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Template Slide - Texas Children's Hospital


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									Welcome to the Texas Children’s Hospital
 Orientation for Nursing Students
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            3. Integrity & Ethical Behavior
  • We sustain and nurture a culture      • We are proud of who we are          • We are honest and trustworthy.
    that supports our mission, vision       and have the passion to make
    and values.                             a daily difference.                 • We hold ourselves to high
                                                                                  standards of moral, ethical, and
  • Above all, we deliver the finest      • We show consideration,                legal conduct.
    possible work, care, and service        compassion and support for all
    with personal and professional          people.                             • We keep our promises and
    excellence and are committed to                                               commitments.
    continuous improvement.               • We carefully consider the
                                            impact our decisions have on        • We have the character to do
  • We have exceptionally high              others.                               what is right, not what is easy.
    standards for individual, team
    and organizational performance.       • We find innovative solutions to     • We exhibit the highest levels of
                                            support the needs of those we         professionalism in all situations.
  • We provide the expertise,               serve.
    innovation and visionary thinking
    that will continue to advance         • We work together to create the
    pediatric health care, education        best possible customer
    and research.                           outcomes.
Texas Children’s Hospital                                     ®

6 Guiding Principles – cont.
4. Valuing Individuals                   5. Communication & Interaction        6. Accountability
  • We treat all people with courtesy,     • We choose to interact in the       • We own our words, actions and
    respect and dignity.                     spirit of collaboration.             outcomes.

  • We constantly strive to create an      • We are honest and forthright in    • We set high performance
    environment of mutual respect,           our relationships with others.       expectations and work together
    teamwork and commitment.                                                      to achieve the organization's
                                           • We actively seek, share, hear        mission, vision, values and
  • We support diverse perspectives,         and value information and            business objectives.
    ideas, backgrounds and cultures          feedback.
    and find value in our differences.                                          • We lead by example.
                                           • We engage others in dialogue,
  • We recognize and value the               planning and decisions that        • We align our work with
    contributions of others.                 involve them.                        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.
Disaster Codes
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:

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.

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.

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

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

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.
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 bio-
hazardous 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.
                                                                             Policy References:
Safety                                                                       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.

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:
Safety                                                                      SAF303 Use of Devices Emitting
                                                                                    electromagnetic Interferences

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
                                                                                       Policy References:
Infection Control                                                                      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

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
                                                                                  Policy References:
Infection Control                                                                 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.
                                                                                 Policy References:
Infection Control                                                                SAF 200 Infection Control Plan Series
                                                                                 SAF 206A OSHA Bloodborne Pathogen Standard

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 x-
    rays 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.
                                                                   Policy References:
Infection Control                                                  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.
                                                                                    Policy References:
Infection Control                                                                   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.
                                                                                   Policy References:
Infection Control                                                                  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 flu-
like 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.
                                                                                 Policy References:
Infection Control                                                                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
                                                           Policy Reference:                        PC118-01: Guidelines on
                                                           CCP101, CCP 101-01: Code of Ethical      Institutional Policies
Ethical Issues                                             Behavior
                                                           PS 100, PS 100-01, PS 100-01a, PS-01b:
                                                           Patient Rights & Responsibilities
                                                                                                     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.

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
                                                                  Policy Reference:                        PC118-01: Guidelines on
                                                                  CCP101, CCP 101-01: Code of Ethical      Institutional Policies
Ethical Issues                                                    Behavior
                                                                  PS 100, PS 100-01, PS 100-01a, PS-01b:
                                                                  Patient Rights & Responsibilities
                                                                                                            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

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
                                                                      Policy Reference:
                                                                      IM 100: Corporate Information Security Policy

Ethical Issues                                                        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
Hand-offs & Report                                                                               Reference:
                                                                                                 UO 1105: Patient Care Report

Goal: Seamless care and professional accountability of patient during nurses breaks/lunches
Objective: This tool was developed to aid communication between nurses relieving one another for breaks
and/or lunch periods. The acronym (MAAPS) highlights universal pieces of critical patient care
communication and should be used by nurses who are exchanging accountability for patient care.
                              (2-5 minutes total time anticipated for communication elements)
M = medications
Communicate those medicines either in progress or due for administration during             M = medications
relief period
                                                                                            A = access
A = access
Communicate IVs, central lines, indwelling tubes (G-Tubes, NG-Tubes, urinary                A = attention
catheters, etc)
                                                                                            P = procedures
A = attention
                                                                                            S = status
Communicate those items requiring IMMEDIATE attention or likely to occur
within the relief period (impending labs, CPS issues)
P = procedures
Communicate any unusual procedure in progress ( renal replacement therapies,
epidural, ECMO)
S = status
Communicate the patient's baseline, any recent changes in status and diagnosis
("B" baseline, "C" change, "D" diagnosis)
Hand-offs & Report                                                                       Reference:
                                                                                         UO 1105: Patient Care Report

Goal: Seamless care and professional accountability of patient during change of shift report or transfer
from one unit to another
Objective: This tool was developed to aid nurses in providing a complete, organized exchange of
information to allow continuity of patient care and patient safety. Whenever leaving any department for
admission or transfer or at any change of shift, the registered nurse (RN) will relate all known pertinent
information to the RN assuming care for the patient.

 R = Reason for admit/surgery
 E = Equipment (in use at home or needed for in-patient care)
 E = Emotional support required or provided
 P = Procedures pending or completed
 P = Pain Issues
 O = Orders for receiving unit including admitting physician, allergies, and medications
 R = results of most recent assessment including vital signs and respiratory status
 T = Transport method
 T = Triggers for ancillary department involvement
 I = I & O status, including current NPO status for procedures and/or surgery
 T = Title and name of RNs giving and receiving report
Hand-offs & Report                                                                     Reference:
                                                                                       UO 1105: Patient Care Report

• Use the standardized hand-offs available at Texas Children’s Hospital.

• 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).

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

• 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 Measurements
Weight: Kilograms or Grams                                 Length/Height: Centimenters

• Using infant scale: Place paper on scale and              • Length – Use recumbent position birth to 3
  zero out. Weigh infant nude.                                years of age Growth Chart or use length board
                                                              (not measuring tape)
• Using standing scale: Clothing and shoes off
  except for underwear or weigh parent & child              • Height – Standing position (only). Uses 2 to
  together minus parent's weight                              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
• 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                            Policy Reference:
                                                                    TM 503

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
Pain Scales at Texas Children’s Hospital                                                       Policy Reference:
                                                                                               TM 503

FLACC is a behavioral pain scale that utilizes five categories to rate pain in patients unable to self-

F - Face
L - Legs                                 The acronym FLACC was devised to facilitate recall of the
A - Activity                             categories included in the tool.

C - Cry
C - Consolability

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
                                            0                                           1                                        2
                                                                                                                     Constant grimace or frown
                                                                         Occasional grimace or frown,          Frequent to constant quivering chin,
        Face                No particular expression or smile              withdrawn, disinterested                        clenched jaw
                                                                           [appears sad or worried]            [Distressed-looking face: Expression
                                                                                                                         of fright or panic]

                                                                                                                    Kicking, or legs drawn up
                                                                            Uneasy, restless, tense
        Legs                    Normal position or relaxed
                                                                             [Occasional tremors]
                                                                                                                  [Marked increase in spasticity,
                                                                                                                   constant tremors or jerking]

                                                                        Squirming, shifting back and forth            Arched, rigid or jerking
                                                                                      tense.                     [Severe agitation head banging;
       Activity         Lying quietly, normal position moves easily    [Mildly agitated (eg. head back and     Shivering (not rigors); Breath holding,
                                                                      forth, aggression);shallow, splinting,    gasping or sharp intake of breath;
                                                                         respirations, intermittent sighs]               Severe splinting]

                                                                             Moans or whimpers;                  Crying steadily, screams or sobs,
                                                                            occasional complaint                       frequent complaints
         Cry                    No cry, (awake or asleep)
                                                                                                                  [Repeated outbursts, constant
                                                                        [Occasional verbal outbursts or
                                                                                   grunts]                                   grunting]

                                                                      Reassured by occasional touching            Difficulty to console or comfort
    Consolability                    Content, relaxed                    hugging or being talked to,            [Pushing away caregiver, resisting
                                                                                distractable                        care or comfort measures]

FLACC (Revised descriptors for children with disabilities shown in [brackets]
Some children, including those with disabilities, may display unique behaviors like self-
harm, 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.

                                                        High-pitched cry or cry face
                                                                                            High-pitched cry or intense cry
Crying                No                                without sound, consolable with
                                                                                            face and inconsolable
                                                        comfort measures
Required FiO 2 for    No oxygen needed or no            FiO 2 is <30% or requires <10%      FiO 2 is >30% or requires ≥10%
adequate color or     increase from baseline FiO   2    increase from baseline FiO 2 to     increase from baseline FiO 2 to
saturation            needed                            maintain saturation or color        maintain saturation or color
Increased vital       HR and BP within 10% of           HR or BP 11% to 20% higher          HR or BP 21% or more above
signs (BP             preop/preprocedure baseline       than preop/preprocedure             preop/preprocedure baseline
performed last)       values                            baseline value                      value
Expression            None - face relaxed               Grimace                             Grimace/grunt
                                                        Postop: Wakes at frequent
                                                                                            Postop: Constantly awake
Sleep/Wake                                              intervals
                      Normal for infant                                                     Postprocedure: Awake, highly
Behavior                                                Postprocedure: Awake, highly
                                                                                            aroused, inconsolable
                                                        aroused, consolable

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.

                     ≥36 weeks                                32 weeks to 35 weeks, 6 days                28 weeks to 31 weeks, 6 days         ≤28 weeks
Behavioral           Active / awake; eyes open;               Quiet / awake; eyes open; no                Active / asleep; eyes closed;        Quiet / asleep; eyes closed; no
state                facial movements                         facial movements                            facial movements                     facial movements
Heart rate                                                                                                                                     25 beats/minute or more
                     0 to 4 beats/minute increase             5 to 14 beats/minute increase               15 to 24 beats/minute increase
maximum                                                                                                                                        increase
saturation           0% to 2.4% decrease                      2.5% to 4.9% decrease                       5.0% to 7.4% decrease                7.5% or more decrease
                     None of the time
Brow Bulge                                                    Minimum >3-12 seconds                       Moderate >12-21 seconds              Maximum >21-30 seconds
                     0-3 seconds
                     None of the time
Eye Squeeze                                                   Minimum >3-12 seconds                       Moderate >12-21 seconds              Maximum >21-30 seconds
                     0-3 seconds
Nasolabial           None of the time
                                                              Minimum >3-12 seconds                       Moderate >12-21 seconds              Maximum >21-30 seconds
furrow               0-3 seconds

Scoring (1) for PIPP                                                                                                             PIPP Scoring Interpretation Guide
1. Score corrected gestational age before you begin.
2. Score behavioral state by observing infant 15 seconds immediately before the event.
                                                                                                                                 6 or less = Minimal to no pain
3. Observe infant immediately before and after a painful event and before and after pain                                         7-12 = Mild pain
   medication is administered (30 minutes after intravenous and 1 hour after oral medication).                                   >12 = Moderate to severe pain
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.
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
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
results in 4 listings
in TCH formulary                                   Entering “CAL”
    & Over 11                                   results in 10 listings in
     listings in                                  the TCH formulary
   Lexi-Drugs.                                        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.


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


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.

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).

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

•   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.

• 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 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.
                                                                                                              Policy Reference:
                                                                                                              MA 304 Medications
Medication Administration                                                                                     requiring special

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.

• 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
• Using dosing charts
• Placing "High-Alert" warning signs on medication stock bins in the
                                                                                                    Policy Reference:
                                                                                                    MA 304 Medications
Medication Administration                                                                           requiring special

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,      IV electrolytes: Sodium chloride injection > 0.9%
epinephrine, isoproterenol,norepinephrine, terbutaline,    concentration (2.5 mEq/mL, 3% bags), magnesium sulfate,
vasopressin, phenylephrine                                 calcium chloride and gluconate, potassium chloride and
Anticoagulants and thrombolytics: Heparin, warfarin        phosphate
(oral), alteplase                                          IIV dextrose > 10%: Including D50% and D70% bags
Local anesthetics: Lidocaine, local anesthetics in large   Chemotherapeutic agents
vials                                                      IV Digoxin
Neuromuscular blocking agents: Atracurium,                 Opiates
pancuronium, rocuronium, succinylcholine, vecuronium
IV adrenergic antagonist: Phentolamine
                                                           Epoprostenol - Flolan®
Factors (antihemophilic agents): Octreotide
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 look-

 alike 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
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
                                                                                                Policy Reference:
                                                                                                SAF 611:
Developmental and Age-appropriate Care                                                          Guidelines to patient

Infants (0 - 12 months)
Normal Vital Signs   Communication                 Pain/Comfort                  Safety
Heart Rate:          • Infants communicate         • Cry, scream and try to      • Avoid small objects in the
Resting 80-180         through their senses          remove themselves from        infant’s bed (syringe tops,
Awake 80-200           (tactile, auditory, and       painful situations.           med bottles, alcohol wipes
                       visual)                                                     and paper or toys with
Respirations:                                      • Allow caregiver to remain     small parts or buttons)
30-60                • Introduce yourself and        with infant as much as
                       explain procedures to         possible                    • Keep crib rails all the way
                       the caregiver                                               up
                                                   • Keep patient warm and dry
                     • Infants have separation                                   • Never prop a bottle in
                       and stranger anxiety        • Avoid continuous bright       infant’s mouth
                     • Minimize separations                                      • Check infants frequently
                       from parent or caregiver    • Allow infant to keep          because IV or oxygen lines
                       as much as possible           pacifier, blanket or toy      can easily get tangled
                     • Talk slowly and calmly to                                   around an infants neck
                                                   • Swaddle infant as
                       the infant. Your touch,       appropriate
                       tone of voice and face
                       help the infant begin a     • Hold and cuddle infant as
                       trusting relationship.        appropriate
                                                                                                 Policy Reference:

Developmental and Age-appropriate Care                                                           SAF 611:
                                                                                                 Guidelines to patient

Toddler (1 - 3 Years)
Normal Vital Signs   Communication                 Pain/Comfort                   Safety
Heart Rate:          • Introduce yourself to       • Cry, scream and try to       • Do not leave
Resting 70-160         patient and caregiver         remove themselves from         unsupervised;…does not
Awake 80-190         • No concept of time            painful situations             recognize danger

Respirations:          (cannot distinguish         • Allow caregiver to remain    • Keep side rails up
                       between few hours and         with toddler as much as
24-40                                                                             • Avoid small objects in the
                       few minutes)                  possible                       infants bed (syringe tops,
                     • Understand simple           • Can tolerate short periods     med bottles, alcohol wipes
                       commands                      of separation from parents     and paper, toys with small
                                                                                    parts or buttons)
                     • Say “No” to everything      • Do not separate from
                     • Learning body control         favorite/usual toy or        • May forget they are
                       and developing                blanket                        attached to IV
                       language                                                     tubing/oxygen and will
                                                   • Allow older                    need help when up and
                     • Like to do things             toddler/preschooler to         walking around
                       independently                 talk/verbalize his or her
                                                     fears                        • Sitter may be necessary
                     • Do not rush patient                                          when family not available
                                                   • Regression can occur with
                     • Preschoolers can view         hospitalization              • Buttons on pumps look
                       illness as punishment for                                    fun, so turn away from
                       bad behavior                • May accept explanations        child and do not put in crib
                                                     on a bear or favorite
                     • Include parent in             stuffed toy
                                                                                                      Policy Reference:

Developmental and Age-appropriate Care                                                                SAF 611:
                                                                                                      Guidelines to patient

Preschooler (3 - 5 Years)
Normal Vital Signs   Communication                       Pain/Comfort                   Safety
Heart Rate:          • Introduce yourself to patient     • Cry, scream, kick,           • Do not leave
Resting 60-120         and caregiver                       withdraw, regress and          unsupervised…does not
Awake 70-140         • Have difficulty distinguishing      cling to caregiver             recognize danger

Respirations:          between reality and fantasy       • Allow caregiver to remain    • Keep side rails up
                                                           with preschooler as much
22-34                • Important they understand                                        • Avoid small objects in the
                                                           as possible
                       why they are in the hospital                                       infants bed (syringe tops,
                     • Understand literal                • Do not separate from           med bottles, alcohol wipes
                       interpretations of word (ie         favorite/usual toy or          & paper, toys with small
                       that is a bad medication: they      blanket                        parts or buttons)
                       think they are bad)               • Allow older                  • May forget they are
                       Click here to refer to table of     toddler/preschooler to         attached to IV
                       considerations in language*         talk/verbalize their fears     tubing/oxygen and will
                                                         • Regression can occur with      need help when up &
                     • Learning body control and                                          walking around
                       developing language                 hospitalization
                                                         • May accept explanations      • Sitter may be necessary
                     • Like to do things by                                               when family not available
                       themselves                          on a bear or favorite
                                                           stuffed toy                  • Buttons on pumps look
                     • Do not rush patient                                                fun, so turn away from
                     • Preschoolers can view                                              child and do not put in crib
                       illness as punishment for bad
                     • Include parent in
                                                                                                     Policy Reference:

Developmental and Age-appropriate Care                                                               SAF 611:
                                                                                                     Guidelines to patient

School age (5 - 9 Years)
Normal Vital Signs   Communication                       Pain/Comfort                  Safety
Heart Rate:          • Peers are becoming more           • Can better describe pain    • Curious
Resting 60-120         important                           location and intensity      • Able to accept limits
Awake 70-140         • Learning to communicate           • Can still be comforted by   • Place bed in low position
Respirations:          ideas and feelings in a clear       caregiver
                       way                                                             • Encourage child to wear
19-30                                                    • Allow child to have input     slippers or shoes
                     • May be willing to ask               into some decisions
                       questions, but might still                                      • Keep side rails up when
                       have outbursts related to                                         child is asleep
                     • 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
                                                                                                   Policy Reference:

Developmental and Age-appropriate Care                                                             SAF 611:
                                                                                                   Guidelines to patient

Preteen (9 - 12 Years)
Normal Vital Signs   Communication                     Pain/Comfort                   Safety
Heart Rate:          • Beginning logical thought       • Can describe pain location   • Feel the weight of peer
Resting 50-90                                            and intensity                  pressure
                     • More conscious of body and
Awake 60-100                                           • May be reluctant to share
                       social image                                                   • Enforce consistent limit
Respirations:        • Some pre-teens may begin          pain for fear of what the      setting
18-30                  puberty early                     pain might mean
                                                       • May regress as a coping
                     • Privacy is very important
                     • Explanations are very helpful
                       and they are able to
                       understand more complex
                     • Worry about separation from
                       family and peers
                     • Opportunities for normal
                       activities can help them cope
                                                                                                  Policy Reference:

Developmental and Age-appropriate Care                                                            SAF 611:
                                                                                                  Guidelines to patient

Adolescent (13 - 19 Years)
Normal Vital Signs   Communication                     Pain/Comfort                   Safety
Heart Rate:          • Socialization is very           • Concerned with body          • Recognize danger
Resting 50-90          important                         image, body changes,         • May engage in unsafe
Awake 60-100         • May vacillate between             sexuality and role             behavior
Respirations:          independence and need for       • Strong need for privacy      • May need reminders to let
13-16                                                  • Ability to cope may be         staff know when they
                     • Can test limits. Be               influenced by the level of     would like to leave their
                       consistent in limits set          support from friends and       room and go to teen rooms
                                                         family                         and other areas within the
                     • May use manipulation,
                                                       • Can describe pain location     hospital.
                       refusal of care and
                       withdrawal in response to         and intensity
                       hospitalization                 • May be reluctant to share
                     • Opportunities for normal          pain for fear of what the
                       activities can help them cope     pain might mean
                     • Concerned with their future     • May refuse pain meds or
                       (sexuality, getting married,      interventions in front of
                       ability to have kids, disease     peers
                       progression, ability to get a   • Permit caregiver to
                       job, missing out on normal        accompany patient, as
                       teen activities and even          desired
                                                                                                     Policy Reference:

Developmental and Age-appropriate Care                                                               SAF 611:
                                                                                                     Guidelines to patient

Adult (19 - 65 Years)
Normal Vital Signs   Communication                     Pain/Comfort                    Safety
Heart Rate:          • View as a productive            • Maintain dignity – decision   • Utilize Fall Prevention
Resting 50-90          member of society                 making ability, privacy,        program
Awake 60-100         • Introduce yourself                normal routines               • Safety issues should be
Respirations:                                          • Offer assistance with           individualized
                     • Continue normal ADL
12-20                                                    activities of daily living
                       routines as much as possible
                                                         (ADLs) as appropriate.
                     • Deal with issues related to
                       loss of wages, insurances,      • Keep informed of available
                       and debilitating effects of       services and polices and
                       their disease                     procedures.

                     • Are adults and can legally      • Can locate, describe, and
                       make their own decisions          identify intensity of pain.
                       (Advanced Directives need
                       to be considered)
                     • Involve family as much as
                       possible (spouse, significant
                       other, children, etc)
                                                                                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
                                                                                    It is never wrong
• Healthcare Team Member activates (R.N., R.T., M.D.)
• Family member activates the RRT                                                    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
 • 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
                                                                                           Policy Reference:
                                                                                           SAF 907, 907a, 907b, 907c, 907d:

Safe Environment of Care                                                                   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.
                                                                                           PC 117: Latex Precautions

Safe Environment of Care                                                                   PC 119-01: Patient
                                                                                           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
                                                                                                             PC 117: Latex Precautions

Safe Environment of Care                                                                                     PC 119-01: Patient
                                                                                                             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
• 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                              The 3M's
                                                                       Medications -medications that place the patient at risk
 REASSESSMENT of each patient's risk for falling for both              (Narcotics, tranquilizers, laxatives, analgesics)
 the patient who is initially placed on falls precautions and          Medical History - Seizure disorder, paresis, weakness,
 the patient whose risk has changed such as related to                 history of falls
 sedation, medication, surgery, change in mental status or             Mobility - Limited or altered mobility or environmental
                                                                       factors such as obstructed pathways to bathroom/side
 mental condition.                                                     rails left in down position
Safe Environment of Care
Fall Prevention Program
Preventative Interventions
• Reassess and document fall risk every shift and as clinical
                                                                  What happens when a fall occurs?
 status changes.
                                                                  • Notify the charge nurse or manager
• Provide patient/family with fall educational material.
                                                                  • Fill out the event report electronically on Connect
• Fall Precautions signage on door and chart .
                                                                   (TCH Intranet) home page under the event
• Indicate Fall Precautions on Kardex.
• Keep side rails up.                                              reporting button.

• 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
• Ensure slip-resistant footwear is worn
• Assist patient with ambulation as needed
• Keep call light within reach
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 –                   The Universal Protocol’s 3 main components are:
   Name and MR#.? You                      1. The pre-operative verification process
   should have reviewed                                                                                               Go through each
   chart including order and               2. Marking of the operative site
                                                                                                                      item OUT LOUD
   consent (if applicable) in              3. Taking a TIME OUT immediately before starting the procedure
   the pre-operative                                                                                                    with the team!
   verification process.
                                           The Time Out has 5 components shown on our sticker:

   2. Does the site need to be
    marked? Mark the site and                                                                                   3. Did you say what
    check YES if:                                                                                               procedure is being done to
   • There is R/L distinction                                                                                   the patient?
   • Multiple structures (fingers, toes)
   • Multiple levels (spinal procedures –
     YES that means an LP!)                                                                                      4. Is the patient
   If the answer is NO, there is no need for
                                                                                                                 positioned correctly for the
      further explanation in your notes.                                                                         procedure?
   Remember the EXCEPTIONS to marking
    the site (the N/A):
   • Practitioner performing procedure                                                                        5. Do you have the right
     remained at BS from time decision was                                                                    implant or piece of equipment
     made to do procedure                                                                                     ready at the bedside? This
   • Single organ cases                                                                                       means a device or piece of
   • Insertion site is not predetermined (i.e.,   The sticker is placed in the progress notes section for     equipment not ordinarily
     line placement)                                                                                          stocked in the hospital such
                                                  inpatients. For outpatients, it is placed on the Sedation
   • Teeth                                                                                                    as a cochlear implant . Will
                                                  form or other paper within the patient’s chart.
   • Near a body orifice                                                                                      be N/A for majority of bedside
   • Emergent - meaning the patient could                                                                     procedures.
     die if you take the time to do the site
     marking!                                                                                                 Are their x-rays or other
   • Neonates – less than 40 weeks                                                                            imaging that need to be
     gestation plus 28 days                                                                                   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

• 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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