Transcript 107 CHS Student Orientation Program

WELCOME TO ETCH!
This module contains:
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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
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Pain Management
Child Abuse
Death & Dying
Emergency Codes
Pneumatic Tube System
Dress Code
Parking and Other Info
Forms to Complete
Instructions for Completing the
ETCH Module
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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!
Our Philosophy
Because Children are Special…
Our Mission…
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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
ETCH History
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Opened in 1937
and located on
Laurel Ave.
Originally called
Knox County
Crippled
Children’s
Hospital
ETCH History
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Moved to 21st and
Clinch in 1970
2018 Clinch Ave
P.O. Box 15010
Much expansion
since then
ETCH 2007 …
155 bed facility with
multiple pediatric
subspecialties
East Tennessee Children’s Hospital
offers many services such as…
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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
Service Excellence…
Our Responsibility. Our Commitment.
Children’s Hospital
People don’t care
how much we know
until they know how
much we care.
Service Excellence Vision
To be the kind of
organization where
children and families
want to come for care,
physicians want to practice,
and
employees want to work.
Service Excellence…
Our Responsibility. Our Commitment.
Statement of Purpose
We strive to give extraordinary care and service to our
patients, their families, members of the Children’s
Hospital family, and the communities we serve.
Our Philosophy of Service Excellence
*We take pride in our professions and feel personal ownership and
responsibility for achieving Children’s 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 people’s 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.
SHARE: Service Excellence in Action
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S SENSE people’s needs before they ask.
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H HELP each other our through teamwork.
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A ACT with empathy and compassion.
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R RESPECT the dignity and privacy of others.
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E EXPLAIN what is happening.
Customer Satisfaction: A fool’s gold?
What is fool’s gold? Something that looks more
valuable than it really is. Let’s compare the difference
between customer “satisfaction” and “loyalty.”
The customer satisfaction formula:
Doing it right the first time+effective complaint handling
The customer loyalty formula:
Doing more than is expected+Doing more than the
situation warrants
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.
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.
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
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93% of what we communicate in attitude
is non-verbal.
– 7% In words
– 38% By tone of voice
– 55% By body language
– And it’s done in the first few seconds. Even
in job interviews by a professional, the
decision is essentially made in 20 seconds!
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 doctor’s willingness to listen and
explain in words I can understand.
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Attitude
The 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
Child/Family Centered Care
Children’s Hospital
Knoxville, TN
Definition of Child/Family
Centered Care
Child/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 relationships
between and among consumers and health providers.
*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.
*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.
Child/Family Centered Care is the
Right Way to Treat People…
*Leadership
*Human Resources
*Architecture and Design
*Family participation in care
*Communicating with families
*Family to family support and networking
*Linking families with community resources
*Educating Child/Family Centered professional
collaboration in policy and program development
In Child/Family Centered Care:
*People are treated with dignity and respect
*Health care providers communicate and share
complete and unbiased information with patients and
families that are affirming and useful
*Individuals and families build on their strengths by
participating in experiences that enhance control and
independence
*Collaboration among patients, families, and
providers occurs in policy and program development
and professional education, as well as in the delivery
of care
In a Hospital that Practices
Child/Family Centered Care,
Administrative, Clinical, and Support
Staff:
*Recognize the family is the constant in the child’s life
*Facilitate collaboration between families and professionals
*Honor the racial, ethnic, cultural, and socio-economic
diversity of family
*Recognize family strengths and respect various methods of
coping
*Share complete and unbiased information with parents
*Encourage and facilitate family to family networking
*Understand and incorporate developmental needs
*Design accessible health care delivery systems
Core Concepts
Strengths
 Collaboration
 Partnership
 Information Sharing
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 Flexibility
 Empowerment
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C/FCC in Action
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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
C/FCC in Action, continued
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Orientation / Inservices / Courses—Inclusion 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
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 patient’s unique needs.
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 age
BUT
at their own pace.
Strategies to Enhance Coping:
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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, PrePost 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
Child Life SpecialistsWhat 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
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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.
The Role of the Child Life
Specialists At ETCH
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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.
The Role of the Child Life
Specialists At ETCH
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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 patient’s progress and needs.
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:
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– Requested toys and supplies
– Visits to the playroom and teen room
(inpatient)
– Play at the bedside
Child Life Staff…
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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!
No Information Procedure
East Tennessee Children’s Hospital
What is the purpose of “No
Information”?
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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.
Who can initiate (ask for) “No
Information” status?
Legal guardian
(HIPAA,
admitting sec.
will ask)
Security
Officers
Community
Relations
Department of
Children’s
Services
Nursing Staff
Social Work
Law
Enforcement
Officers
Attending MD
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 patient’s name
with a “c” (e.g. cSmith, John). This
patient’s 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…
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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)
Responding to requests for
information…
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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.
Patient Safety Goals for ETCH
East Tennessee Children’s Hospital
Patient Safety Goals
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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.
The next few slides will present the Patient
Safety Goals and the systems in place here
at ETCH to reach these goals.
Improve Accuracy of
Patient 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
Improve Accuracy of
Patient 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.
Improve Accuracy of
Patient 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.
Improve Effectiveness of
Communication Among Caregivers
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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.
ETCH “Do Not Use” Abbreviations List
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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.
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
Improve the Safety of Using Medications
Remove concentrated electrolytes from patient
care units. There should be no sodium chloride with
concentrations > 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
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)
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 careacquired infection.
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
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
Accurately and Completely Reconcile
Medications Across the Continuum of Care
This goal requires a complete and accurate list of the patient’s 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.
Here is our
current Admission
Discharge
Medication Order
Sheet…
If a patient is transferred
to PICU, or Surgery, a
summary list of all
current medications
is printed for the MD’s
review and use as an
order sheet for
medications. This
Transfer Medication
Reconciliation Order
Sheet is available through
the Pharmacy Module.
Reduce the Risk of Patient Harm From Falling
Utilizing existing data on our patient falls from the last few
years and using research from Children’s 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.
•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 patient’s risk for falls in the progress notes and on the
IPER. This documentation addresses the patient/family’s
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.
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.
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.
“Patient safety must remain the first priority.”
Restraint Use at ETCH
Physical Restraint
Any manual method or physical or mechanical
device that restricts freedom of movement or
normal access to one’s body, material or
equipment attached or adjacent to patient’s 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!!
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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.
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
What Students Need to Know!
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Read the policy on
Restraints!
If you are assigned to
a patient requiring
restraint, notify your
instructor, allowing
her or the patient’s
nurse to guide you in
your care of that
patient.
Isolation/Infection Control
East Tennessee Children’s Hospital
Standard Precautions
-All patients will be
considered to be on
Standard Precautions
-Applies to blood, all body
fluids except sweat, nonintact 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
References Available on ALL
Units:
OSHA Manual
Isolation Guidelines Manual
Infection Control Nurse x8191
Employee Health Nurse x8644
Policies/Procedures – ETCHnet –
nursing
infection control
Contact Isolation
-#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)
-Hand washing is
PUDDLE – lying
around
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
Droplet Isolation
-The infectious material
-Mask if working
is big, thick, heavy
within 3 feet of
respiratory droplets
patient
-Coughed, sneezed out,
-Maintain Standard
then drop to the ground
Precautions
-When drop, die
-Usually droplet
isolation does not
last very long
Combination Droplet plus Contact
refer to algorithms for diagnoses of
Meningitis and Pneumonia
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
Linens and Isolation…
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-Remember – all
linens are handled as
infectious
– Blue bags – blood
and/or body fluids
– Green bags – clean
linens you determine
can’t be used
– Red bags – ONLY if
SATURATED/DRIPPING
with blood
Trash/Disposable items and
Isolation (B.I.C.)
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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.
In Summary…
Stop and apply the signs…
 Use personal protective equipment…
 Use appropriate trash bags for contaminated
items…(BIC)
 Educate parents…
 PRACTICE isolation principles!

Pain Assessment and
Management
Philosophy
The staff at Children’s 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.
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 nonpharmacological
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.
Documentation
Record location, description, intensity and
pain scale used.
 Record pharmacological/nonpharmacological 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.

Pediatric Myths
Children don’t experience pain like adults or they won’t
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.
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.
Numeric Pain Scale
0
1
No
Pain
2
3
4
5
6
Moderate
Pain
7
8
9
10
Worst
Possible
Pain
*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.
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 don’t 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.
Optimal management of the
patient experiencing pain
enhances healing and promotes
physical and psychological
wellness.
Recognizing Signs & Symptoms
of Child Abuse
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.
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.
Four Forms of Child Abuse
Physical Neglect
Definition:
a child.
Failure to provide the necessities of life for
Examples would include:
•
•
•
Lack of Medical care
Inadequate nourishment and/or housing
Lack of supervision
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.
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 doesn’t do.
» Children who receive no love, care, support or
guidance will carry those scars into adulthood.
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.
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 Children’s Hospital we would report any suspicions
to the Social Work Department.

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.
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
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
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/contradictory
explanations or have no explanations of child’s injury
• Usually attempt to conceal the child’s injury or protect the
person responsible
• Routinely employ harsh, unreasonable discipline
inappropriate for child’s age or transgressions
Recognition and prompt action on
the part of healthcare providers are
important in the
prevention of further abuse!
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Death and Dying
Caring for children nearing the end of
life…
ETCH 2006
Back
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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
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

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Barriers to end of life care
•Children don’t 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 it’s
parents, even grandparents, in death
•It can’t happen to my child
BUT CHILDREN DO DIE
Over 50,000 children between the ages of 019 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
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

Why don’t 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 lifeextending measures alongside
comfort measures
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How can we provide the best
possible care?



Multi-disciplinary= MD’s, nurses, chaplains, social
work, child life, nutritionists, respiratory therapists
Culturally sensitive=religious differences, family
dynamics and interactions, ceremonies
Family centered=care extends beyond patients to all
other significant family members; family wishes are
honored
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Healthcare members as
Advocates
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
death—even 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

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Family Support
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

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Patient Care Conferences




The physical, medical, emotional needs of the patient with a lifelimiting 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.
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Ethical Considerations



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
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Boundaries




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 patient’s families
know as much about our problems, situations, or
loved ones as a close friend would know; We are
taking care of their family—they 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
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?
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Taking Care of Us
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 support—rather than enable– each
other?

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Ideas
Exercise—no, really
 Eat healthy—contrary to popular belief,
chocolate does not have heal all powers
 Laugh—find something, someone who will
always tickle your funny bone
 Cry—when you need to--in private, among
friends, at funerals; however, patient’s
families should not be the ones to comfort you
 Spend time with the people you love doing
things that are fun for you

ETCH
Emergency Codes
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
Code Red
Rescue
Alert
Confine
Extinguish
Code Black




Bomb Threat
Report to your original
work area & wait for
instructions
Stay calm and alert!
Report anything
suspicious
Code White




Tornado Warning
(sighting of a tornado)
Remain calm…speed is
essential
Move patients & visitors
to center of building
away from windows
Close blinds, drapes &
doors
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:

Initiate Disaster Plan
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
Code Green



Security breeches that
threaten immediate
danger to patients,
staff or hospital
property
Security will respond
immediately
Other designated staff
may respond
Code Pink

3 levels
-Code Pink 0 (<1 yr)
-Code Pink 1 (1 – 5yrs)
-Infant or Child
Abduction
Code Pink 5 (>5 yrs)


Nursing –secure area
& support family
Security – secure all
exits
Code Boy/Girl



Elopement / Runaway
risk
Secure area
Be alert!
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
PNEUMATIC TUBE SYSTEM
I THINK I JUST
SENT THAT
STOOL TO
PHARMACY…
PNEUMATIC TUBE SYSTEM
- Key Points
DO NOT SEND ANY
SPECIMENS THROUGH
 ALL SPECIMENS
MUST BE SEALED IN THE TUBE SYSTEM
THAT CAN’T READILY
A BIOHAZARD BAG
AND THEN SEALED IN BE REPLACED OR
A PADDED “BUBBLE” MAY LEAK


BAG BEFORE BEING
PLACED IN A TUBE
FOR TRANSPORT
USE EXTRA PADDING
AS NEEDED TO
ASSURE STABILITY
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
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
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
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!
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
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!
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
ITEMS THAT MAY NOT BE SENT THROUGH
THE TUBE SYSTEM – Continued….

Pharmacy
– Chemotherapy
– Narcotics
– Employee prescriptions; over the counter
purchases

Central Supply
– Employee purchases
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
Pneumatic Tube System Spill
Procedure


Stop sending carriers from the station where the
contamination was first noticed
Notify Engineering and state:
–
–
–
–
Receiving station’s number
Sending station’s 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
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
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
Dress Code for Students
at ETCH
At Children’s 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.
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!
Parking:
During 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)
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!

Children’s 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~
FINAL STEP:
Click the link below to view and then PRINT these 2 pages:
Children’s Hospital Component Compliance Form
&
Information Security Compliance Statement
Sign both and give the originals to your instructor
Click here for forms