid and medication administration; careful management is crucial to prevent dislodgement in children.

Pulse Oximeters: Non-invasive devices that measure oxygen saturation in the blood, helping to monitor respiratory function.

Central Venous Catheters (CVC): Long-term IV lines inserted into large veins, often used for delivering medications that require precise control, such as chemotherapy. (Important note, central lines are different from midlines!) 

Arterial Lines: Catheters placed in an artery to monitor blood pressure in real-time and obtain blood samples for analysis.

High-Flow Nasal Cannulas: Devices that deliver heated, humidified oxygen at higher flow rates than standard cannulas, often used in respiratory distress.

Syringe Pumps: Specialized infusion pumps that deliver very small, precise doses of medication, critical in pediatric care.

Chest Tubes: Tubes inserted into the pleural space to remove air, fluid, or pus, commonly used in cases of pneumothorax or after thoracic surgery. Not all PICU kids will require these devices. In all patients, but children in particular, it’s imperative to use the least amount of equipment possible. Therefore, once something is no longer medically necessary, it should be discontinued. 

Pediatric Medication Administration

Administering medication to pediatric patients is notably different from adult care due to the reliance on weight-based dosing. Almost all pediatric medications are calculated based on the child’s weight in kilograms to ensure accuracy and safety.

“Why is everything weight-based!?” you ask. 

Well, children’s medications are weight-based because their bodies are still growing and developing, which affects how they metabolize and respond to drugs. Using a child’s weight ensures that the dose is appropriately tailored to their size and physiology, preventing under-dosing, which may be ineffective, or overdosing, which could lead to serious side effects or toxicity. So, it’s annoying that you have to make a custom dose basically every single time, but it is 100% necessary. 

Another way medication administration is different in the pediatric population is because young children and babies cannot simply swallow pills like adults. Medications may be given as liquids, through IV lines, or even rectally if needed. Nurses must also be particularly cautious with IV sites, as children are more prone to removing or dislodging their IVs, necessitating secure placement and frequent checks.

Mental Health in the PICU

Mental health considerations are critical in the PICU, especially since many children have pre-existing behavioral issues that can be exacerbated by the stress of a new, frightening environment and concurrent medical conditions. For example, a child on the autism spectrum may struggle with the sensory overload of the PICU, while a teenager might grapple with body image issues or identity formation, making them resistant to treatment or less cooperative with the medical team.

Puberty further complicates the picture, as adolescents may be dealing with emotional turbulence and the challenges of growing independence. Their reactions to illness and treatment can be unpredictable, which requires you to be sensitive and adaptive in your communication and care strategies.

Emergency Preparedness: Pediatric Codes and Rapid Response

Emergency preparedness in the PICU is vital because pediatric codes and rapid response calls differ significantly from those in adult care. Children’s physiology, smaller size, and varied developmental stages require that emergency interventions be tailored specifically to them.

During pediatric codes, the team must quickly calculate medication doses based on the child’s weight, which is critical for effective resuscitation. Equipment sizes, such as endotracheal tubes and defibrillator pads, are also different, and the approach to airway management must consider the anatomical differences between children and adults. 

Additionally, the emotional response from the family during a pediatric code can be intense, requiring not just medical expertise but also compassionate communication and support from the healthcare team.

The Not-So-Glamorous Aspects of PICU Nursing

Being a pediatric ICU nurse is a pretty rewarding career. You have the privilege of making a profound impact on the lives of children and their families. You get to see children recover from life-threatening conditions, help them through complex medical procedures, and provide comfort and care during some of the most critical moments in their lives. The skills you develop—responding to emergencies, managing intricate medical equipment, and administering life-saving treatments—are impressive and make a real difference. 

When you tell others that you are a PICU nurse, people will be immediately impressed. It feels awesome. 

But it’s essential not to romanticize this role. There are a lot of not-so-amazing and downright awful parts of this job that must be carefully considered before embarking on this career path. 

(But bonus points if you can speak to your awareness of this in the interview process to demonstrate that you’re ready for the challenge ahead and not walking in blind.)

Pediatric care often means confronting the harsh realities of life, including seeing children who have been abused, abandoned, or hurt by those who are supposed to love and protect them. These experiences can be heart-wrenching, leaving you questioning the world around you.

Also, you may encounter unhealthy family dynamics that are frustrating to observe, leaving you feeling powerless to change. Navigating these situations requires not only clinical expertise but also a deep well of emotional resilience and empathy. You’re not just treating a patient; you’re often dealing with the complexities of their entire family system.

One of the most challenging aspects of PICU nursing is coping with the death of a child. As an adult ICU nurse, dealing with death is hard, but it’s even more difficult when it involves children who should have their whole lives ahead of them. The loss of a young life is a profound tragedy, and it’s something that can weigh heavily on your heart and mind. The emotional burden of these experiences is significant, and it’s important to acknowledge that while PICU nursing is rewarding, it comes with a high emotional cost.

(For a very real conversation about taking care of critically ill patients and how to proactively prevent burnout, watch the video below. 👇)

In the end, while the work you do in the PICU is vital and can be life-saving, it’s also a role that requires immense emotional strength, compassion, and self-care to manage the toll it can take on your mental and emotional well-being.

What Does a Pediatric ICU Nurse Do: Final Thoughts

Excelling in the Pediatric Intensive Care Unit (PICU) is about more than mastering clinical skills; it’s about embracing the profound responsibility of caring for the most vulnerable patients—children. 

While the technical aspects of PICU nursing are essential, it’s your compassion, resilience, and ability to support both the child and their family that will truly make a difference. The journey is challenging, often emotionally taxing, but also incredibly rewarding as you’ll play a crucial role in helping children overcome some of life’s toughest battles.

For those stepping into this specialty, remember that while the PICU can be intense and demanding, it’s also a place where your efforts will have a lasting impact on countless lives. Embrace the challenges, seek support when needed, and always remember the difference you’re making each day.

More Resources

1. 9 Tips to Excel as a PICU Nurse: A Comprehensive Guide
2. Behind the Scenes of Oncology Nursing: Insights from Two Nursing Leaders at St. Jude’s
3. Mastering Common ICU Drips: A Nurse’s Guide to Lifesaving Medications
4. All About IV Pumps – Smart Pumps, Syringe Pumps, Oh My!