WELCOME TO ETCH!

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WELCOME TO ETCH!
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This module contains

• Instructions for completion of module
• Welcome to ETCH
• Service Excellence
• Family-Centered Care
• Child Life
• No Information Patient
• Patient Safety Goals
• Restraints
• Isolation/Infection Control

• Pain Management
• Child Abuse
• Death Dying
• Emergency Codes
• Pneumatic Tube System
• Dress Code
• Parking and Other Info
• Forms to Complete

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Instructions for Completing the ETCH Module

• Carefully read through the entire module.
• When you have completed the module, download the
  Completion Form and the Information Security
  Compliance Statement Form.
• Sign these two forms and turn in to your
  instructor.
• IMPORTANT! These forms, along with your
  Centralized Student Orientation transcript and
  immunization record, MUST be in the ETCH
  Education office PRIOR to your clinical rotation!

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Our Philosophy
Because Children are Special
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Our Mission

• Delivery of Care to patients between the ages of
  birth to 21 years, in the East Tennessee and
  surrounding region
• Education of patients, families, the community,
  students in medical disciplines, ETCH employees
  and healthcare providers in the CRPC area
• Research through participation in the BENCH
  networking program
• Community Involvement

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ETCH History

• Opened in 1937 and located on Laurel Ave.
• Originally called Knox County Crippled Childrens
  Hospital

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ETCH History

• Moved to 21st and Clinch in 1970
• 2018 Clinch Ave
• P.O. Box 15010
• Much expansion since then

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ETCH 2007 155 bed facility with multiple
pediatric subspecialties
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East Tennessee Childrens Hospital offers many
services such as

• Child Life
• Pastoral Care
• Social Work
• Specialty Outpatient Clinics
• Home Health Services
• Rehabilitation Services
• Clinical Nurse Specialists in the areas of
  Surgery, Critical Care, Hematology/Oncology, and
  Pulmonary Care
• Nutrition Services
• Healthy Kids Program
• Ronald McDonald House

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Service Excellence

• Our Responsibility. Our Commitment.
• Childrens Hospital

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People dont carehow much we knowuntil they
know how much we care.
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Service Excellence VisionTo be the kind of
organization wherechildren and familieswant to
come for care,physicians want to
practice,andemployees want to work.
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Service ExcellenceOur Responsibility. Our
Commitment.Statement of PurposeWe strive to
give extraordinary care and service to our
patients, their families, members of the
Childrens Hospital family, and the communities
we serve.
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Our Philosophy of Service ExcellenceWe take
pride in our professions and feel personal
ownership and responsibility for achieving
Childrens Hospital mission.We seek
opportunities to be friendly and to help
patients, families, and coworkers.We are always
courteous and respectful.We show care and
compassion by acknowledging peoples
feelings.We demonstrate respect for privacy and
confidentiality in all we do.We never tire of
explaining what to expect, what we are doing, and
why.We try to understand how our work affects
others and look for ways to help each other.We
respect diversity among our patients, families,
co-workers and community.
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SHARE Service Excellence in Action

• S SENSE peoples needs before they ask.
• H HELP each other our through teamwork.
• A ACT with empathy and compassion.
• R RESPECT the dignity and privacy of others.
• E EXPLAIN what is happening.

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Customer Satisfaction A fools gold?What is
fools gold? Something that looks more valuable
than it really is. Lets compare the difference
between customer satisfaction and
loyalty.The customer satisfaction
formulaDoing it right the first timeeffective
complaint handlingThe customer loyalty
formulaDoing more than is expectedDoing more
than the situation warrants
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Does customer satisfaction customer
loyalty?On a five-point scale, people who mark
a 4 (satisfied), compared to those who mark a 5
(very satisfied) are 5 times more likely to
defect to the competition.Satisfaction is based
much on convenience, while loyal customers will
often drive longer to seek out your services
because of the way they are treated and the
service they receive. Loyal customers will tell
others about how good you are---they have a story
to tell.What separates the excellent from the
best?Nothing---They do the same things
especially more consistently and under pressure
over time.
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The secret of excellence is consistency and the
enemy of excellence is too much
variation.Organizations with a reputation for
world-class service simply know how to attract
and keep individuals who will deliver the same
courteous, compassionate care, day in and day
out, regardless of the circumstances.
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ATTITUDE The one thing I have control over

• An attitude is my frame of mind when I approach a
  situation. I choose my attitude in every
  situation.
• Stimulus--------Interpretation----------Response
• All emotional growth in life occurs in the
  interpretation phase.
• Learn to ask What would cause me to act like
  that?
• Asking this simple question when we are faced
  with difficult people can help us maintain
  tolerance and even compassion for our patients,
  families, and co-workers.

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Non-Verbal Communication

• 93 of what we communicate in attitude is
  non-verbal.
• 7 In words
• 38 By tone of voice
• 55 By body language
• And its done in the first few seconds. Even in
  job interviews by a professional, the decision is
  essentially made in 20 seconds!

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Never get tired of explaining!

• 75 of all medical malpractice lawsuits could
  have been prevented by explaining things better.
• One of the most common complaints patients and
  their families have is that things were not
  better explained.
• The highest ranked quality desired in choosing a
  doctor is the doctors willingness to listen and
  explain in words I can understand.

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AttitudeThe longer I live, the more I realize
the impact of attitude on life. Attitude, to me,
is more important than facts. It is more
important than the past, than education, than
money, than circumstances, than failures, than
successes, than what other people think or say or
do. It is more important than appearance,
giftedness, or skill. It will make or break a
company a church a home. The remarkable thing
is we have a choice every day regarding the
attitude we will embrace for that day. We cannot
change our past we cannot change the fact that
people will act in a certain way. We cannot
change the inevitable. The only thing we can do
is play on the one string we have, and that is
our attitude. I am convinced that life is 10
what happens to me and 90 how I react to it.
And so it is with you we are in charge of our
attitudes. Charles Swindoll
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Child/Family Centered Care

• Childrens Hospital
• Knoxville, TN

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Definition of Child/Family Centered
CareChild/Family Centered Care is an approach
to the planning, delivery, and evaluation of
health care that is grounded in mutually
beneficial partnerships among health care
providers, patients, and families. It redefines
the relationshipsbetween and among consumers and
health providers.
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Child/Family Centered practitioners recognize
the vital role that families play in ensuring the
health and well-being of infants, children,
adolescents, and family members of all ages.
They acknowledge that emotional, social, and
developmental support are integral components of
health care. They promote the health and
well-being of individuals and families and
restore dignity and control to them.
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Child/Family centered care is an approach to
health care that shapes policies, programs,
facility design, and staff day-to day
interactions. It leads to better health
outcomes, and wiser allocation of resources, and
greater patient and family satisfaction.
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Child/Family Centered Care is the Right Way to
Treat PeopleLeadershipHuman
ResourcesArchitecture and DesignFamily
participation in careCommunicating with
familiesFamily to family support and
networkingLinking families with community
resourcesEducating Child/Family Centered
professional collaboration in policy and program
development
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In Child/Family Centered CarePeople are
treated with dignity and respectHealth care
providers communicate and share complete and
unbiased information with patients and families
that are affirming and usefulIndividuals and
families build on their strengths by
participating in experiences that enhance control
and independenceCollaboration among patients,
families, and providers occurs in policy and
program development and professional education,
as well as in the delivery of care
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In a Hospital that Practices Child/Family
Centered Care, Administrative, Clinical, and
Support StaffRecognize the family is the
constant in the childs lifeFacilitate
collaboration between families and
professionalsHonor the racial, ethnic,
cultural, and socio-economic diversity of
familyRecognize family strengths and respect
various methods of copingShare complete and
unbiased information with parentsEncourage and
facilitate family to family networkingUnderstand
and incorporate developmental needsDesign
accessible health care delivery systems
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Core Concepts

• Strengths
• Collaboration
• Partnership
• Information Sharing
• Support
• Flexibility
• Empowerment

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C/FCC in Action

• Inclusion of parents on Steering Committee
• Increased MD involvement
• Parent Advisor Programs
• Resident Education
• Website Changes
• Chronic Care Parent Notebook
• NICU Journal
• Questions for My Doctor
• Family presence during procedures and codes
• Kangaroo Care in the NICU

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C/FCC in Action, continued

• Orientation / Inservices / CoursesInclusion of
  Family Centered Care Concepts
• Disaster Planning
• Review of Parent Materials
• Family Resource Center
• Welcome Guide for Families
• Inclusion of Parent Advisors on Hospital
  Committees

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Benefits of Child/Family Centered Care

• Improves medical and developmental outcomes
• Leads to health care that is more responsive to
  patient and family-identified needs and
  priorities
• Reduces health care costs
• Enhances patient/family/staff satisfaction

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Age-Specific Interventions

• Age-Specific Interventions are the skills you use
  to give care that meets each patients unique
  needs.

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Every patient is an individual with his or her
own...

• likes and dislikes
• feelings
• limitations and abilities
• experiences

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Everyone grows and develops in a similar way or
stages that are related to their ageBUTat
their own pace.
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Strategies to Enhance Coping

• Newborns Pacifier, Blanket, Soothing sounds,
  Touch, Music
• Toddlers Pacifier, Blanket, Favorite toy,
  Holding a hand, Party Blowers, Blowing bubbles,
  Pop-up books, Toys, Mobiles, Pre-Post Procedural
  play, Play Dough
• Preschoolers Party Blowers, Blowing bubbles,
  Counting, Pop-up Books, Holding a hand,
  Manipulative toys, Computer games, Listening to
  music, Singing songs, Pre-Post Procedural Play,
  Play Dough
• School Age Deep breathing exercises, Music,
  Hand-held games, Computer games, Imagery/fantasy,
  Pretending to be in a favorite place or doing a
  favorite thing, Pre-Post Procedural play,
  Squeezing Nerf balls
• Adolescents Deep breathing exercises, Music
  (head sets are popular), Computer games,
  Imagery/fantasy, Imagine a favorite activity,
  Squeezing a Nerf ball, Hand-held games

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Child Life Specialists-What do they do?

• Child Life Specialists are individuals who have a
  degree in a type of early childhood education or
  development.
• They may sit for a national certification exam
  after obtaining a certain number of clinical
  hours on the job.
• They have many roles, and this may vary
  institution to institution.

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The Role of the Child Life Specialists At ETCH

• Provide therapeutic play for stressed, anxious
  patients.
• Provide play opportunities and other experiences
  which foster continued growth and development and
  prevent adverse reactions.
• Provide developmentally appropriate education and
  preparation to patients for upcoming procedures.
  Help patients express their feelings and cope
  with stress in ways that enhance their sense of
  mastery and self-esteem.

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The Role of the Child Life Specialists At ETCH

• Teach patients appropriate coping techniques
  relaxation, deep breathing, etc
• Provide distraction for patients during
  procedures in the clinical setting and other
  procedural areas in the hospital.
• Initiate medical play with patients to encourage
  the expression of fears and misconceptions.
• Incorporate place to encourage positive
  interactions with taking medicine and other
  behaviors to be in compliance with their
  treatment plan.

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The Role of the Child Life Specialists At ETCH

• Provide planning/scheduling to help with patient
  behavior modification.
• Serve as a resource to all departments relating
  to development and psychosocial issues and
  provide ways by which these needs can be met.
• Provide a means by which the hospital staff can
  make meaningful observations of patients in
  normal play and educational situations to better
  assess the patients progress and needs.

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The Role of the Child Life Specialists At ETCH

• Orient new Child Life students and volunteers to
  the appropriate departments.
• Organize volunteers to provide the following
  services
• Requested toys and supplies
• Visits to the playroom and teen room (inpatient)
• Play at the bedside

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Child Life Staff

• During your rotation, notice the Child Life staff
  and how they interact with your patients!
• Child Life Specialists provide an invaluable
  service to our patients and families here at ETCH!

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No Information Procedure

• East Tennessee Childrens Hospital

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What is the purpose of No Information?

• This procedure provides guidelines for addressing
  a No Information status on a patient and
  outlines steps to initiate, authorize, notify
  personnel, and flag pertinent records.
• The procedure defines a No Information patient
  as one who is not acknowledged as being in the
  institution.
• The procedure provides a basis for all staff that
  may have contact with the patient. Everything is
  done on a need to know basis.

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Who can initiate (ask for) No Information
status?
Legal guardian (HIPAA, admitting sec. will ask) Department of Childrens Services Nursing Staff
Security Officers Social Work Law Enforcement Officers
Community Relations Attending MD
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Who has the authority to authorize (give the OK)?

• Nursing Coordinators
• Nurse Managers
• Nursing Directors
• Social Work
• Security

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Flagging the medical record

• Meditech - admitting flags the patient as
  confidential by preceding the patients name with
  a c (e.g. cSmith, John). This patients
  medical record is tracked by Information Systems.
  All staff DO have computer access to
  confidential patients, but volunteers do not.
• Medical Record chart is flagged with the name
  Cody Seagreen

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Flagging the medical record

• Patient assignment board room number will list
  the name Cody Seagreen
• Label tag with Cody Seagreen
• Patient door sign Cody
• Surgery Schedule actual patient name will be
  listed
• Patient census actual name will print if run by
  authorized personnel
• Over-the-bed card actual patient name listed
  (keep door closed, call child by REAL name)

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Responding to requests for information

• Respond to ALL requests for information with the
  following We have no information on a patient
  by that name.
• Community relations will respond to all media
  requests for information.

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Patient Safety Goals for ETCH

• East Tennessee Childrens Hospital

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Patient Safety Goals

• Improve accuracy of patient identification.
• Improve effectiveness of communication among
  caregivers.
• Improve safety of using medication.
• Universal protocol for preventing wrong person,
  wrong site, wrong procedure surgery.
• Reduce risk of health care-associated infections.
• Accurately and completely reconcile medications
  across the continuum of care.
• Reduce the risk of patient harm resulting from
  falls.

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The next few slides will present the
Patient Safety Goals and the systems in place
here at ETCH to reach these goals.
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Improve Accuracy ofPatient Identification

• Use at least two patient identifiers whenever
  taking blood samples or other specimens for
  clinical testing, administering medications or
  blood products, or providing any other treatments
  or procedures.
• Inpatient units Name and E number (account )
• Clinic uses Name and E number
• ED Uses Name and Birth Date
• Radiology Name and Date of Birth
• Neurology Lab Name and E number

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Improve Accuracy ofPatient Identification

• When treatment involves an Invasive Procedure
  such as
• Vascular catheterizations
• to include PICC lines, femoral lines, etc.
• Endoscopies
• GI procedures and bronchoscopies
• Lumbar punctures
• Implantations
• Extraventricular drains, Intracranial bolt, etc.

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Improve Accuracy ofPatient Identification

• Invasive Procedures (cont)
• Bone marrow aspirations
• Paracentesis
• Surgical procedures performed outside the
  Operating Room
• fracture myringotomies in the ED
• reductions circumcisions
• Then, a Pre- Procedure Checklist, Invasive
  Procedures is to be completed.

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Improve Effectiveness of Communication Among
Caregivers

• Approved abbreviations may be used on any
  permanent charting document. Approved
  abbreviations are those deemed acceptable by the
  Medical Records Committee when charting on a
  patient document in lieu of the written word or
  phrase. Only approved abbreviations are to be
  used.
• Reference Medical Abbreviations and Eponyms,
  2nd Edition, Sheila Sloane, 1997.
• The Registered Nurse must obtain clarification of
  orders from the MD prior to carrying out an order
  containing an unapproved abbreviation or
  illegible order.

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ETCH Do Not Use Abbreviations List

• All Chemotherapy drugs Use the complete spelling
  for drug names.
• MS, MSO4, or MgSO4-(Magnesium sulfate or Morphine
  sulfate) Use the complete spelling for drug
  names.
• TAC-(triamcinilone)-Use the complete spelling for
  drug names.
• Ug-(microgram)-Use mcg
• U or u IU-(Unit or International unit)-Write out
  unit or
• international units
• QD or QOD-(every day or every other day)-Write
  out every day or every other day
• X3d-(Days OR doses)- Write out for three days
  or for three doses
• Zero after decimal point (1.0)-(1 mg)-Do not use
  terminal zeros for doses expressed in whole
  numbers
• No zero before decimal point (.5mg)-(0.5mg)-Always
  use zero before a decimal when the dose is less
  than a whole unit.
• Miscellaneous corrections-Do not write over words
  for corrections. Line or X out errors.

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Improve Effectiveness of Communication Among
Caregivers

• Read-Back Policy
• For verbal or telephone orders, OR for telephonic
  reporting of critical test results, the order or
  result should be read back according to
  procedure. The procedure requires that the first
  and last name of the prescriber be included when
  reading back the order. (Nursing Policy PO4
  Physician Orders Procedure)
• Reporting Results
• Critical test results and lab values must be both
  reported and received by the responsible,
  licensed caregiver in a timely manner.
• Trends in test results must be recognized and
  reported.
• Utilize the Report results to physician/PA/NP
  intervention as part of the care plan to document
• Hand Off Communication
• -Be sure to provide accurate/pertinent patient
  care information to the healthcare provider
  assuming care of the patient, allow time for
  questions

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Improve the Safety of Using Medications

• Remove concentrated electrolytes from patient
  care units. There should be no sodium chloride
  with
• concentrations gt 0.9.
• Standardize and limit the number of drug
  concentrations available in the organization.
• Each unit to develop a list of look-alike, sound
  alike drugs to be reviewed annually to help
  prevent errors
• Label all medications, medication containers on
  and off sterile fields

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• Universal Protocol for
• preventing wrong site,
• wrong procedure, wrong
• person surgery.
• This protocol involves the following steps
• Pre-op verification (documents, patient
  expectations)
• Marking site
• Timeout (active communication)

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Reduce the risk of Healthcare Associated
Infections

• Comply with current CDC hand hygiene guidelines.
• Manage as sentinel events all identified cases of
  unanticipated death or major permanent loss of
  function associated with a health care-acquired
  infection.

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Reduce the risk of Healthcare Associated
Infections

• Full report available at
• http//www.cdc.gov/handhygiene/
• Specific recommendations
• Indications for handwashing and hand antisepsis
• Visibly soiled, use soap and water
• Not visibly soiled, may use alcohol-based hand
  rub
• List of specific clinical circumstances
• Towelettes are not a substitute
• Non-alcohol-based hand rubs not recommended

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Reduce the risk of Healthcare Associated
Infections

• Specific recommendations (cont)
• Hand hygiene technique
• Alcohol-based hand rub until dry
• Soap and water at least 15 seconds
• Surgical hand antisepsis
• Selection of hand hygiene agents
• Skin care
• Other aspects of hand hygiene
• No artificial nails for direct caregivers

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Accurately and Completely Reconcile Medications
Across the Continuum of Care
This goal requires a complete and accurate list
of the patients Current medications be placed on
the chart on admission to the hospital system,
at transfer and at discharge. The list
is compared and reconciled with other prescribed
medications to prevent errors of omission,
duplication, wrong dose etc. All home medications
(including herbals) and new med orders on
admission will be listed on the form. The form
is placed on top of the order section of the
chart. At discharge, any meds the MD wishes to
continue at home should be added to the bottom
of the form. Therefore, the form serves as
both the admission and discharge medication order
sheet for the MD. The Outpatient Surgery nurse is
responsible for obtaining a medication history
and recording on the Pre-Operative Record. The
Outpatient Medication Reconciliation form will be
placed on the chart prior to transport to
surgery. The MD will review and sign the
Outpatient Medication Reconciliation Sheet. The
MD is responsible for filling out the
Admission/Discharge Medication Order Sheet. A
new requirement is that the complete list of
medications be given to the patient when
discharged from the hospital. This requirement
goes into effect January 2007.
 
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Here is our current Admission Discharge
Medication Order Sheet
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If a patient is transferred to PICU, or Surgery,
a summary list of all current medications is
printed for the MDs review and use as an order
sheet for medications. This Transfer
Medication Reconciliation Order Sheet is
available through the Pharmacy Module.
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Reduce the Risk of Patient Harm From Falling

• Utilizing existing data on our patient falls from
  the last few years and using research from
  Childrens Memorial Hospital in Chicago, ETCH
  determined that our patients at greatest risk for
  falls are those on seizure medications and those
  receiving PT/OT services.

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• Our existing seizure precautions contain
  interventions such as keeping the bed in the low
  position and keeping the side rails up. These
  interventions, as well as others related to
  safety, are reassessed every shift.
• For patients in our NICU and PICU, interventions
  were added to the routine plan of care - under
  the category of safety. This ensures
  appropriate documentation.
• Lastly, physical therapists are documenting the
  education process regarding a patients risk for
  falls in the progress notes and on the IPER.
  This documentation addresses the patient/familys
  
• understanding of the risk of falls, and what can
  specifically be done to prevent falling. From
  the IPER, the nurse can then reassess and
  determine if the patient/family needs
  reinforcement with this teaching.

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Encourage Patients Active Involvement in their
Own Care as a Patient Safety Strategy.
ETCH is beginning to look at ways to define and
communicate different ways for patients and
their families to report concerns about safety,
and encourage them to do so. Compliance with
this goal begin in January 2007.
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The Organization Must Identify Safety Risks
Inherent in its Patient Population
ETCH must evaluate how we identify patients at
risk for suicide. Compliance with this goal will
begin in January 2007.
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Patient safety must remain the first priority.
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Restraint Use at ETCH
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Physical Restraint

• Any manual method or physical or mechanical
  device that restricts freedom of movement or
  normal access to ones body, material or
  equipment attached or adjacent to patients body
  that he or she cannot easily remove which
  include
• Soft wrist
• Soft ankle
• Soft vest
• Leather restraints are not used at ETCH!

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Important!!

• Patients rights, including the right to be free
  from unnecessary seclusion and restraint and to
  receive the least restrictive treatment possible,
  must be protected and upheld for patients
  secluded and restrained, in postural and safety
  support devices, and requiring routine treatment
  immobilization.

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• Restraining devices are used only when
  alternative measures to provide safety are
  ineffective. These may include, but are not
  limited to
• Increased supervision
• Pain control (if applicable)
• Emotional reassurance
• Reorientation
• Diversion

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What Students Need to Know!

• Read the policy on Restraints!
• If you are assigned to a patient requiring
  restraint, notify your instructor, allowing her
  or the patients nurse to guide you in your care
  of that patient.

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Isolation/Infection Control

• East Tennessee Childrens Hospital

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Standard Precautions

• All patients will be considered to be on Standard
  Precautions
• -Applies to blood, all body fluids except sweat,
  non-intact skin, mucous membranes
• -Gloves are to be worn when coming in contact
  with any of the above
• -Gowns are to be worn when splashing is likely
• -Mask or face shields when splashing is likely

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References Available on ALL Units
OSHA Manual Isolation Guidelines Manual Infection
Control Nurse x8191 Employee Health Nurse
x8644 Policies/Procedures ETCHnet nursing
infection control
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Contact Isolation
-Hand washing is the 1 way to prevent
spread -Gloves when entering room for touching
ANY surface/patient/bed/ linens/equipment -Gowns
if uniform/ clothes will touch patient/bed/linens
/ equipment
-1 way things passed -Contact with
the secretions (feces, emesis, nasal
secretions) -Secretions live on dry
surfaces, some for 72 hours -Infected secretions
make contact with mucous membranes (mouth)
PUDDLE lying around
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Droplet Isolation
-The infectious material is big, thick, heavy
respiratory droplets -Coughed, sneezed out, then
drop to the ground -When drop, die -Usually
droplet isolation does not last very long
-Mask if working within 3 feet of
patient -Maintain Standard Precautions
Combination Droplet plus Contact refer to
algorithms for diagnoses of Meningitis and
Pneumonia
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Airborne Isolation
-Infectious materials are airborne
particles -Airborne plus Contact -AFB
precautions very strict isolation, Hepa mask
required (children with TB are not always on
Isolation)
Airborne -Observe Standard Precautions -Mask
unless you are immune
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Linens and Isolation

• -Remember all linens are handled as infectious
• Blue bags blood and/or body fluids
• Green bags clean linens you determine cant be
  used
• Red bags ONLY if SATURATED/DRIPPING with blood

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Trash/Disposable items and Isolation (B.I.C.)

• Anything with blood (B) goes into red bag trash.
• The disease and mode of transmission of the
  organism in question determines the way
  secretions/excretions are disposed of. Any
  materials containing the infectious (I) agent go
  in red bag trash (diapers of a Rotovirus patient,
  tissues used with an RSV patient).
• Tissues, diapers etc. not containing the
  infectious agent are put into regular trash.
• If the disposable item is a suction container
  with body fluids, add the solidifier and put into
  Red bag trash.
• If the disposable item is either a syringe
  (without needle) or IV tubing and there is
  visible blood present, these must go into Red bag
  trash.
• Foley bags containing urine always go into red
  bag trash.
• Chemotherapy (C) materials go into red bag trash.

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In Summary

• Stop and apply the signs
• Use personal protective equipment
• Use appropriate trash bags for contaminated
  items(BIC)
• Educate parents
• PRACTICE isolation principles!

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Pain Assessment and Management
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Philosophy

• The staff at Childrens Hospital believes that
  pain is a negative experience best measured by
  the individual in pain. Compassionate care
  includes the assessment of pain on admission and
  regularly during the visit, accompanied by
  effective interventions. Pain is manageable
  through pharmacological and non-pharmacological
  interventions using a multidisciplinary approach
  with the patient and/or care giver as an integral
  part of the team. Effective pain management
  focuses on minimizing the pain and the adverse
  psychological and physiological effects of
  unrelieved pain.

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Pain Management includes

• Assessment includes
• Assessment on admission
• Pain history
• Pain description and intensity using appropriate
  pain scales
• Before, during and after pain producing events
• Each new report of pain
• Before and after each pain management
  intervention pharmacological and
  non-pharmacological

• Supportive care includes
• Pharmacologic relief-give as ordered per
  physician
• Provide non-pharmacologic pain relief measures
  including behavioral techniques such as breathing
  techniques, relaxation, rocking, etc. cognitive
  interventions such as positive thoughts,
  distractions, medical play and sensory
  interventions such as hot/cold, stroking
  repositioning.

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Documentation

• Record location, description, intensity and pain
  scale used.
• Record pharmacological/non-pharmacological
  interventions. Note any side effects of
  medication. Note sedation level when opioids in
  use.
• Record response to pain interventions.
• Record assessment data as needed. Record in
  accordance with unit specific standards.

97
Pediatric Myths

• Children dont experience pain like adults or
  they wont remember it. One myth is that young
  children, particularly infants, have immature
  central nervous systems and this immaturity
  decreases pain intensity.
• The fact is that the anatomic requirements for
  pain processing are intact by mid to late
  gestation. Research further indicates that
  preterm infants may have a greater sensitivity to
  pain that term infants and older children because
  their ability to modulate the pain is not
  developed.

98
Pediatric Myths

• Children are at an increased risk for
  respiratory depression from opioids.
• Research indicates that infants older than 1
  month are at no greater risk for respiratory
  depression from opioids than older infants.
  Careful monitoring can minimize adverse effects.

99
Numeric Pain Scale


0 1 2 3 4 5 6 7
8 9 10
The patient is asked to rate pain from 0 to 10,
with 0 equaling no pain and 10 equaling the worst
possible pain. This scale should be used for
children age 7 or above.
100
WONG-BAKER FACES PAIN SCALE
Explain to the patient that each face is a person
who may feel happy because they have no pain or
sad because they have some pain. The scale
ranges from 0 No Hurt to 10 Hurts Worst, (as
much as you can imagine), although you dont have
to be crying to feel this bad. Ask them to
choose the face that best describes how they are
feeling. This scale is recommended for persons
ages 3 and older.
101
Optimal management of the patient experiencing
pain enhances healing and promotes physical and
psychological wellness.
102
Recognizing Signs Symptoms of Child Abuse
103
CHILD ABUSE
Recognizing Signs Symptoms of Child
Abuse There are four forms of Child
Abuse Physical Abuse Physical Neglect Sexual
Abuse Emotional Abuse/Neglect This module will
help you to recognize signals of child abuse and
the characteristics of abusive parents.
104
Four Forms of Child Abuse
Physical Abuse

• Definition The non-accidental injury of a child.
  
• Guidelines to follow in determining
  non-accidental injury are

• Any injury that requires medical treatment
  outside the range of normal corrective measures.
• Any punishment that involves hitting with a
  closed fist or instrument, kicking, inflicting
  burns, or throwing the child obviously represent
  child abuse.

105
Four Forms of Child Abuse
Physical Neglect

• Definition Failure to provide the necessities
  of life for a child.

• Examples would include
• Lack of Medical care
• Inadequate nourishment and/or housing
• Lack of supervision

106
Four Forms of Child Abuse
Sexual Abuse

• Definition The exploitation of a child for the
  sexual gratification of an adult or any
  significantly older person.

• It is called incest if it occurs between family
  members.

107
Four Forms of Child Abuse
Emotional Abuse / Neglect

• Definition Excessive, aggressive or
  unreasonable parental behavior that places
  demands on a child to perform beyond his/her
  capabilities.
• Sometimes emotional abuse is not what a parent
  does, but what the parent doesnt do.
• Children who receive no love, care, support or
  guidance will carry those scars into adulthood.

108
OVERVIEW

• Child abuse is not usually a single physical
  attack or a single act of deprivation.
• It occurs across economic and social lines and is
  usually a pattern of behavior.
• It takes place over a period of time and its
  effects are cumulative.
• The longer the child abuse continues the more
  serious the injury to the child.

109
REPORTING ABUSE

• All 50 states have MANDATORY reporting laws for
  child abuse.
• In Tennessee, the state agency that deals with
  child abuse or neglect is the Department of Child
  Services (DCS).
• Anyone who suspects child abuse or neglect MUST
  report it.
• At Childrens Hospital we would report any
  suspicions to the Social Work Department.

110
INDICATORS OF ABUSIVE PARENTS
The behavior and attitudes of the parents, their
own life histories, even the condition of their
home, can offer valuable clues to the presence of
child abuse and neglect.
111
CHARACTERISTICS OF ABUSIVE PARENTS
These parents

• Were often abused as children
• Were expected to meet high demands by their
  parents
• Were unable to depend on their parents for
  love/nurturing
• Cannot provide emotionally for themselves as
  adults
• Expect their children to fill their emotional
  void

112
CHARACTERISTICS OF ABUSIVE PARENTS
These parents

• Have poor impulse control
• Expect rejection
• Have low self-esteem
• Are emotionally immature
• Are isolated, have no support system
• Marry a spouse who is not emotionally supportive
  and who passively supports the abuse

113
CHARACTERISTICS OF ABUSIVE PARENTS
They

• May seem unconcerned about the child
• May see the child as bad, evil, a monster or
  witch
• Usually offer illogical, unconvincing/contradictor
  y explanations or have no explanations of childs
  injury
• Usually attempt to conceal the childs injury or
  protect the person responsible
• Routinely employ harsh, unreasonable discipline
  inappropriate for childs age or transgressions

114
Recognition and prompt action on the part of
healthcare providers are important in the
prevention of further abuse!
115
Death and Dying
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• Caring for children nearing the end of life
• ETCH 2006

116
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Principles for End of Life Care

• Respecting patient and family goals, wishes and
  choices
• Caring for the entire family
• Using resources and skills from different team
  members
• Listening to and attending to the concerns of the
  caregiver
• Building systems and mechanisms of support

117
Children are Different

• Children understand the concept of death
  differently according to their age and
  developmental stages
• Children most often focus on living, not on dying
• Children do not have the same burdens as parents,
  such as financial concerns, but children are
  often protecting their parents or other family
  members at the same time that their families are
  trying to protect them

118
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Barriers to end of life care

• Children dont die
• The death of a child is so unthinkable, painful,
  that many individuals cannot accept the
  possibility that it may occur
• It is unnatural for a child to precede its
  parents, even grandparents, in death
• It cant happen to my child

119
BUT CHILDREN DO DIE

• Over 50,000 children between the ages of 0-19 die
  in the United States each year
• 26,000 children die in the first year of life
  from
• Asphyxia
• Congenital Birth Defects
• Prematurity
• Respiratory distress
• SIDS

120
Where do children die?

• When hospitalized, most deaths occur in intensive
  care units, either in the NICU or the PICU
• Many of those deaths may be unexpected and
  despite all efforts and intents by the healthcare
  staff to preserve life
• On the other hand, many of the deaths have been
  anticipated by the hospital staff and efforts
  have been made to prepare the family

121
Why dont children die at home?

• Sudden tragic or traumatic death
• Difficult to predict when children will die
• Difficult to make decisions for minors
• Difficulty in transporting and caring for
  children on ventilators
• Parental fears of controlling symptoms effectively

• Families rely on long term relationship with
  hospital care team
• Lack of pediatric palliative care expertise in
  the community
• Insurance issues such as lack of payment for home
  services or refusal to allow life-extending
  measures alongside comfort measures

122
How can we provide the best possible care?
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• Multi-disciplinary MDs, nurses, chaplains,
  social work, child life, nutritionists,
  respiratory therapists
• Culturally sensitivereligious differences,
  family dynamics and interactions, ceremonies
• Family centeredcare extends beyond patients to
  all other significant family members family
  wishes are honored

123
Healthcare members as Advocates
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• Studies reveal that most times parents perceive
  that their child suffers some or a great deal
  with symptoms and side effects their child
  experiences prior to deatheven when providers
  described the child as comfortable
• Our greatest goal is to assist the child and the
  family in the achievement of what they perceive
  as a good, peaceful death

124
Family Support
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• Many different team members may be called upon to
  support family members, extended family and
  friends
• Families develop a special attachment for those
  who share this very special journey with them
• Any team member may become the one person a
  specific family member wants to talk with, vent
  to, cry on

125
Patient Care Conferences
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• The physical, medical, emotional needs of the
  patient with a life-limiting diagnosis are not
  only overwhelming to the family, but oftentimes
  also to the healthcare providers
• Patient care conferences are an excellent means
  of improving communication, brainstorming for new
  ideas, providing continuity of care and being
  supportive of one another
• Any team member can request a patient care
  conference and one may be helpful even if every
  single team member is not able to attend
• Common reasons for a patient care conference are
  anticipated discharge, pain control, difficulties
  with coping, etc.

126
Ethical Considerations
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• Sometimes we may not agree with the care a
  patient is receiving from his/her family,
  physician, hospital nurse, home health agency,
  etc.
• Please refer to policy/procedure regarding
  Ethical Patient Care Issues E03 in the nursing
  documents found on etchnet.
• Should you feel you are in a situation that puts
  you in direct conflict of your own ethics, please
  discuss it with your instructor and he (or she)
  will assist you in resolving that issue

127
Boundaries
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• Sometimes it is very difficult to find the
  balance of caring for and supporting a family yet
  not overstepping professional boundaries
• It is always inappropriate when our patients
  families know as much about our problems,
  situations, or loved ones as a close friend would
  know We are taking care of their familythey are
  not taking care of us
• Likewise, we only need to know enough pertinent
  information about a family to allow us to take
  excellent care of that patient
• It is NEVER about US

128
Where is the balance?

• Is it possible to care for someone without caring
  about them?
• Is it possible to provide comfort to a child who
  is dying and not be affected by that?
• Is it possible to become so involved with the
  family that it detracts from our ability to
  provide optimum care for the patient?

129
Taking Care of Us
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• How do we refill our tank?
• What are things we can do for ourselves that heal
  our spirit?
• How do we manage stress?
• How do we know when to step back? How can we
  know when enough is enough?
• Do we supportrather than enable each other?

130
Ideas
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• Exerciseno, really
• Eat healthycontrary to popular belief, chocolate
  does not have heal all powers
• Laughfind something, someone who will always
  tickle your funny bone
• Crywhen you need to--in private, among friends,
  at funerals however, patients families should
  not be the ones to comfort you
• Spend time with the people you love doing things
  that are fun for you

131
ETCHEmergency Codes
132
Emergency Phone Number

• Dial 333 to report an emergency
• Report Location and type of emergency
• Be specific!
• Emergency Code Plan Notebook in each work area

133
Code Red

• Rescue
• Alert
• Confine
• Extinguish

134
Code Black

• Bomb Threat
• Report to your original work area wait for
  instructions
• Stay calm and alert!
• Report anything suspicious

135
Code White

• Tornado Warning (sighting of a tornado)
• Remain calmspeed is essential
• Move patients visitors to center of building
  away from windows
• Close blinds, drapes doors

136
Code Able

• External Disaster
• Code Able I Any mass casualty incident that
  threatens the integrity and function of the
  institution and requires mobilization of all
  hospital resources
• Code Able II Any mass casualty incident
  involving nuclear, biological and /or chemical
  injuries, and that threatens the integrity and
  function of the institution and requires
  mobilization of all hospital resources
• Initiate Disaster Plan

137
Code Green

• Security breeches that threaten immediate danger
  to patients, staff or hospital property
• Security will respond immediately
• Other designated staff may respond

138
Code Pink

• 3 levels
• -Code Pink 0 (lt1 yr)
• -Code Pink 1 (1 5yrs)
• -Infant or Child Abduction
• Code Pink 5 (gt5 yrs)
• Nursing secure area support family
• Security secure all exits

139
Code Boy/Girl

• Elopement / Runaway risk
• Secure area
• Be alert!

140
Code 99

• Medical Emergency
• BLS certified staff will begin CPR
• Non BLS certified staff will call code and seek
  nursing assistance
• Code Team will respond and will be in charge of
  the situation

141
PNEUMATIC TUBE SYSTEM

• I THINK I JUST SENT THAT STOOL TO PHARMACY

142
PNEUMATIC TUBE SYSTEM - Key Points

• DO NOT SEND ANY SPECIMENS THROUGH THE TUBE SYSTEM
  THAT CANT READILY BE REPLACED OR MAY LEAK

• ALL SPECIMENS MUST BE SEALED IN A BIOHAZARD BAG
  AND THEN SEALED IN A PADDED BUBBLE BAG BEFORE
  BEING PLACED IN A TUBE FOR TRANSPORT
• USE EXTRA PADDING AS NEEDED TO ASSURE STABILITY

143
Pneumatic Tube System Key Points

• Packaging and handling of items to be transported
• Secure breakable items in the carrier with either
  a liner or bubble wrap
• Place all items, with the exceptions of plastic
  bags of IV fluid and medical records, into a zip
  lock bag prior to placing in the carrier\Reuse
  bags that have been used to transport
  pharmaceuticals, sterile supplies or paper

144
Pneumatic Tube System Key Points

• Packaging and handling of items to be transported
  Continued..
• Snap the carrier properly at both ends or middle
  latch prior to sending through the tube
• Wash hands after handling a carrier - the
  pneumatic tube system is not clean

145
Pneumatic Tube System Key Points

• Laboratory Specimens - Continued
• Place specimen(s) in BIOHAZARD zip lock bag with
  the following precautions
• Only specimens from the same patient in one bag
• Wrap glass items (blood culture bottles, glass
  tubes) with bubble wrap before placing in
  Biohazard zip lock bag
• Place all labels or paperwork in the side pouch
  of the biohazard bag
• Secure zip lock closure

146
Pneumatic Tube System Key Points

• Laboratory Specimens Continued
• Place BIOHAZARD bag within the bubble wrap bag,
  Add extra bubble wrap as necessary and fold bag
  to immobilize contents
• Note This step is critical for Blood Culture
  bottles and glass tubes to prevent breakage!

147
Pneumatic Tube System Key Points

• Blood product bags can be returned via the tube
  system with the following precautions
• Remove all sharps
• Close all tubing ends
• Place in BIOHAZARD bag with paperwork in the
  outside pouch

148
Pneumatic Tube System Key Points

• Laboratory Specimens
• Check to ensure that all container lids or tube
  stoppers have been tightened securely
• Note For Urine or liquid stool specimens - do
  not completely fill containers!

149
ITEMS THAT MAY NOT BE SENT THROUGH THE TUBE
SYSTEM

• Laboratory
• Surgical specimens
• CSF specimens (Spinal fluid) from LP
• Formalin and/or alcohol preserved specimens
• Tissues for pathology
• Trach traps, Gastric washings
• Blood products for transfusion

150
ITEMS THAT MAY NOT BE SENT THROUGH THE TUBE
SYSTEM Continued.

• Pharmacy
• Chemotherapy
• Narcotics
• Employee prescriptions over the counter
  purchases
• Central Supply
• Employee purchases

151
ITEMS THAT MAY NOT BE SENT THROUGH THE TUBE
SYSTEM Continued.

• Other Items
• Contaminated patient used products (ie,
  instruments, sharps) used laryngoscope blades may
  be sent if placed into Biohazard Bag, sealed
  placed in bubble wrap and then placed in
  container
• Patient valuables
• Any container that might leak

152
Pneumatic Tube System Spill Procedure

• Stop sending carriers from the station where the
  contamination was first noticed
• Notify Engineering and state
• Receiving stations number
• Sending stations number (if known)
• Type of spill (specimen type and suspected amount
• Time the contaminated carrier arrived (or was
  first noticed)
• Number of contaminated carriers that have arrived
• If no answer, page at 417-0328

153
Pneumatic Tube System Spill Procedure Continued

• Remove contents of carrier using protective
  clothing (utilizing Standard Precautions, ie.,
  gloves gown and goggles as needed)
• Discard the specimen and secondary containment
  bag into red bag trash
• Call the sending station and notify of spill
  (request another specimen if applicable)
• Place the carrier in a biohazard bag, contact
  Central Service and deliver the carrier to
  Central Service

154
Pneumatic Tube System Spill Procedure Continued

• Complete an Employee Injury Report form
  explaining the type of exposure and personnel
  exposed. Call Employee Health or Infection
  Control (or the Nursing Coordinator if on nights,
  weekends, or holidays)
• DO NOT leave a voice-mail message - Contact with
  Employee Health or the Coordinator must be made
  within 2 hours
• When a spill occurs, the entire system will be
  shut down for clean up by Engineering

155
Dress Code for Students at ETCH
156
At Childrens Hospital, projecting a professional
image is important in our work.

• Students should be in school uniforms when in the
  hospital. Identification should be visible at
  all times! Uniforms should be neat, clean and
  not interfere with your work.
• Students must maintain a clean body, free of
  odors, Fingernails must be clean, neatly trimmed
  and no more than ¼ inch in length. Due to
  infection control concerns, the use of artificial
  nails and/or extenders is prohibited for students
  in clinical areas. The use of perfumes,
  colognes, aftershave and other scented items must
  be avoided.
• Hair must be neat and well groomed. No hairstyle
  that detracts from the ability to carry out your
  responsibilities will be allowed. Mustaches and
  beards must be well groomed and neatly trimmed.
• Feet must be covered with hose or socks at all
  times. Shoes must be clean. Sandals,
  open-backed shoes and canvas shoes are not
  permitted for clinical areas.

157
Dress Code, cont.

• Students who are in the building to pre-plan or
  for other school-related tasks must be dressed
  appropriately and be properly identified.
• The following are NOT allowed Jeans, leather
  skirts or pants, sweat pants, shorts or
  tight-fitting pants, mini-skirts, halter or
  spaghetti strap tops, sleeveless tops,
  tight-fitting or sheer tops, air-brush or screen
  printed T-shirts.
• Jewelry should be appropriate. Earrings and
  jewelry should not be excessive. Female students
  should wear no more than two earrings per ear,
  male students should refrain from wearing
  earrings while in the clinical area.
• Students SHOULD wear lab coats and school ID when
  on campus!

158
ParkingDuring your clinical rotation, you may
park in the ETCH Employee Parking Garage at the
end of White Ave, past Primary Care Center, which
is located on the corner of 22nd Ave and White
(not shown on map). If you arrive before 8 AM,
you may enter the garage without a card, however
if your clinical start time is between 8 AM-2 PM,
you must obtain an entry card from your
instructor. IF you are scheduled for clinicals
AFTER 2 PM, you may park in the MOB Parking
Garage (7 on the map)
159
Come Prepared!

• Come in dress code! Wear your Student ID!
• Due to very limited storage space, bring as
  little with you as possible! Do not bring large
  backpacks, coats, etc.!
• Leave your valuables at home!
• No cell phones in patient care areas!

160
Childrens Hospital wishes the very best to
each of you in your new career!

• Success is not the key to happiness. Happiness
  is the key to success. If you love what you are
  doing, you will be successful.
• Albert Schweitzer

161
FINAL STEP
Click the link below to view and then PRINT these
2 pages Childrens Hospital Component Compliance
Form Information Security Compliance
Statement Sign both and give the originals to
your instructor
Click here for forms