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WELCOME TO ETCH!

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Title: WELCOME TO ETCH!


1
WELCOME TO ETCH!
2
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

3
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!

4
Our Philosophy
Because Children are Special
5
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

6
ETCH History
  • Opened in 1937 and located on Laurel Ave.
  • Originally called Knox County Crippled Childrens
    Hospital

7
ETCH History
  • Moved to 21st and Clinch in 1970
  • 2018 Clinch Ave
  • P.O. Box 15010
  • Much expansion since then

8
ETCH 2007 155 bed facility with multiple
pediatric subspecialties
9
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

10
Service Excellence
  • Our Responsibility. Our Commitment.
  • Childrens Hospital

11
People dont carehow much we knowuntil they
know how much we care.
12
Service Excellence VisionTo be the kind of
organization wherechildren and familieswant to
come for care,physicians want to
practice,andemployees want to work.
13
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.
14
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.
15
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.

16
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
17
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.
18
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.
19
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.

20
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!

21
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.

22
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
23
Child/Family Centered Care
  • Childrens Hospital
  • Knoxville, TN

24
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.
25
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.
26
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.
27
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
28
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
29
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
30
Core Concepts
  • Strengths
  • Collaboration
  • Partnership
  • Information Sharing
  • Support
  • Flexibility
  • Empowerment

31
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

32
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

33
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

34
Age-Specific Interventions
  • Age-Specific Interventions are the skills you use
    to give care that meets each patients unique
    needs.

35
Every patient is an individual with his or her
own...
  • likes and dislikes
  • feelings
  • limitations and abilities
  • experiences

36
Everyone grows and develops in a similar way or
stages that are related to their ageBUTat
their own pace.
37
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

38
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.

39
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.

40
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.

41
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.

42
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

43
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!

44
No Information Procedure
  • East Tennessee Childrens Hospital

45
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.

46
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
47
Who has the authority to authorize (give the OK)?
  • Nursing Coordinators
  • Nurse Managers
  • Nursing Directors
  • Social Work
  • Security

48
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

49
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)

50
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.

51
Patient Safety Goals for ETCH
  • East Tennessee Childrens Hospital

52
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.

53
The next few slides will present the
Patient Safety Goals and the systems in place
here at ETCH to reach these goals.
54
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

55
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.

56
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.

57
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.

58
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.

59
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

60
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

61
  • 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)

62
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.

63
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

64
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

65
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.
 
66
Here is our current Admission Discharge
Medication Order Sheet
67
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.
68
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.

69
  • 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.

70
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.
71
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.
72
Patient safety must remain the first priority.
73
Restraint Use at ETCH
74
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!

75
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.

76
  • 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

77
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.

78
Isolation/Infection Control
  • East Tennessee Childrens Hospital

79
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

80
References Available on ALL Units
OSHA Manual Isolation Guidelines Manual Infection
Control Nurse x8191 Employee Health Nurse
x8644 Policies/Procedures ETCHnet nursing
infection control
81
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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83
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
84
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86
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
87
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90
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

91
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.

92
In Summary
  • Stop and apply the signs
  • Use personal protective equipment
  • Use appropriate trash bags for contaminated
    items(BIC)
  • Educate parents
  • PRACTICE isolation principles!

93
Pain Assessment and Management
94
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.

95
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.

96
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
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