Orientation for Students and Faculty Welcome to the Texas Children’s Hospital

Welcome to the Texas Children’s Hospital
Orientation for Students and Faculty
Texas Children’s Hospital
®
Who We Are
Texas Children's Hospital is an integrated delivery
system that includes a full range of services for
infants, children and teenagers throughout Houston
and around the world. As one of the nation’s largest,
free standing pediatric health care institutions, Texas
Children’s is committed to redefining children’s health
care through patient care, education, and research.
Texas Children’s Hospital
®
6 Guiding Principles
At the heart of Texas Children’s vision and mission is a set of core values that guide us individually and
collectively as an organization. These are Texas Children’s 6 Guiding Principles and they are part of all
of our interactions. They are the following:
1. Commitment to Excellence
2. Customer Center Service
• We sustain and nurture a culture
that supports our mission, vision
and values.
• We are proud of who we are
and have the passion to make
a daily difference.
• Above all, we deliver the finest
possible work, care, and service
with personal and professional
excellence and are committed to
continuous improvement.
• We show consideration,
compassion and support for all
people.
• We have exceptionally high
standards for individual, team
and organizational performance.
• We provide the expertise,
innovation and visionary thinking
that will continue to advance
pediatric health care, education
and research.
• We carefully consider the
impact our decisions have on
others.
• We find innovative solutions to
support the needs of those we
serve.
• We work together to create the
best possible customer
outcomes.
3. Integrity & Ethical Behavior
• We are honest and trustworthy.
• We hold ourselves to high
standards of moral, ethical, and
legal conduct.
• We keep our promises and
commitments.
• We have the character to do
what is right, not what is easy.
• We exhibit the highest levels of
professionalism in all situations.
Texas Children’s Hospital
®
6 Guiding Principles – cont.
4. Valuing Individuals
5. Communication & Interaction
6. Accountability
• We treat all people with courtesy,
respect and dignity.
• We choose to interact in the
spirit of collaboration.
• We own our words, actions and
outcomes.
• We constantly strive to create an
environment of mutual respect,
teamwork and commitment.
• We are honest and forthright in
our relationships with others.
• We set high performance
expectations and work together
to achieve the organization's
mission, vision, values and
business objectives.
• We support diverse perspectives,
ideas, backgrounds and cultures
and find value in our differences.
• We recognize and value the
contributions of others.
• We actively seek, share, hear
and value information and
feedback.
• We lead by example.
• We engage others in dialogue,
planning and decisions that
involve them.
• We align our work with
organizational priorities.
Diversity At Texas Children’s Hospital
Texas Children's creates and fosters a work environment that attracts, welcomes,
supports and develops a diverse organization.
A critical part of this culture is for every individual to feel valued for his or her contribution to the mission
and vision of Texas Children's. All of us are responsible for embracing and nurturing a culture of
inclusiveness in our own work areas.
Important things to remember when dealing with patients, families and employees:
• Always be respectful in both words and actions
• Display an overall positive body language
• Whenever possible, offer assistance
• Maintain confidentiality
• Use the resources available to assist in resolving conflicts
• Always create an environment that is respectful of differences
• Be mindful of the seen and unseen Dimensions of Diversity and be respectful in word and action based on the Guiding
Principles, especially the principle of Valuing Individuals.
By understanding the Dimensions of Diversity, every employee can:
• Truly understand what is unique and special about others
• Better serve our patients, their families and other customers
• Find value and richness interacting with co-workers and maximize their contributions to Texas Children's
ongoing success
Family-centered care
Family-centered care is a philosophy of care that is based on the belief that:
Parents (caretakers) are experts when it comes to dealing with their own children and want what is best
for them. Parents need adequate information and support in order to care for their children in the best
possible way.
A child is not merely a patient, but a part of a family, and the family is a partner in the child's health care.
A family-centered care approach to pediatric health care is one that:
• Recognizes that the family is the constant in a child's life, while the health care service system and the personnel within
the system may fluctuate.
• Facilitates family/staff collaboration on all levels of heath care
• Consistently demonstrates a caring attitude towards patients and families, honoring their racial, ethnic, cultural and
socioeconomic diversity.
• Recognizes and respects the strengths, values, concerns and choices of families.
• Identifies family needs and collaborates with families to determine actions needed to meet those needs.
• Understands and incorporates the developmental needs of infants, children and adolescents and their families into a
health care plan.
Family-centered care
LANGUAGE SERVICES
A child is not merely a patient, but a part of a family, and the family is a partner in the child's health care.
A family-centered care approach to pediatric health care is one that:
• Recognizes that the family is the constant in a child's life, while the health care service system and the personnel within
the system may fluctuate.
Disaster Codes
CARLA
At Texas Children’s, there is a plan in place so that all staff know how to respond in the event of a natural
disaster or emergency. During the past several years, Texas Children’s has worked closely with federal,
state and local agencies to prepare for domestic situations in the event of a nuclear, biological or
chemical disaster. The word that describes emergency preparedness and response at Texas Children’s
is CARLA and preparation for the emergency begins long before the event itself is imminent. For the
purposes of your orientation, it is important to be familiar with 3 terms:
CARLA Alert
An emergency event is imminent. Some examples include: external emergencies either natural or
manmade, mass casualties, internal disasters, or severe weather like a storm or hurricane.
CARLA
This is the highest level of emergency response. CARLA activates the hospital’s emergency response
teams of preparation, ride-out and relief. Examples of CARLA may include: hurricane landfall, freezing or
icing conditions, community wide emergencies requiring a coordinated response and patient relocation
and evacuation.
CARLA Clear
Hospital returns to normal operations with continued care for casualties.
Disaster Codes
Call *9999 in the hospital to report any of the following:
Code RED - A cardiac or respiratory arrest in any Texas Children’s Hospital building
• If you are in a patient's room, press the Emergency Call button and dial *9999 on the phone.
• If you are in another area of the hospital dial *9999.
• Begin CPR only if you are certified to do so. If you are not certified, wait for qualified code response team members to
arrive.
Code Pink – A patient under the age of 18 is missing from the unit or has been abducted
• The hospital will then be in lock down and everyone must remain in current location until the Code Pink is cleared.
Dr. Pyro STAT – Fire Emergency - A fire has been reported in the hospital
• Follow the procedures in place for your unit. Know your unit's evacuation plan, fire exits and fire extinguisher
location. Never shout "FIRE"
If you are working at any off-campus location including a Health center, Nabisco Building, TCPA
Practice or Meyer Building, the number to dial for emergencies is 9-1-1.
Emergency / Safety Situations
Fire Safety - Protection
To be well prepared in the event of a fire, all Texas Children's staff including Baylor staff, Volunteer
Services, students, faculty and anyone who works in a Texas Children location should know the following:
• Locations of fire alarms and pull stations on your floor or area
• Locations of fire extinguishers, specific types and procedures for using them
• Locations of fire doors
• Locations of exits, stairwells and proper routes to safety that you are to use
• Specific number you call in your work location in order to contact the fire department, emergency medical system and/or
the appropriately trained employee response teams
• Locations of smoke compartments on your floor or area
Only the FIRE DEPARTMENT or Nursing Administrative Coordinator (NAC) can authorize evacuation down the stairs and
out of the building.
If you are trying to extinguish a fire:
• Discontinue the use of oxygen or gas and disconnect electrical appliances in the immediate area.
• Always stand between the fire and the way out to safety.
• Crouch low to avoid the smoke and heat from the fire. Avoid inhaling the smoke or fire gases.
If you are working at any off-campus location including a Health Center, Nabisco
Building, TCPA Practice or Meyer Building, the number to dial for emergencies is 9-1-1.
Emergency / Safety Situations
Extinguishing a fire - cont.
If you are trying to extinguish a small fire by using a fire extinguisher, first choose the appropriate fire
extinguisher and then remember the letters P A S S.
P - Pull the pin
A - Aim at the base of the flames
S - Squeeze the handle
S - Sweep form side to side
RACE
The acronym R.A.C.E. is used throughout Texas Children’s main campus to help staff to remember what steps to take in
the event of a fire emergency. The letters stand for:
R - Rescue
The safety of the patient comes first. If a patient in in immediate danger, remove the patient to safety before doing anything else.
A - Alert
Activate fire alarm system by pulling the closest fire alarm pull station. Report the fire to the hospital operator at Ext. *9999
C - Confine
Confine the fire to prevent it from spreading by closing doors and windows.
E - Extinguish
Try to control the fire by using the proper fire extinguisher only if your safety can be assured.
Safety
Waste Control
Red Bag Waste:
Any item which is visibly contaminated with blood or blood-tinged body
fluids, or contains or has contained visible blood or blood-tinged body
fluids is considered special waste and will be placed in a cardboard
bio-hazardous waste (Red Bag Waste) container marked with the biohazardous label. The red bio-hazardous waste bag is enclosed or
placed in a cardboard box to ensure proper disposal.
Blue Bag Waste:
All linens are to be placed in the labeled linen (blue bag lined)
containers. No other items are placed in the linen containers.
Safety
Policy References:
SAF 103 Hazardous Chemicals & waste management
SAF 104 Smoking and Tobacco Use
SAF 302 Balloons
Material Safety Data Sheet - Hazardous Materials
Hazardous materials are handled everyday in the hospital environment. Precautions need to be taken
when handling these materials. Hazardous materials can be identified by the product label and warning
symbols or by the proper Material Data Safety Sheet (MSDS). The MSDS provides the user with physical
hazards, route of entry, precautions for safe handling, control measures, and emergency first aid. The
MSDS sheets for chemicals at Texas Children's can be accessed through Connect (Texas Children’s
intranet) on the Office of Safety Management Web page.
Smoking
It is Texas Children's Hospital policy to be a smoke-free institution and to extend that policy to all hospital
premises include parking garages. There are designated smoking areas around each building.
Balloon Policy
Latex/rubber balloons and similar products create safety hazards for small
children (i.e., choking). Therefore, it is the policy of Texas Children’s to
ban the sale, use or display of latex/rubber balloons, which includes
surgical gloves when being used as a toy in any Texas Children’s building
or Hospital sponsored function.
Policy References:
SAF303 Use of Devices Emitting
electromagnetic Interferences
Safety
Devices Emitting Electro-Magnetic Interferences
Devices emitting radio frequencies such as cellular phones, citizen band radios and other personal
communication devices or games operated by radio remote control are not permitted unless approved by
the Biomedical Engineering Department. An approved cellular phone list is available on Connect under the
Biomedical Engineering Department web site under "Services". Areas where devices are allowed include all
general floors, patient rooms, corridors and lobbies.
Cell phones may NOT be used in the Intensive Care Units (ICU) or within a proximity of three
feet or less from patient care equipment.
Restricted Areas
All devices must stay in their off position while in restricted areas where life support
equipment may be in use. Restricted areas include:
OR ands all ICU areas
Cath Lab
PICU
CV-ICU
Neonatal ICU
Dialysis
Infection Control
Policy References:
SAF 207 Standard Precautions
PC120-01 on Fingernails
Standard Precautions
"Standard Precautions" provide a method of effective infection control that considers all patients
to be potentially:
• Infected with a bloodborne pathogen
• Infected with a microorganism capable of spreading communicable diseases
Standard Precautions should be utilized for all body fluids. Treat all blood and potentially infectious
materials as infectious.
Fingernail Policy
All health care workers, including volunteers who care for patients directly, must have short, clean and
natural fingernails. No artificial nails, tips, jeweled insets or overlays should be worn by direct patient care
providers.
All health care workers who prepare medications or serve food must have short, clean and natural
fingernails. No artificial nails, tips, jeweled insets or overlays should be worn by these health care workers.
Infection Control
Can I get a HY5? Only if those hands are clean!
Hand Washing
• Wash hands thoroughly with soap and water for 10 seconds when hands are visibly soiled.
• Use gel or foam for cleansing hands when they are not visibly soiled and rub over all surfaces of hands and fingers.
Remember, gloves are not a substitute for hand hygiene!
Hand hygiene should be performed:
• BEFORE and AFTER each patient contact
• Between different types of patient care on the same patient
• After removing protective gloves
• Before preparing or administering medications or food
• After touching inanimate sources that are likely to be contaminated with microorganisms
• Before performing any invasive procedure such as starting an IV, suctioning or inserting a Foley catheter
• Before and after eating and drinking
• After using the restroom
Infection Control
Policy References:
SAF 200 Infection Control Plan Series
SAF 206A OSHA Bloodborne Pathogen Standard
Selecting Personal Protective Equipment (PPE)
PPE may include gloves, gowns, disposable lab coats, face shields or masks, eye protection,
pocket masks and other protective gear.
The Personal Protective Equipment (PPE) must be “readily available” in the workplace and in appropriate
sizes. If employees/students/faculty anticipate that they will have contact with blood and/or other
potentially infectious materials or contaminated surfaces, they must wear gloves.
Please remember:
Single use gloves cannot be washed or decontaminated for reuse.
Utility gloves may be decontaminated, if they aren't damaged or otherwise unable to protect the wearer.
Gloves should be replaced if they show signs of cracking, peeling, tearing, puncturing or deteriorating.
Single use gowns are recommended during patient care to prevent soiling of clothing with secretion/excretion, such
as rocking a baby with diarrhea.
• Masks are recommended to prevent transmission of infectious agents through the air. Masks protect the wearer
from inhaling:
-Large particle aerosols (droplets) that are transmitted by close contact and generally travel only short distances
(about 3 feet)
-Small-particle aerosols (droplet nuclei) that remain suspended in the air and thus travel longer distances.
• Wearing gloves, gowns, masks and other eye protection can significantly reduce health care worker risks for
exposure to blood and other potentially infectious materials.
• All PPE must be disposed of in the proper isolation reciprocal
after each use.
•
•
•
•
Infection Control
Policy References:
SAF 200 Infection Control Plan Series
SAF 206A OSHA Bloodborne Pathogen Standard
Tuberculosis
Tuberculosis (TB) is an airborne disease that affects the lungs or other organs where the lymph
system may be involved.
TB maybe transmitted by inhalation of respiratory secretions from infected individuals. Generally, very
young children cannot transmit TB since they cannot cough forcefully enough to generate sputum.
Signs and symptoms of active TB include:
•
•
•
•
•
Fever
Malaise
Night Sweats
Cough
Unexplained Weight Loss
• Blood in the sputum
Evaluation Criteria
Pediatric patients with suspected or confirmed TB are evaluated for infection using the same evaluation criteria as adults.
These children must be placed in airborne isolation. Because family members are usually the source of infection, parents
and other caregivers should do the following:
• Be evaluated for TB as soon as possible. Call the Infection Control Department to assist in arranging chest xrays for two caregivers who will be staying with the patient.
• Wear surgical masks when in the hospital setting until an evaluation is complete. A surgical mask is not
necessary for a family member if the family member is in the negative pressure room
with the patient.
Infection Control
Policy References:
SAF 200 Infection Control Plan Series
SAF 206A OSHA Bloodborne Pathogen Standard
Tuberculosis – Engineering (Physical) Controls
There are two (2) types of engineering controls that are used to keep TB bacteria from spreading.
These include:
1. Isolation rooms with special ventilation called “negative pressure airflow.”
Patients suspected or known to have active TB should be placed in these rooms and the doors to
these rooms are kept closed. Facilities Operations ensures that a room is under “negative
pressure.” Call Facilities Operations to verify that the room is operating properly.
An N-95 mask should be worn by all healthcare workers when entering these isolation rooms.
2. Airborne isolation procedures should be maintained until the patient is no longer contagious, as
determined by Infection Control.
Before ruling out TB and discontinuing airborne isolation, clinical
staff must first contact the Infection Control Department.
Infection Control
Isolation Signs at Texas Children’s
Infection Control
Isolation Signs at Texas Children’s – cont.
Infection Control
Policy References:
SAF 200 Infection Control Plan Series
SAF 206A OSHA Bloodborne Pathogen Standard
Bloodborne Pathogens
Bloodborne pathogens are communicable diseases that are transmitted by blood or other body
fluids, including but not limited to semen and vaginal secretions.
All body fluids visibly contaminated with blood should be considered as potentially infectious for:
HBV – the virus that causes Hepatitis B
HCV – the virus that causes Hepatitis C
HIV – the virus that causes AIDS
What is Hepatitis B (HBV)
Hepatitis B (HBV) is a liver disease that is caused by a virus and can alter liver function. The liver, when
functioning normally, stops bleeding, stores energy and removes drugs and toxins from the blood.
How is HBV spread?
HBV is spread by contact with an infected person's blood, semen, or other bodily fluids. Anyone with
occupational exposure to blood is at risk of contracting HBV.
What are the signs and symptoms of HBV?
HBV can make you feel like you have the flu. You might experience fatigue, nausea, diarrhea, fever or loss of
appetite. Some people who are infected with HBV produce dark yellow urine and/or light colored stools. They
also may have yellowish eyes and skin.
Infection Control
Policy References:
SAF 200 Infection Control Plan Series
SAF 206A OSHA Bloodborne Pathogen Standard
Bloodborne Pathogens - Cont.
What is Hepatitis C (HCV)
Hepatitis C (HCV) is an infection of the liver caused by a virus. It is less common than Hepatitis A or Hepatitis B.
How is Hepatitis C spread?
Hepatitis C is spread by contact with an infected person’s blood. In rare cases, a person could get Hepatitis C from sexual
contact with an infected person. Some blood transfusions or organ transplants conducted before 1992 have resulted in
exposure to the virus. Prior to that time, health care facilities did not test to detect Hepatitis C antibodies.
What are the signs and symptoms of Hepatitis C?
Hepatitis C infections typically have no symptoms for a period of years. Most cases of Hepatitis C are identified when
people have liver tests or Hepatitis C antibody tests done before donating blood. Some people eventually experience flulike symptoms with fatigue, nausea, diarrhea and loss of appetite. They may have dark yellow urine, light colored stools or
yellowish skin or eyes.
How can health care workers protect themselves from HCV?
Currently, no vaccine exists to prevent Hepatitis C.
Studies have found that health care workers exposed to the Hepatitis C virus through a needle stick or other injuries that
enter the skin have become infected at an average of 1.8% per injury.
Those at risk should use appropriate Personal Protective Equipment (PPE) and
appropriate safety devices to protect themselves from Hepatitis C.
There is a vaccine to protect against Hepatitis B; however,
there is no vaccine to protect against Hepatitis C.
Infection Control
Policy References:
SAF 200 Infection Control Plan Series
SAF 206A OSHA Bloodborne Pathogen Standard
Blood-borne Pathogens – cont.
What is the Human Immunodeficiency Virus (HIV)?
HIV is the virus that causes AIDS. The virus is passed from one person to another through direct blood to blood contact.
HIV kills an important kind of blood cell – the CD4 T lymphocyte or T cell. As the T cells die off, the body becomes more
and more vulnerable to other diseases called "opportunistic infections." When persons with HIV get these infections or if
their CD4 T cell levels become too low, they may contract AIDS.
Who is at risk for contracting HIV?
Health care workers whose job duties involve potential contact with a patient's blood or other hazardous body fluids in a
health care setting are at risk.
How can exposures to HIV occur?
Exposures can occur through contact with blood or other hazardous body fluids. Exposures can occur through needle
sticks, cuts, lacerations and contact with non-intact skin or mucous membranes.
Protection Against Exposures
To protect against exposure to blood-borne pathogens, health care workers should use Standard
Precautions. Complying with these precautions will help to maintain a safe work environment for everyone.
Some examples of Standard Precautions are:
• Properly using Personal Protective Equipment (PPE) such as
respirators, goggles, gloves, gowns, masks and properly disposing
of safety sharps.
• Removing all contaminated or dirty gloves promptly.
• Disposing of closed, locked sharps containers in
designated red bag waste containers immediately after use
and when the sharps containers are 2/3 full.
Infection Control
Protect Yourself
1. Never overfill the
sharps container
2. Change the container
out when it is 2/3 full
Don’t put yourself at risk for a
needle stick injury.
Please visit the Infection Control
Webpage on the Texas Children’s
Hospital Intranet “Connect” for further
information & resources
Ethical Issues
Policy Reference:
CCP101, CCP 101-01: Code of Ethical
Behavior
PS 100, PS 100-01, PS 100-01a, PS-01b:
Patient Rights & Responsibilities
PC118-01: Guidelines on
Institutional Policies
on the Determination of Medically
Inappropriate Interventions
What is an ethical issue?
Patient care providers may be faced with ethical issues in their work environment. When forced to consider
two different, but morally defensible alternatives to the same problem, an individual may experience
conflicting loyalties to their profession, colleagues, patients and families, institution and society. The
following information may be helpful to students, faculty, and new employees at Texas Children's Hospital.
Definitions:
Ethical: pertaining to ethics or morality: conforming to moral standards
Issue: A matter that is in dispute between two parties
What are some examples of ethical issues?
Some examples of ethical issues may be:
•
•
•
•
Prolonged life support - medically futile procedures
Withdrawal of life support
Administration of blood or blood products
Abortion
What resources are available to me?
Should an ethical issue arise, resources are available to staff at Texas Children's Hospital, including:
•
•
•
•
•
Policy & Procedures
Leadership team
Human Resources Department
Chaplain Services
Bioethics Committee
Ethical Issues
Policy Reference:
CCP101, CCP 101-01: Code of Ethical
Behavior
PS 100, PS 100-01, PS 100-01a, PS-01b:
Patient Rights & Responsibilities
PC118-01: Guidelines on
Institutional Policies
on the Determination of Medically
Inappropriate Interventions
Corporate Compliance Program
What is your role?
• Follow the Texas Children's Code of Ethical Behavior.
• Understand your job responsibilities.
• Ask questions if you don't fully understand your responsibilities or are able to identify a potential issue.
• Report potential issues.
What is the Code of Ethical Behavior?
At Texas Children's, the Code of Ethical Behavior means that we are committed to:
• Following the laws
• Following ethical business practices
• Following the Mission, Vision, Values and Guiding Principles of Texas Children's
• Avoiding conflicts of interest
• Adhering to Texas Children's policies and procedures
• Reporting inappropriate or unethical conduct or activity
• Maintaining confidentiality
• Keeping accurate and complete records
• "Doing what is right, not what is easy"
Ethical Issues
Compliance
Texas Children's and related personnel are required to comply with all laws, regulations and
policies including the following:
• Fraud and abuse laws such as the Federal False Claims Act
• Medicare and Medicaid coding and billing regulations
• Employment and labor laws
• Texas Children's policies
How To Report Suspected Ethics and Compliance Violations
Please report all suspected ethics and compliance violations to any of the following:
• Your unit leader
• Any other Texas Children's leader
• The Compliance Office at 832-824-2085
• Texas Children's Confidential Hotline at 1-866-478-9070
Ethical Issues
Policy Reference:
IM 100: Corporate Information Security Policy
IM 105: Use and Disclosure of Protected Health Information
IM 106-01: “No Information” Patient Status
IM 201-201A: Patient Access to Protected Health Information
Information Management & Privacy
1. Never discuss any private information about patients with anyone except other health care workers who
are providing care.
2. Password protect or logoff the computer if you leave the area.
3. Do not share your password with anyone.
4. If a patient is identified as "no information” status, do not give out ANY information.
5. Place "hardback" charts in the appropriate place.
6. Only obtain information about a patient or a patient's family that is necessary to work in your role. This
means you may not look up information about you friend’s ro co-worker’s child or your own child just
because you have access to the information.
7. All students and professionals entering Texas Children's Hospital will be required to provide completed
HIPPA & Patient Confidentiality forms prior to coming into the Texas Children’s Hospital facility.
8. If you suspect any illegal or unethical activity, you must report this to one of the following:
• Privacy office
• Security Services
• Texas Children’s Hospital Confidential Hotline 1-866-478-9070
Welcome to the Texas Children’s Hospital Orientation for
Nursing Students
Hand-offs & Report
Reference:
UO 1105: Patient Care Report
SBAR
Goal: Seamless care and professional accountability of patient during change of shift report or transfer
from one unit to another
Objective: Complete, organized exchange of information between nursing staff is essential for continuity of
patient care and patient safety. Patient report/handoff is interactive, direct communication between care
providers allowing for questioning between giver and receiver of patient information. This report/handoff
may be for an entire shift or a portion of a shift, such as meal relief, change in assignment or transfer to
another department for testing or treatment.
Pertinent information includes but is not limited to:
Situation- name, age, height, weight, allergies, diagnosis, problem list, isolation
status, code status and language preferred
Background- history (medical/surgical), custodial issues, special needs, disposition
of valuables, lab results, treatment team and name of attending.
Assessment- vital signs, lines, drains, ventilatory status, blood products, skin
issues, diet, IV access, monitoring
Recommendation/Request- all medications infusing, psych/emotional support, plan
for continuing care, documentation up to date
S: Situation
B: Background
A: Assessment
R: Recommendation
Hand-offs & Report
Reference:
UO 1105: Patient Care Report
Tips
• Gather all pertinent data available before calling report.
• Use the standardized hand-offs available at Texas Children’s Hospital. The SBAR form can be found on
each unit.
• Take your time when doing a hand-off or report.
• A student should always have an RN present during the report /hand-off process.
• Hand-offs and report are an important safety net to catch and prevent mistakes and errors.
• Reporting errors as soon as they are found allows us to create new processes to enhance patient care
and prevent future errors or near misses.
• Any time you need to be away from your immediate patient care area/bedside, such as lunch, breaks,
restroom or clinical conclusion, you must report off to the RN caring for your assigned patients.
• Document the name and credentials of the person you are getting report from or giving report to.
Nutrition
Nutrition Tips
• Nutrition Care Manual is located on the Food & Nutrition home page on the Texas Children’s Hospital
intranet (Connect).
• All food must be discarded two hours after delivery, except packaged chips, cookies, non-refrigerated
foods.
• All standard formulas and medical nutritionals are available.
• Formula is only mixed in the formula room due to infection control requirements.
• Open containers of formula or nutritional supplement must be stored in a sealed labeled container in the
refrigerator for no longer than 24 hours.
Nutrition
Nutrition Measurements
Weight: Kilograms or Grams
• Using infant scale: Place paper on scale and
zero out. Weigh infant nude.
• Using standing scale: Clothing and shoes off
except for underwear or weigh parent & child
together minus parent's weight
Length/Height: Centimenters
• Length – Use recumbent position birth to 3
years of age Growth Chart or use length board
(not measuring tape)
• Height – Standing position (only). Uses 2 to
20 age Growth Chart Stadiometer (wall
mounted or on standing scale)
Other Measurements
Weight/Length Percentile
Frontal Occipital Circumference
• Use the Birth – 36 month Growth Chart
• On the Birth – 36 month Growth Chart only
• Helps evaluate underweight or overweight
• Places a flexible measuring tape around occipital
bone to frontal bone
BMI Calculation
• Calculator is on the TCH internet Connect (nursing and
nutrition pages)
• Uses 2 – 20 years of age Growth Chart (replaces
weight/height percentile)
Care of the NGT/OGT
Policy Reference:
TM 503
With or Without feeds
Verify NG/OG placement by the following methods:
• Using a 10cc syringe, aspirate 0.5ml-1ml of gastric contents. Note appearance (expect white undigested or curdled, pale
green, or clear to brown fluid). If unable to obtain aspirate, advance the tube slightly and aspirate gently again.
• Apply aspirate (0.5ml-1ml) to pH indicator strip. Note the pH value:
-pH of 5 or less indicates gastric position.
-pH of 6 or greater suspect incorrect tube placement. Notify physician or designee of results.
• Immediately after confirmation of correct placement, use an indelible marker to mark the point where the tube exits the
nose/mouth. Document on tube label and kardex the depth of insertion (cm). Document tube size, time and date of
placement.
• Refer to the documented depth of insertion (cm) to verify placement prior to each subsequent use of the tube
• Record the pH and aspirate description as well as any other noted abnormalities on the nursing flow sheet.
Before you feed:
• Check gastric pH prior to each bolus feed or medication administration.
• Place patient supine, on right side, or upright during and after feed.
• Measure and return gastric residuals prior to each bolus feed or each shift with continuous feeds.
• Rinse the feeding bag/syringe every four (4) hours with tap water prior to refilling with formula. Discard feeding bags
and syringes after 24 hours.
• Feeding bag/syringe and tubing should be changed every 24 hours.
• Exception: For breast milk and premature formulas, use syringes only and change the
syringe every four hours.
• Measure and return gastric residuals every four hours with the
rinsing of the feeding bag/syringe or prior each bolus feed.
Pain Scales at Texas Children’s Hospital
Pain Rating Scales
Wong-Baker Faces Rating Scale:
Explain to the child that each face is for a person who feels
happy because he has no pain, hurt or sad because he has
some or a lot of pain. Face 0 is very happy because he
doesn't hurt at all. Face 2 hurts just a little bit. Face 4 hurts
a little more. Face 6 hurts even more. Face 8 hurts a whole
lot, but face 10 hurts as much as you can imagine. Ask the
child to choose a face that best describes how he feels.
Visual Numeric Pain Scale:
Explain to the child that at one end of the line
is a 0, which means that person has no pain or hurt. At the
other end is a 10, which means that person feels the worst
pain Imaginable. The numbers 1 through 9 represent a
range from every little pain to a whole lot of pain. Ask the
child to choose the number that best describes how he is
feeling.
Policy Reference:
TM 503
Pain Scales at Texas Children’s Hospital
Policy Reference:
TM 503
FLACC
FLACC is a behavioral pain scale that utilizes five categories to rate pain in patients unable to selfreport:
F - Face
L - Legs
A - Activity
C - Cry
C - Consolability
The acronym FLACC was devised to facilitate recall of the
categories included in the tool.
The FLACC assessment tool was developed with input from clinicians to provide a simple, consistent
method to identify, document and evaluate pain.
Each category is scored on a 0 to 2 scale which results in a total score between 0 and 10, a range often
found in other clinical assessment tools.
Pain Scales at Texas Children’s Hospital
Policy Reference:
TM 503
FLACC - Scale
SCORING
CATEGORIES
0
1
2
Face
No particular expression or smile
Occasional grimace or frown,
withdrawn, disinterested
[appears sad or worried]
Constant grimace or frown
Frequent to constant quivering chin,
clenched jaw
[Distressed-looking face: Expression
of fright or panic]
Legs
Normal position or relaxed
Uneasy, restless, tense
[Occasional tremors]
Kicking, or legs drawn up
[Marked increase in spasticity,
constant tremors or jerking]
Lying quietly, normal position moves easily
Squirming, shifting back and forth
tense.
[Mildly agitated (eg. head back and
forth, aggression);shallow, splinting,
respirations, intermittent sighs]
Arched, rigid or jerking
[Severe agitation head banging;
Shivering (not rigors); Breath holding,
gasping or sharp intake of breath;
Severe splinting]
Cry
No cry, (awake or asleep)
Moans or whimpers;
occasional complaint
[Occasional verbal outbursts or
grunts]
Crying steadily, screams or sobs,
frequent complaints
[Repeated outbursts, constant
grunting]
Consolability
Content, relaxed
Reassured by occasional touching
hugging or being talked to,
distractable
Difficulty to console or comfort
[Pushing away caregiver, resisting
care or comfort measures]
Activity
FLACC (Revised descriptors for children with disabilities shown in [brackets]
Some children, including those with disabilities, may display unique behaviors like selfharm, shaking or slapping when they are in pain. The revised-FLACC allows you to add
such behaviors to better assess pain in your pediatric patient. Please ask the
Parent/Caretaker to tell the Nurse if their child has specific behaviors
that means he or she is hurting.
Pain Scales at Texas Children’s Hospital
Policy Reference:
TM 503
Pain Rating Scales
CRIES Neonatal Pain Measurement Scale for Infants ≥38 Weeks
Indicator
0
1
2
Adapted from Bildner J and Krechel S, (1996), Neonatal Network, 15(1); 11-16.
Crying
No
High-pitched cry or cry face
without sound, consolable with
comfort measures
High-pitched cry or intense cry
face and inconsolable
Required FiO 2 for
adequate color or
saturation
No oxygen needed or no
increase from baseline FiO 2
needed
FiO 2 is <30% or requires <10%
increase from baseline FiO 2 to
maintain saturation or color
FiO 2 is >30% or requires ≥10%
increase from baseline FiO 2 to
maintain saturation or color
Increased vital
signs (BP
performed last)
HR and BP within 10% of
preop/preprocedure baseline
values
HR or BP 11% to 20% higher
than preop/preprocedure
baseline value
HR or BP 21% or more above
preop/preprocedure baseline
value
Expression
None - face relaxed
Grimace
Grimace/grunt
Normal for infant
Postop: Wakes at frequent
intervals
Postprocedure: Awake, highly
aroused, consolable
Postop: Constantly awake
Postprocedure: Awake, highly
aroused, inconsolable
Sleep/Wake
Behavior
The CRIES Pain Scale is used to assess pain in neonates, infants, and preverbal children. As with any pain scale it should
be used in combination with other patient data such as physiologic, environmental stressors, general status, plus the
presence or absence of pain risk factors.
Scoring the CRIES Scale
•Minimal to no pain = 0 to 1
•Mild pain = 2 to 4
•Moderate to severe = 5 or greater
Pain Scales at Texas Children’s Hospital
Policy Reference:
TM 503
Pain Rating Scales
Management/Monitoring: Premature Infant Pain Profile (PIPP) Infants ≤37 Weeks
Indicator
0
1
2
3
Stevens B, Johnston C, Petryshen P, et al, “Premature Infant Pain Profile: Development and Initial Validation”, Clin J Pain, 1996; 12:13-22.
Gestational
age
≥36 weeks
32 weeks to 35 weeks, 6 days
28 weeks to 31 weeks, 6 days
≤28 weeks
Behavioral
state
Active / awake; eyes open;
facial movements
Quiet / awake; eyes open; no
facial movements
Active / asleep; eyes closed;
facial movements
Quiet / asleep; eyes closed; no
facial movements
Heart rate
maximum
0 to 4 beats/minute increase
5 to 14 beats/minute increase
15 to 24 beats/minute increase
25 beats/minute or more
increase
Oxygen
saturation
min.
0% to 2.4% decrease
2.5% to 4.9% decrease
5.0% to 7.4% decrease
7.5% or more decrease
Brow Bulge
None of the time
0-3 seconds
Minimum >3-12 seconds
Moderate >12-21 seconds
Maximum >21-30 seconds
Eye Squeeze
None of the time
0-3 seconds
Minimum >3-12 seconds
Moderate >12-21 seconds
Maximum >21-30 seconds
Nasolabial
furrow
None of the time
0-3 seconds
Minimum >3-12 seconds
Moderate >12-21 seconds
Maximum >21-30 seconds
Scoring (1) for PIPP
1. Score corrected gestational age before you begin.
2. Score behavioral state by observing infant 15 seconds immediately before the event.
3. Observe infant immediately before and after a painful event and before and after pain
medication is administered (30 minutes after intravenous and 1 hour after oral medication).
4. Assess baseline heart rate, oxygen saturation, and facial expression.
5. Score heart rate, oxygen saturation change from baseline (30 seconds).
6. Facial expression is not an absolute calculation of time, but rather an estimation of time
present during 30 second observation.
7. Calculate total pain score.
PIPP Scoring Interpretation Guide
6 or less = Minimal to no pain
7-12 = Mild pain
>12 = Moderate to severe pain
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
•
Lexi-Comp/Drugs is a comprehensive online database of drugs available in the United States. The information
provided in Lexi-Drugs is referenced through studies and supportive literature.
•
TCH Formulary uses Lexi-Comp as a service to provide our formulary online. The information in the TCH
formulary is customized to reflect TCH practices.
•
Available through the TCH Connect homepage (intranet)
•
Under the Clinical Resources Tab, Click on Drug info and formulary
Click here
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Home Page
SEARCH by drug
How to use the
database
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
What is on TCH formulary?
Drug available on
TCH Formulary
Drug not available on TCH formulary =
“No occurrences” Use Lexi-Drugs
Utilize the TCH formulary for your reference unless the medication you are
looking for is not in there & then you can utilize the Lexi-drugs online
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Helpful Hints
Finding the drug
The correct spelling is required when entering in the drug name in its entirety
Sometimes less is more - entering only 3 or 4 letters may take longer to search but will provide
results and can decrease time to find drug information due to decreases in spelling error
Entering
“CALCIUM”
results in 4 listings
in TCH formulary
& Over 11
listings in
Lexi-Drugs.
Entering “CAL”
results in 10 listings in
the TCH formulary
Lexi-Drugs.
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Helpful Hints
“Jump To” Fields: Alphabetical or Frequently Used
“Jump To” fields are available for you to go directly to a section:
An example is when looking for Medication Dosing, you can “JUMP-TO” the Dose section by going to
1 of 2 locations. The one on the left is listed according to use frequency. The one with the drop down
menu on the right is listed alphabetically. They both work in the same way. When clicked, it will take
you directly to a section without having to scroll down the page.
Jump-To
Jump-To
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Helpful Hints
“Jump To” Fields: Compatibility and Stability
Another use of the “Jump to” fields is to look up stability of a medication, which is a frequently
asked question from Nursing Staff.
Information can be found for IV compatibility of certain medications.
IV Compatibility
Jump-To
Jump-To
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Helpful Hints
“Jump To” Fields: Stability
If you are looking for information concerning what to flush your medication with…You
would want to know what your medication is stable in (i.e.. NS, D5W, etc) You would use
the jump to field or scroll to “STABILITY” since you want to know what DILUENT your
medication is STABLE in.
Jump-To
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Helpful Hints
“Jump To” Fields: IV Compatibility
If you are wondering what medications can run through the same line, you will want to click the IV
COMPATIBILITY button. This will take you to the KING’S GUIDE. Instructions (next page).
Jump-To
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Helpful Hints
IV Compatibility:
King’s Guide Online
1.
Enter Drug (click drug)
2.
Enter additional drugs
3.
View Results
Medication Administration
TCH Formulary & Lexi-Comp/Drugs
Helpful Hints
IV Compatibility
The result is the picture below, which tells you whether you can run your drugs together. In the
example…the table indicates incompatibility since the RED dots appear. Green dots are
compatible, yellow are mixed information and blank = No information.
Medication Administration
Important information about the Pharmacy
The Inpatient Nurses Guide to Pharmacy Services
• Overview of the Medication Distribution System
• Medication Safety strategies and helpful hints
• Available on Connect (TCH Intranet) on the nursing home page
under resources or on the Pharmacy home page
The unit dose system
One dose of Medication
For one patient
For one time of administration
The printed information on the Unit Dose Envelope is the same information that is on the computerized Medication
Administration Record (MAR)
• Any special instructions concerning the medication will be entered by the pharmacist
•
•
•
•
Medication
•
•
•
•
•
•
•
Tablets will only be cut and/or crushed by pharmacy
Injectable medications are printed in black on the syringe label and have a yellow cap
Oral solution medications are printed in blue on the syringe label and have a blue cap
Oral solids come in commercial unit dose containers or in-house pre-packs
PRN Medications are in an envelope stamped with "PRN"
Injectable PRNs are not drawn up in syringes
In order to get a replacement for a PRN medication the nurse must check the "send
another dose" box on the envelope and return to pharmacy
Medication Administration
Once you have completed your report and chart check in morning report, the MAR
should be available for reconciliation.
Before preparing to give meds, all medications listed on the Medication Administration Record (MAR)
should be:
•
•
•
•
•
•
•
•
Investigated in the Texas Children’s Hospital Formulary found on Connect (TCH Intranet) home page
verified with the latest order in the chart
Compare chart order to MAR
Compare MAR to envelope
Compare envelope to contents
Verify contents (correct volume for concentration)
Verify all patient allergies
Then proceed to the patient
Two patient identifiers should be checked at every step: patient name and medical record number.
Your patient must be wearing an armband in order to administer medication.
Never leave medications unattended.
Tips
• Students may not administer blood or blood products, chemotherapy, or any investigational medications.
• Students must be directly supervised by their RN faculty member or Texas Children’s Hospital staff RN when providing
medications to any patient.
• Students may not take any verbal or telephone orders.
Medication Administration
Did you check the 5 R’s?
• Is this the right drug?
• Is this the right dose/volume?
• Is this drug for this patient?
• Is this the right time?
• Is this the right route of administration?
• Don’t forget to check to see if the patient is allergic to the medication or a similar medication.
• Don’t forget to compare the two patient identifiers with the patient label on the dose or with
the order if giving a dose from floor stock.
• Don’t forget to double check the IV line attachment & pump settings prior to starting the
medication
Medication Administration
High Risk Medications
It would seem that in the world of the pediatric patient, most medications could be termed high risk
or high alert if the medications are mistaken for one another, the doses are miscalculated or other
significant errors occur.
However, national reporting shows that specific medications are
repeatedly implicated as a cause of catastrophic errors due to its
narrow therapeutic index.
While the occurrence rate of errors with this group of medications
may not be greater than with other medications, it is the severity of
the outcome of errors that distinguishes them.
Medication Administration
Policy Reference:
MA 304 Medications
requiring special
considerations
High Risk Medications Category 1
Medications for which special requirements or restrictions (i.e. safety strategies) have been put in
place by policy or practice.
Examples
• Special signature requirements for orders for chemo, IV digoxin
• Preprinted order forms
• Storage requirements for potassium chloride, potassium phosphate, and sodium chloride > 0.9% (these concentrated
electrolytes cannot be floor stocked in patient-care areas)
• Nursing double checks before administration of specific medications as required by policy
• Limiting the number of concentrations and standardizing concentrations and formulations
• Requirement for prescribers to spell out the entire name of medications on the do-not-use abbreviation list (magnesium
sulfate, morphine, insulins)
• Kinetics monitoring service for aminoglycosides
• Drug-specific alerts generated by the pharmacy computer system
• Restricting access by removing a drug from floor stock in order to utilize the double checks within the pharmacy dispensing
process
• Using dosing charts
• Placing "High-Alert" warning signs on medication stock bins in the
pharmacy
Medication Administration
Policy Reference:
MA 304 Medications
requiring special
considerations
High Risk Medications Category 2
Medications shown in the table below, which represent the core group of medications which ISMP
has historically identified as having the potential for catastrophic errors due to their narrow
therapeutic index
The list of Category 2 medications is familiar to many practitioners is the high-alert medications list in the
Texas Children’s Hospital Drug Information and Formulary. Safety strategies have been implemented in
many phases of the medication management process for these medications (see some examples above).
Within the pharmacy areas, medications in this category present particular safety issues in the
preparation/dispensing phase and are physically segregated from other stock in bins labeled with the
distinctive “High-Alert Medication" warning label shown here.
Adrenergic agonists: Dobutamine, dopamine, ephedrine,
epinephrine, isoproterenol,norepinephrine, terbutaline,
vasopressin, phenylephrine
Anticoagulants and thrombolytics: Heparin, warfarin
(oral), alteplase
IV electrolytes: Sodium chloride injection > 0.9%
concentration (2.5 mEq/mL, 3% bags), magnesium sulfate,
calcium chloride and gluconate, potassium chloride and
phosphate
IIV dextrose > 10%: Including D50% and D70% bags
Local anesthetics: Lidocaine, local anesthetics in large
vials
Chemotherapeutic agents
Neuromuscular blocking agents: Atracurium,
pancuronium, rocuronium, succinylcholine, vecuronium
Opiates
IV adrenergic antagonist: Phentolamine
Factors (antihemophilic agents): Octreotide
IV Digoxin
Insulin
Epoprostenol - Flolan®
Medication Administration
High Risk Medications Category 3
Medications with look-alike/sound-alike names known to cause mix-ups in prescribing, dispensing,
or administration. In practice, we employ a variety of safety strategies for these medications and for
many other look-alike/sound-alike combinations on formulary.
Several strategies are listed below
• Consideration of look-alike/sound-alike drug names during Texas Children’s Hospital formulary addition process
• Limiting availability of look-alike/sound-alike combinations as floor stock in the same area
• Pre-printed order forms
• Heightened awareness due to inclusion on the list of look-alike/sound-alike drug names
• Use of TALLman letters for look-alike medication names in the formulary, in the pharmacy computer database, on unit dose
labels, on the MAR and on pharmacy shelf labels
• TALLman lettering helps visually distinguish between similar drug names by enhancing the unique letter characters of lookalike names with the use of upper case characters
With TALLman lettering, the eye is drawn to the portions of the drugs’ names that are different
Click here for examples
of look-alike/sound alike
medications.
Medication Administration
Do Not Use Abbreviations
Medication Administration
Intravenous Therapy
• All peripheral IV’s must be checked every hour for signs of phlebitis, leaking, infection, infiltration or
extravasation and documented on the nursing flow sheet. If any of the above is noted, the site should be
changed immediately.
• PIV sites must be visible at all times
• IV fluid bags should be changed out every 24 hours
• IV administration sets should be changed every 96 hours along with any connection component such as
a lure lock with the flowing exceptions:
• Change Intralipd sets every 24 hours
• Change propofol tubing sets every 12 hours
Medication Administration
Medication Reconciliation
What is it?
It is a formal process for:
• Developing a complete and accurate home medication list
• Comparing that list against medication orders at each stage of the patient's hospitalization
• Resolving any discrepancies
How do we do it?
It is a three step process:
1. Collect an accurate medication history
2. Compare this history to the physician orders at all transition points
• Admission
• Transfer
• Discharge
3. Resolve discrepancies between the lists
Developmental and Age-appropriate Care
Policy Reference:
SAF 611:
Guidelines to patient
saftey
Infants (0 - 12 months)
Normal Vital Signs
Heart Rate:
Resting 80-180
Awake 80-200
Respirations:
30-60
Communication
Pain/Comfort
Safety
• Infants communicate
through their senses
(tactile, auditory, and
visual)
• Cry, scream and try to
remove themselves from
painful situations.
• Avoid small objects in the
infant’s bed (syringe tops,
med bottles, alcohol wipes
and paper or toys with
small parts or buttons)
• Introduce yourself and
explain procedures to
the caregiver
• Infants have separation
and stranger anxiety
• Minimize separations
from parent or caregiver
as much as possible
• Talk slowly and calmly to
the infant. Your touch,
tone of voice and face
help the infant begin a
trusting relationship.
• Allow caregiver to remain
with infant as much as
possible
• Keep patient warm and dry
• Avoid continuous bright
lights
• Allow infant to keep
pacifier, blanket or toy
• Swaddle infant as
appropriate
• Hold and cuddle infant as
appropriate
• Keep crib rails all the way
up
• Never prop a bottle in
infant’s mouth
• Check infants frequently
because IV or oxygen lines
can easily get tangled
around an infants neck
Developmental and Age-appropriate Care
Policy Reference:
SAF 611:
Guidelines to patient
saftey
Toddler (1 - 3 Years)
Normal Vital Signs
Heart Rate:
Resting 70-160
Awake 80-190
Respirations:
24-40
Communication
Pain/Comfort
Safety
• Introduce yourself to
patient and caregiver
• Cry, scream and try to
remove themselves from
painful situations
• Do not leave
unsupervised;…does not
recognize danger
• Allow caregiver to remain
with toddler as much as
possible
• Keep side rails up
• No concept of time
(cannot distinguish
between few hours and
few minutes)
• Understand simple
commands
• Can tolerate short periods
of separation from parents
• Say “No” to everything
• Do not separate from
favorite/usual toy or
blanket
• Learning body control
and developing
language
• Like to do things
independently
• Do not rush patient
• Preschoolers can view
illness as punishment for
bad behavior
• Include parent in
explanations
• Allow older
toddler/preschooler to
talk/verbalize his or her
fears
• Regression can occur with
hospitalization
• May accept explanations
on a bear or favorite
stuffed toy
• Avoid small objects in the
infants bed (syringe tops,
med bottles, alcohol wipes
and paper, toys with small
parts or buttons)
• May forget they are
attached to IV
tubing/oxygen and will
need help when up and
walking around
• Sitter may be necessary
when family not available
• Buttons on pumps look
fun, so turn away from
child and do not put in crib
Developmental and Age-appropriate Care
Policy Reference:
SAF 611:
Guidelines to patient
saftey
Preschooler (3 - 5 Years)
Normal Vital Signs
Heart Rate:
Resting 60-120
Awake 70-140
Respirations:
22-34
Communication
Pain/Comfort
Safety
• Introduce yourself to patient
and caregiver
• Cry, scream, kick,
withdraw, regress and
cling to caregiver
• Do not leave
unsupervised…does not
recognize danger
• Allow caregiver to remain
with preschooler as much
as possible
• Keep side rails up
• Have difficulty distinguishing
between reality and fantasy
• Important they understand
why they are in the hospital
• Understand literal
interpretations of word (ie
that is a bad medication: they
think they are bad)
Click here to refer to table of
considerations in language*
• Do not separate from
favorite/usual toy or
blanket
• Learning body control and
developing language
• Regression can occur with
hospitalization
• Like to do things by
themselves
• May accept explanations
on a bear or favorite
stuffed toy
• Do not rush patient
• Preschoolers can view
illness as punishment for bad
behavior
• Include parent in
explanations
• Allow older
toddler/preschooler to
talk/verbalize their fears
• Avoid small objects in the
infants bed (syringe tops,
med bottles, alcohol wipes
& paper, toys with small
parts or buttons)
• May forget they are
attached to IV
tubing/oxygen and will
need help when up &
walking around
• Sitter may be necessary
when family not available
• Buttons on pumps look
fun, so turn away from
child and do not put in crib
Developmental and Age-appropriate Care
Policy Reference:
SAF 611:
Guidelines to patient
saftey
School age (5 - 9 Years)
Normal Vital Signs
Heart Rate:
Resting 60-120
Awake 70-140
Respirations:
19-30
Communication
Pain/Comfort
Safety
• Peers are becoming more
important
• Can better describe pain
location and intensity
• Curious
• Learning to communicate
ideas and feelings in a clear
way
• Can still be comforted by
caregiver
• Place bed in low position
• May be willing to ask
questions, but might still
have outbursts related to
hospitalization
• They are information seekers
(what and why)
• Understand literal
interpretations of word (ie
that is a bad medication: they
think they are bad)
Click here to refer to table of
considerations in language*
• Introduce yourself
• Maintain privacy for the older
child
• Allow child to have input
into some decisions
• Able to accept limits
• Encourage child to wear
slippers or shoes
• Keep side rails up when
child is asleep
Developmental and Age-appropriate Care
Policy Reference:
SAF 611:
Guidelines to patient
saftey
Preteen (9 - 12 Years)
Normal Vital Signs
Heart Rate:
Communication
Pain/Comfort
Safety
• Beginning logical thought
Resting 50-90
Awake 60-100
• More conscious of body and
social image
• Can describe pain location
and intensity
• Feel the weight of peer
pressure
Respirations:
• Some pre-teens may begin
puberty early
• May be reluctant to share
pain for fear of what the
pain might mean
• Enforce consistent limit
setting
18-30
• Privacy is very important
• Explanations are very helpful
and they are able to
understand more complex
explanations
• Worry about separation from
family and peers
• Opportunities for normal
activities can help them cope
• May regress as a coping
mechanism
Developmental and Age-appropriate Care
Policy Reference:
SAF 611:
Guidelines to patient
saftey
Adolescent (13 - 19 Years)
Normal Vital Signs
Heart Rate:
Resting 50-90
Awake 60-100
Respirations:
13-16
Communication
Pain/Comfort
Safety
• Socialization is very
important
• Concerned with body
image, body changes,
sexuality and role
• Recognize danger
• Strong need for privacy
• May need reminders to let
staff know when they
would like to leave their
room and go to teen rooms
and other areas within the
hospital.
• May vacillate between
independence and need for
caregiver
• Can test limits. Be
consistent in limits set
• May use manipulation,
refusal of care and
withdrawal in response to
hospitalization
• Opportunities for normal
activities can help them cope
• Concerned with their future
(sexuality, getting married,
ability to have kids, disease
progression, ability to get a
job, missing out on normal
teen activities and even
death
• Ability to cope may be
influenced by the level of
support from friends and
family
• Can describe pain location
and intensity
• May be reluctant to share
pain for fear of what the
pain might mean
• May refuse pain meds or
interventions in front of
peers
• Permit caregiver to
accompany patient, as
desired
• May engage in unsafe
behavior
Developmental and Age-appropriate Care
Policy Reference:
SAF 611:
Guidelines to patient
saftey
Adult (19 - 65 Years)
Normal Vital Signs
Heart Rate:
Resting 50-90
Awake 60-100
Respirations:
12-20
Communication
Pain/Comfort
Safety
• View as a productive
member of society
• Maintain dignity – decision
making ability, privacy,
normal routines
• Utilize Fall Prevention
program
• Introduce yourself
• Continue normal ADL
routines as much as possible
• Deal with issues related to
loss of wages, insurances,
and debilitating effects of
their disease
• Are adults and can legally
make their own decisions
(Advanced Directives need
to be considered)
• Involve family as much as
possible (spouse, significant
other, children, etc)
• Offer assistance with
activities of daily living
(ADLs) as appropriate.
• Keep informed of available
services and polices and
procedures.
• Can locate, describe, and
identify intensity of pain.
• Safety issues should be
individualized
Policy Reference:
Safe Environment of Care
PAWS for Patient Safety
Pediatric Advanced Warning Score (PAWS)
• A scoring system to assess patient risk
• Utilized in the Acute Care settings
• Recognizes the deteriorating patient condition using the “watchful eye”
• Assesses behavior, cardiovascular and respiratory systems
• Patient assigned a color (green, yellow, orange, red) based on score of 0-9
• Treatment algorithm utilized to manage patient based on score
• PAWS score used with clinical judgment
Policy Reference:
Safe Environment of Care
PAWS for Patient Safety
Pediatric Advanced Warning Score (PAWS)
Policy Reference:
PC 102-01
Safe Environment of Care
Rapid Response Team (RRT)
There are two ways to activate the RRT
•
Healthcare Team Member activates (R.N., R.T., M.D.)
• Family member activates the RRT
It is never wrong
to call an RRT!
What is the Rapid Response Team
• Three member from Critical Care (M.D., R.N., & R.T.)
• Activate by calling the page operator at *9999 or Family members can dial 2-7233 (2-SAFE)
• They work with the team in the acute care to determine whether the patient’s
condition requires a higher level of care or what interventions can be made to
keep the patient in acute care.
• They are not the Code Team. If the patient is an actual or impeding cardiac or
respiratory arrest, the Code Team must be called.
Criteria for call in RRT
• Staff or Physician are worried about a patient
• Family is worried about patient
• Acute change in patient’s vital signs (HR, RR, BP, or Oxygen saturation)
• Respiratory distress
• Prolonged seizure
• Acute change in Mental status
• Difficult to control pain/agitation
• Acute change in urine output
Safe Environment of Care
Policy Reference:
SAF 907, 907a, 907b, 907c, 907d:
Patent Abduction
PC 129, 129a:
Abuse/Neglect of Children or Adults
Child Abuse or Neglect
The focus of the Child Protection Program at Texas Children’s Hospital is to identify infants, children, and
adolescents who are or may be victims of abuse or neglect by their caretaker(s). For these purposes, a
“caretaker” may be a parent, grandparent, other adult relative, guardian, other parent figure (such as the
boyfriend or girlfriend of a parent), sitter, etc.
Criteria for Recognizing Abuse Victims
1. Child abuse injuries are severe injuries, frequently without a known history, inflicted by either a parent or
caretaker. They include multiple bruises, multiple fractures, head trauma, fracture in a non-ambulatory
patient, burns greater than 10%, inner abdominal trauma, “spontaneous perforation of the viscera”,
vaginal lacerations and poisoning when no known source can be obtained.
2. Child neglect includes absence or deficiency of appropriate supervision, shelter, food, clothing and
medical care.
3. Child/adolescent sexual abuse includes the victim’s outcry of sexual fondling or penetration; an adult’s
observation of a cluster of behavioral and affective patterns associated with sexual abuse; or physical
symptoms of bleeding or discharge from vagina or anus or tears of either orifice.
4. Munchausen's by Proxy includes parent/caretaker induced medical symptoms, often bizarre in nature
and/or not fitting any diagnostic category.
5. Abuse of adult/elders includes deprivation of food, medical care, shelter and personal hygiene by
caretakers. It also includes bruises, fractures, and lacerations with an unexplained history by caretaker
or by report of an observation of abusive behavior.
6. Abuse of spouse or significant others includes outcry by victim or
battering resulting in fractures, bruises, lacerations, head injuries
or a victim presenting with injuries without a known history to
explain the injury.
Safe Environment of Care
Reference:
PC 117: Latex Precautions
PC 119-01: Patient
Identification
SAF 302 Balloons
Latex Allergy and Precautions
Did you know?
• Latex allergies have been reported in patients and health care workers.
• Latex (natural rubber) is a component of many medical devices such as surgical and examination
gloves, catheters, intubation tubes, anesthesia masks, stethoscope tubing, tourniquets, bulb syringes,
band-aids, tape and injection ports in IV tubing.
• Proteins in the latex appear to be the primary source of the allergic reaction.
• It has been reported that 2.8 – 12 percent of all health care worker, 20 percent of surgical personnel, and
50 to 60 percent of spina bifida and bladder extrophy patients are sensitive to latex.
• The prevalence of latex sensitivity in individuals appears to be increasing.
• There seems to be a correlation between latex sensitivity and allergies to bananas, avocados, chestnuts
and peaches.
• Local responses such as contact dermatitis or blister formation are the most common allergic reaction
and occur within 24 to 48 hours after exposure.
• Systemic allergic reactions also can occur. These are usually immediate responses, rather than delayed.
They are characterized by rhinitis conjunctivitis, wheezing, bronchospasm, facial swelling, tachycardia,
flushing and/or anaphylaxis.
Click here for a list of “Latex-free” Alternatives
Safe Environment of Care
Reference:
PC 117: Latex Precautions
PC 119-01: Patient
Identification
SAF 302 Balloons
Latex Allergy and Precautions
Do you know what your responsibilities are in initiating latex precautions?
Identify patients at risk for latex allergy and those with documented latex allergy upon initial assessment at
Texas Children's Hospital (inpatient or outpatient).
• Patients at risk for latex allergy include those with spina bifida and major abdominal wall defects
• Reactions to latex include both local and systemic responses
Implement latex precautions for patients at risk and those with a documented allergy to latex.
Latex precautions include:
• "Latex Precaution" sign displayed at the bedside and on the patient's door. Extra signs maybe obtained from Nursing
Operations
• Latex Precautions Kit obtained from Central Distribution.
• "Latex Precaution" stickers placed on the front of the inpatient medical record.
• "Latex Precaution" bracelet (orange) applied by nursing to the wrist of allergic and at risk patient.
• "Latex Precaution" documented in the appropriate place in the chart for patients at risk.
• "Latex Allergy" documented in the appropriate place in the chart for patient's with a history of allergic responses to latex.
Document any patient response to latex exposure in the past.
• “Latex Allergy” diet should be ordered.
• "Latex Precautions" indicated on all requisitions/referrals for ancillary services.
Use silicone or other non-latex products for patient care when possible. Latex precaution
supply packs are available from Central Distribution. Additional supplies can be identified
through Oasis computer system by selecting the "Non-Latex Supplies" listing.
Tape all latex IV ports to discourage use.
Educate families regarding latex precautions as needed. A Latex Allergy
fact sheet is available.
Safe Environment of Care
Fall Prevention Program
What are my requirements for the Texas Children's Hospital Fall Prevention Program?
• Falls Assessment form will need to be placed in every patient's chart (see example on unit)
• Assess patient on admission for fall risk (see example on unit)
• Remember the 3 M's
• Assess patient each shift for Fall risk (see example on unit)
• Place the Fall Precautions sign on the door of patients at high risk for falls.
(see example right)
• Place Fall Precautions sticker on the chart of patients assessed to be at risk for falls.
• Remove it when patient is no longer at risk
Joint Commission requires assessment and
REASSESSMENT of each patient's risk for falling for both
the patient who is initially placed on falls precautions and
the patient whose risk has changed such as related to
sedation, medication, surgery, change in mental status or
mental condition.
The 3M's
Medications -medications that place the patient at risk
(Narcotics, tranquilizers, laxatives, analgesics)
Medical History - Seizure disorder, paresis, weakness,
history of falls
Mobility - Limited or altered mobility or environmental
factors such as obstructed pathways to bathroom/side
rails left in down position
Safe Environment of Care
Fall Prevention Program
Preventative Interventions
• Reassess and document fall risk every shift and as clinical
status changes.
• Provide patient/family with fall educational material.
• Fall Precautions signage on door and chart .
• Indicate Fall Precautions on Kardex.
• Keep side rails up.
• Ensure call light is within reach.
• Offer fluids, toileting at least every two hours while awake.
• Communicate patient's fall risk to patient/family
• Ensure adequate light in room.
• Ensure environmental safety.
• Avoid clutter in patient room and bathroom.
• Ensure an unobstructed walkway to bathroom and door.
• Keep IV tubing off floor to prevent tripping.
• Do not leave patient unattended in bathroom or on bedside
commode.
• Ensure slip-resistant footwear is worn
• Assist patient with ambulation as needed
• Keep call light within reach
What happens when a fall occurs?
• Notify the charge nurse or manager
• Fill out the event report electronically on Connect
(TCH Intranet) home page under the event
reporting button.
Safe Environment of Care
Did you know that the “Time Out” is only 1 part of the UNIVERSAL PROTOCOL? It is Joint
Commission’s UNIVERSAL PROTOCOL for Preventing Wrong Site, Wrong Procedure,
and Wrong Person Surgery.
1. Did you verify 2
patient identifiers –
Name and MR#.? You
should have reviewed
chart including order and
consent (if applicable) in
the pre-operative
verification process.
The Universal Protocol’s 3 main components are:
1. The pre-operative verification process
2. Marking of the operative site
3. Taking a TIME OUT immediately before starting the procedure
The Time Out has 5 components shown on our sticker:
2. Does the site need to be
marked? Mark the site and
check YES if:
Go through each
item OUT LOUD
with the team!
3. Did you say what
procedure is being done to
the patient?
• There is R/L distinction
• Multiple structures (fingers, toes)
• Multiple levels (spinal procedures –
YES that means an LP!)
4. Is the patient
positioned correctly for the
procedure?
If the answer is NO, there is no need for
further explanation in your notes.
Remember the EXCEPTIONS to marking
the site (the N/A):
• Practitioner performing procedure
remained at BS from time decision was
made to do procedure
• Single organ cases
• Insertion site is not predetermined (i.e.,
line placement)
• Teeth
• Near a body orifice
• Emergent - meaning the patient could
die if you take the time to do the site
marking!
• Neonates – less than 40 weeks
gestation plus 28 days
The sticker is placed in the progress notes section for
inpatients. For outpatients, it is placed on the Sedation
form or other paper within the patient’s chart.
5. Do you have the right
implant or piece of equipment
ready at the bedside? This
means a device or piece of
equipment not ordinarily
stocked in the hospital such
as a cochlear implant . Will
be N/A for majority of bedside
procedures.
Are their x-rays or other
imaging that need to be
available?
Documentation Tips
• Any student documenting in the patient's chart must complete and sign complete name and title (i.e.
Suzy Q. Student, UTHSCH nursing student)
• All personnel or students interacting with the patient and/or family should document the care provided on
the appropriate form, flowsheet or in the computer, as appropriate.
• Use appropriate forms.
• Always adhere to the hospital's policy and procedures.
• Write legibly so that the care you provided and the data that you have recorded can be properly
interpreted.
• Document only the care you have provided and not the care done by anyone else.
• Avoid generalizations. Be specific in your charting.
• Date and time every entry as well as initialing or signing every entry.
You have now completed the Texas Children’s Hospital Orientation for
Nursing Students
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