Heme / OncNursing Update

Michelle Burke MSN, ARNP, CPN, CPON

Sarah Taylor – Amador BSN, RN, CPON

Standard Requirements Non-Violent/Medical

Restraints

Violent Restraint/Seclusion for Behavior

Management

Initial Physician verbal or written

order

Within 1 hour of restraint As soon as safely possible; verbal order signed

within 24 hours of initiation

Modification of Plan of Care Yes Yes

Notification of Nursing Leadership

(OA/Director)

Yes Yes

Documentation of observations and

vital signs

At initiation and every 2 hours At initiation and every 15 minutes

Monitoring: all patients

mechanically restrained on a floor

outside of ICU/ED require 1:1

observation

Every 2 hours Continuous observation

Re-written physician order Each calendar day and each

time patient comes out of

restraint and restraint must be

reapplied

Within 1 hour of need for next episode of

restraint/seclusion

Notification of guardian of the

initiation of restrained/seclusion

Yes Yes- Promptly

Notification of treating/attending

physician if orders and face-to-face

assessment performed by other

Within 24 hours Yes- As soon as possible

Face to Face Assessment Within 24 hours of initiation by

physician or resident

Within 1 hour of restraint by physician, resident or

trained RN, ARNP, PA

Debriefing N/A Immediately- within 24 hours max.

RN Evaluation Every 2 hours Every 60 minutes

Education Documentation Yes Yes

Alternatives Documented Yes Yes

Dec

isio

n M

atri

x

Medication Safety

Please note that these new clear syringes with an amber colored plunger will be replacing the syringes we currently receive from pharmacy with the white

plunger. They will be used to administer oral medications, just as the color of the ones we use on the units/floors.

(0.5ml & 20ml syringes are not available at this time)

Old

New Amber Colored Oral Syringes coming from Pharmacy

Syringes

Old

Clinical Education Team

NLK July 2016

MannitolGiven with or before Cisplatin

FILTER REQUIRED (RN responsibility if pharmacy did not put filter on tubing during drug preparation)

MannitolMost COG protocols state“per institution guidelines”

• The role of mannitol as a nephroprotectant in patients receiving cisplatin therapy. (2012 abstract on PubMed)•University of North Carolina, Chapel Hill, USA.•Abstract• To review the efficacy and safety of concomitant mannitol

administration with cisplatin therapy to reduce the incidence of nephrotoxicity.

Mannitol• DATA SYNTHESIS: • Cisplatin therapy can lead to transient and permanent renal impairment. Molecular

and histologic changes occur in the renal tubules, which contribute to nephrotoxicity. The adverse effect profile of cisplatin is well documented, but the prevention strategies to alleviate renal impairment due to treatment are less understood. Mannitol plus hydration has been used for several years to alleviate toxicity associated with cisplatin therapy. However, the data for mannitol administration have not been convincing. When the use of mannitol and hydration is compared directly to hydration alone, mannitol shows no benefit. In some patients, not only was mannitolnot protective, its administration was associated with worsening renal function.

• CONCLUSIONS: • Although mannitol plus hydration is used to decrease cisplatin-induced

nephrotoxicity, there are no compelling data that the addition of mannitol is more nephroprotective than the use of hydration alone. Appropriate hydration remains the most reasonable strategy to reduce the incidence of cisplatin-induced nephrotoxicity

Inhibits the activation and proliferation of T-lymphocytes thus preventing GvHD

IV Dosage: Initially started at 0.02 mg/kg/day and titrated depending on levelsoDose dependent on achieving and sustaining therapeutic blood levels

oLevels should be drawn from LARGE lumen

IV to PO conversion is approximately 1:3

Therapeutic Levels range between 5 – 15 (dependent on diagnosis)o Increased absorption with “azoles”

oDecreased absorption with food

Tacrolimus (FK-506, Prograf)

Must be given on dedicated line with either NS or D5WoCompatible with several medications

Levels usually obtained Mondays and Thursdays from LARGE lumenoContinuous IV: stop Tacrolimus infusion, clamp line, and draw from opposite lumenoOral: Draw from lumen that never received Tacrolimus

Sign should be placed at bedside indicating to draw Levels from Large lumen

Take on empty stomach

Instruct patient/caregiver on importance of strict adherence to administration schedule (9AM / 9PM)

Side effects: hypomagnesemia, tremors, headaches, hypertension, and nausea

Tacrolimus Nursing Implications

Pneumocystis carinii pneumoniaClinical features

• Tachypnea• Dry cough• Fever• Dyspnea• Rapid respiratory deterioration

•Diagnosis•Chest x-ray

Pneumocystis carinii pneumonia•Treatment•Prophylaxis•Trimethoprim-sulfamethoxazole (TMP-SMX)•Dapsone•Pentamidine• Inhaled • Intravenous

PentamidineInhaled pentamidine

-Picked up by RT from pharmacy

- Usually for 5 years and older

- For specifics, see administration procedures from Respiratory

PentamidineIntravenous pentamidine-Potential for anaphylaxis- Monitor vitals - Hypotension / cardiac arrest with rapid infusion

-High alert / second witness

This includes (but not limited to) :

• Pentamidine• IV Electrolyte Boluses

- Potassium, Magnesium, Phosphorous, Calcium

• Bleomycin• Vancomycin• Gentamicin• Cyclosporine• Tacrolimus

BE Alert Medication Safety Update:Small Volume Infusions (dispensed in a syringe) with Specific Rates should ALWAYS be given on

a Syringe Pump

Remember to run the flush at the same rate as the medication infused

Contact your Clinical Education team for questions

Clinical Education Team 6/2016Nicklaus Children’s Hospital (2014). IV Policies- General Retrieved from: http://policies/dotNet/documents/?docid=4835&mode=view

ALL medications dispensed in a volume of less than 10ml should be on a syringe pump

• Azithromycin• Tobramycin• Amikacin• Ciprofloxacin• Levofloxacin

High Alert Table of Drugs

New Epinephrine Labeling

Labeling will be in mg/mL

Previously: Epinephrine 1:10,000 new Labeling 0.1mg/mL

Epinephrine 1:1,000 new Labeling 1mg/mL

New Epinephrine Labeling

Labeling will be in mg/mL

Previously: Epinephrine 1:10,000 new Labeling 0.1mg/mL

Epinephrine 1:1,000 new Labeling 1mg/mL

Mesna•Protects from cystitis caused by Ifosfamide or Cyclophosphamide

•Prevents adherence of acroleinmetabolities to bladder wall

•Causes false positive ketones in urine dipstick

•HIGH ALERT / MUST BE GIVEN ON TIME

Leucovorin

• Given for MTX clearance / rescue

•HIGH ALERT / MUST BE GIVEN ON TIME

PCA documentation -Always remember handoff documentation

-Always remember second witness with NEW VIAL and DOSE CHANGE

-WATCH your I & Os- Especially if not 1mg / 1 ml

Patient Safety

Patient FALLS

Monthly audits in progressHIGH RISK must have:

• Humpty sign at bedside• Humpty ID band on• White board updated• Magnet on the census

board• Teaching documented • IPOC updated

FALLS FACTS

CLABSI

Top 5 Places for germs in your area

•Cell Phone

•Door handle

•Computer keyboard

•Keys

•TV remote/Call bells

Survival Times of Microbes on SurfacesSurvival Times of Microbes on Surfaces

Microbe Survival Time

Acinetobacter 3 days to 5 months

C. difficile 5 months

E. Coli 1.5 hrs to 16 months

Enterococcus (VRE) 5 days to 4 months

CRE weeks to months

Pseudomonas 6 hours to 16 months

S. Aureus 7 days to 7 months

HIV </= 7 days

HBV > 1 week

Influenza 1 to 2 days

Norovirus 8 hours to 7 days

Candita Albicans up to 4 months

Mycobacterium Tuberculosis undetermined months

Blood-related Infections• Intravenous sites can become seeded when organisms from

distant infection sites are transported to the access port or adhere to the catheters

•When attempting to determine if the patient has a catheter-associated infection staff should be suspicious of an IV catheter-related infection if the blood drawn from the central line culture has five times the organism growth compared to blood obtained from a peripheral vein.

Blood-related InfectionsPrevention:

When infection is suspected, best practice is to get two blood cultures. One peripheral culture and one central line culture. Gold standard are peripheral blood cultures.

Infection Prevention Basics

Hub Care •Clean needleless connector/hub with prevantics CHG wipes before opening the line•When to Replace Needleless Connectors •With dressing change•As needed if occluded or if visible blood or debris is seen in or on connector •Prior to drawing blood cultures•After giving Blood Products

Wipes versus Curos CapsPrevantics Wipes Curos Caps

One time use One time use

Disinfects in 30 sec and dries in 30 sec

Minimum duration is 3 min

Use when port is frequently used Protects port protected from environmental contamination

CHG and Alcohol Just alcohol

Can be used for 7 days

Chloraprep Skin Cleansing

•ChloraPrep is 2% chlorhexidine and 70% alcohol product:

• The skin should be scrubbed in a back to forth motion for 30 sec and allowed to dry for 30 sec. When used in moist areas(inguinal fold scrub for 2 minutes and allow to dry for 1 minute.

One 3ml applicator covers

4 in. x 5 in.

Proper Insertion Practices• Ensure utilization of insertion bundle•Chlorhexidine for skin antisepsis•Maximal sterile barrier precautions (e.g., mask, hair

cap, sterile gown, sterile gloves, and large sterile drape)•Hand hygiene•All people in the room not performing the procedure

need to wear a hair cap, mask, and clean gloves•Primary RN for the patient at the time of the procedure

is responsible for documenting timeout in the EMR

Flushing CVL• Use aseptic non touch technique• All Central lines need to be flushed once a shift using the

power flush method unless the patient is receiving pressors or TPN through the line. In these situations, the lumen should be power flushed when the lines are being changed.

• Follow SASH• S: Saline 8-10ml saline flush (3ml for NICU)• A: Administer medication • S: Saline 8-10ml saline flush (3ml for NICU)• H: Heparin (10units/ml) Length of lumen heparin flush

Lab draws using Stopcock method

Important to know!

•DO NOT reconnect any previously used Peripheral IV tubing or IVF’s to a central line

Remember: The 3 main sources of bacteria responsible for IV-associated infections are:

• Air/Environment • Skin • Blood

Clinical Education Team L.S. 06/2016

C. L. A. B. S. I

Let’s be CLABSI Free!

Chlorohexidine

Wipes

Curos Caps/TIPS

Discuss line necessity

with Physician

Daily linen changes

Air Dry your port

Scrub your Hub Bedside Cleanliness

Wipe it down & document

Survey and

assess your

site! Make

sure it is

clean, dry and

intact. Date

should be

visible!

Clinical Education Team L.S. 06/2016

Be mindful of

Isolation Precautions

Keep an “I” out!

Be CLABSI

FREE!!

Major Changes•MUST CHART AND COMPLETE DAILY BATH and twice a day CHG to CVL

•Daily wipe down of leads, bed rails, TV remote, and bedside table. QSHIFT wipe down of CVL tubing

•Powerflushes !!!! Twice a day

•Clean gloves SHOULD be worn ANY time staff come into contact with the patient, IV catheters, IV pumps, Medications, or IV tubing

•Flushing guidelines for CVAD’s

Skin care / Oral care

ONC care bundle review

Documentation for Bathing and Oral Care

NEW IMPROVED PROCESS- Changes from DNV site

recommendation - Remember the system will

generate a order and TASK, work off the TASK

- If patient needs dressing change earlie, RN to place a PRN change order

Daily Line Necessity Documention:

PICC – “YES” must be charted;

Broviacs – N/A must be charted since they are surgically placed for long-term use.

Cover with CUROS

Pain re-assessment / comfort

•All patients with a pain score of 4 or greater need an intervention and

RE-ASSESSMENT within 60 minutes

•Also, any intervention also needs a

RE-ASSESSMENT

9/29/2017

During, patient report, verify last weight on

hand-off tool in PEDS

Assessment sheet.

Patient must always be weighed upon

admission or transfer to the unit.

Patient height & weights

Document & Post ISOLATION PRECAUTIONS

Document in PEDS Post Signage

Must Document Isolation type every 12 hours under treatments and care section

Please see your Clinical Educator/Specialist and Infection Prevention Team for any questions

Clinical Educati

on Team

Nicklaus Children’s Hospital (2013). Isolation Precaution. Retrieved from: http://policies/dotNet/documents/?docid=3819&mode=view

Isolation guidelines are located in the Isolation Precaution policy

Gastrostomy site care• Gently lift plastic ring on GT and clean around stoma site. • Use cotton tipped applicators to cleanse area around tube

with soap and water ONCE A DAY and as needed. • Spandex should always be on when patient has a MIC -gtube

• A soft wick can be used, only use one at a time. • Document G-tube site care in EHR (PEDS) MIC g-tube

If you didn’t document, it wasn’t done.

Waste Streams of NCHWastes saturated

with blood or

other bodily

fluids

Non-Hazardous Trace

Chemotherapy (< 3 % ) or any used

PPE’s

Hazardous Bulk

Chemotherapy

(Partial Chemo Items)

Needles and

empty sharps

(syringes w/needle,

vials, ampules)

Maintenance IV

solutions

without

additives

Controlled

substances

(witness waste in

sink)

Pharmaceutical Wastes

BKC

• Syringe w/ meds• Ampules w/ meds• Glass vials w/meds

* NO empty items, NOtrash, NO controlled substances, NO plain IV solutions *

Medications left in a non-sharp format

For medications left in a SHARP

• Partial IV bags• Pills/Capsules• Medicated ointments &

creams (capped)* NO trash, gloves, etc., NOcontrolled substances, NOSHARPS

Items to send to pharmacy in a medication

ziploc bag

• Items that have a BLACK DOT

• Aerosols/Inhalers• Corrosives/Oxidizers

IMPORTANTBMT labs for chimerism

Always verify MD order for “source” of lab.

Ex- source is

Bone Marrow Specimen

Chemotherapy Updates

Chemo worksheet

ALL admissions for chemo MUST have a chemo worksheet completed on admission when orders are inititated.

Discussion- When chemo is moved up daily?

Chemo Documentation

Chemo Documentation

Chemo Documentation

Oncology Flowsheet

Oncology Flowsheet

Childrens Oncology Group

Sample MTX orders set

Blood updates

Collection of sample for Type and

Screen/ Crossmatch

• Two people must go to the

bedside to ID patient and

SCAN and label specimen tubes at

PATIENT BEDSIDE

Type and Screen

• Was the patient identified by collector AND witness by comparing the first and last name, DOB and MR # on the request with the info on the patients wristband

• Ask patient (or parent) to “state name and date of birth”

The collector and witness must write their employee numbers, date, time obtained on specimen tube

If blood is drawn from a central line, specimen should be obtained after appropriate amount of waste blood is discarded.

WASTE BLOOD MUST NOT BE USED AS SAMPLE FOR T & S

Cerner Bridge Transfusion

Administration• Enables providers to positively identify the patient and verify the

administration of blood products using bar-code technology.

• Bridge Transfusion solution is used to:

• Start a Transfusion

• Hold a Transfusion

• End a Transfusion

• Consents and Orders will continue to be reviewed in PEDS

PowerChart

Bridge Transfusion Chart Overview

Bridge Transfusion Workflow

Start a Transfusion

1. Click on the Bridge button from the

PEDS menu toolbar

2. Scan the Patient’s Wristband

3. Select the Start Transfusion button

4. Complete the Pre-Checks

5. Scan the Recipient Label

Bridge Transfusion Workflow Cont’d6. Scan the Blood Bag (4 Scans)

7. Document Start Vital Signs

8. Document IV Line and Initial

Rate

9. Click the Start button

10.Document first 15 minutes and

hourly vital signs in PEDS

PowerChart (IView)

❹❶

❷❸

Starting the Transfusion

• Start infusion slowly (5% of total

volume) infusing this amount for

the first 15 minutes.

• Review what to do for platelets

• Nurse (or designee) must remain

with patient for the first 15

minutes!

During the Transfusion

• Calculating Rate (After the 15 minutes)

• Do not infuse other IV solutions simultaneously with blood through the same IV.

• Do not add medications to blood.

• Vital signs must be obtained before, 15 minutes, and every hour during the infusion.

After the TransfusionMust save bag for at least one hour after

transfusion has ended.

Possible signs and symptoms of a transfusion reaction:

Urticaria Hypotension

Fever Tachycardia

Chills Respiratory distress

Myalgias Bleeding

Nausea Shock

Vomiting Back pain

Diarrhea Abdominal pain

Pain at infusion site Chest pain

Action Steps for Reactions1. STOP transfusion and disconnect tubing and

cover with a sterile cap

2. Flush IV with normal saline

3. Notify physician immediately and document

“Clinician Notification” in EHR

4. Recheck all identifying labels

5. Treat symptoms per MD order(s)

6. Monitor vital signs Q 15 min or per MD orders

until stable

7. Follow MD orders to either “End” or “Hold”

transfusion

Placing Transfusion on HOLD:

Mild Reactions

To Restart Transfusion: Symptoms

Resolved

END Transfusion:

Transfusion Discontinued:

Moderate/Severe Reaction• Complete the transfusion reaction section

in Bridge

• Report the suspected reaction to blood

bank personnel and determine what lab

specimens are required

• Return remaining blood with ALL attached

tubing to blood bank• NOTE: if reaction occurs AFTER product is completed or during

downtime a PAPER “Transfusion Reaction Form” will need to be

completed.

Transfusion Reaction Documentation

Transfusion Reaction

• Transfusion Reaction

Investigation Report will be

completed based off the

bridge documentation on all

actual and suspected blood

reactions.

• REMEMBER TO NOTIFY

ATTENDING MD

• Also complete incident report

When do I do a Huddle Form?

Quality Indicators

Patient Falls

CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE ED PACU Psych

NDNQI Mean:Total patient falls per 1,000patient days

(Magnet Facility Comparison)0.43% 0.43% 0.01% 1.62% 1.62% 1.62% 1.62% 1.24% 1.54% 0.37% 0.04% 1.58%

Nicklaus Children's Hospital Mean: Totalpatient falls per 1,000 patient days

0.00% 0.00% 0.00% 0.56% 0.77% 1.01% 0.00% 1.37% 0.00% 0.12% 0.00% 0.64%

0.00%

0.40%

0.80%

1.20%

1.60%

2.00%

Falls

rat

e p

er 1

,00

0 p

atie

nt

day

s

Patient Fall Rates per Unit1st Quarter 2016

NDNQI® Benchmark Comparison

Patient Falls with Injury

CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE ED PACU Psych

NDNQI Mean:Total patient falls per 1,000 patientdays

(Magnet Facility Comparison)0.09% 0.09% 0.00% 0.64% 0.64% 0.64% 0.64% 0.23% 0.34% 0.08% 0.02% 0.52%

Nicklaus Childrens Hospital Mean: Total patientfalls with Injury per 1,000 patient days

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.68% 0.00% 0.00% 0.00% 0.64%

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

0.80%

Falls

Rat

e w

ith

Inju

ry p

er

1,0

00

pat

ien

ts d

ays

Patient Fall Rates with Injury per Unit1st Quarter 2016

NDNQI® Benchmark Comparison

Pain AIR Cycles

CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE

NDNQI Mean: % Pain AIR cycles completed(Magnet Facility Comparison)

97.35% 97.35% 96.8% 96.9% 96.9% 96.9% 96.9% 96.3% 96.6%

Nicklaus Children's Hospital Mean: % Pain AIRcycles completed

90.0% 100.0% 100.0% 100.0% 88.5% 100.0% 100.0% 86.7% 100.0%

80.00%

82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

% c

om

ple

te P

ain

AIR

cyc

les

Pain Assessment-Intervention-Reassessment (AIR) Cycle Completion1st Quarter 2016

NDNQI® Benchmark Comparison

Hospital Acquired Pressure Ulcer (HAPU)Stage II and above

CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE

NDNQI Mean: Hospital Acquired PressureUlcer (HAPU) Stage II and above

(Magnet Facility Comparison)3.5% 3.5% 0.23% 0.14% 0.14% 0.14% 0.14% 0.43% 0.25%

Nicklaus Children's Hospital Mean: HospitalAcquired Pressure Ulcer (HAPU) Stage II and

above0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

-0.5%

0.5%

1.5%

2.5%

3.5%

4.5%

5.5%

6.5%

7.5%

% o

f su

rve

yed

pat

ien

ts w

ith

H

AP

U S

tage

II a

nd

ab

ove

Hospital Acquired Pressure Ulcer (HAPU) ≥ Stage II 1st Quarter 2016

NDNQI® Benchmark Prevelance Comparison

RN Education

CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE Psych ED OR PACU

NDNQI Mean: %BSN or higher education(Magnet Facility Comparison)

83.68% 83.68% 71.00% 79.1% 79.1% 79.1% 79.1% 80.2% 68.9% 59.2% 63.9% 61.6% 63.8%

Nicklaus Children's Hospital Mean: % BSN orhigher education

73% 73% 69.4% 69.7% 87% 56.8% 71.1% 91% 63.6% 69.23% 49.1% 59.3% 50.0%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

% B

SN d

egre

e o

r h

igh

er

BSN or higher prepared nurses per unit1st Quarter 2016

NDNQI® Benchmark Comparison

RN Certification

CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE Psych ED OR PACU

NDNQI Mean: % Nationally Certified RNs(Magnet Facility Comparison)

31.4% 31.4% 32.1% 33.4% 33.4% 33.4% 33.4% 35.7% 36.8% 18.3% 20.0% 33.5% 33.9%

Nicklaus Children's Hospital Mean: %Nationally Certified RNs

43.3% 41.8% 49.4% 15.2% 33.3% 37.8% 47.37% 46.9% 36.4% 23.1% 36.2% 33.3% 50.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

% o

f D

irec

t C

are

RN

wit

h S

pec

ialt

y N

urs

ing

Ce

rtif

icat

ion

Certified Nurses per Unit1st Quarter 2016

NDNQI® Benchmark Comparison

Catheter Associated Urinary Tract Infections

CICU PICU 3 E 3 N 3 S 3 NE 2 E 2 NE

NDNQI Mean:CAUTIs per 1000 Catheter Days(Magnet Facility Comparison)

1.98% 1.98% 0.5% 0.5% 0.5% 0.5% 0.87% 0.5%

Nicklaus Children's Hospital Mean: CAUTIs per1000 Catheter Days

16.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

CA

UTI

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e P

er

10

00

Cat

het

er D

ays

Catheter Associated Urinary Tract Infections1st Quarter 2016

NDNQI® Benchmark Comparison

Central Line Associated Blood Stream Infections (CLABSI)

CICU PICU NICU 3 E 3 N 3 S 3 NE 2 E 2 NE

NDNQI Mean: CLABSI per 1000 Central linedays (Magnet Facilty Comparison)

1.05% 1.05% 0.90% 1.15% 1.15% 1.15% 1.15% 1.05% 1.3%

Nicklaus Children's Hospital Mean: CLABSI per1000 Central line days

3.57% 0.00% 0.00% 0.00% 1.24% 0.00% 0.00% 12.35% 0.00%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

CLA

BSI

Rat

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er

10

00

cat

he

ter

day

s

Central Line Associated Blood Stream Infections (CLABSI)1st Quarter 2016

NDNQI® Benchmark Comparison

Code Blue

Code Blue

Code RolesWhat is my role in a code?

• 1 person-Team Lead

• 1 person-Airway

• 1 person-Compressions

• 1 person-get cart/call code

• 1-2 person(s)-Meds/calculations

• 1-2 person(s)-documentation

Code Blue Basics

• Call a code (555)

• HOB DOWN

• Lower bed in order to perform adequate chest compressions

• Place patient on backboard

• Airway person should be at HOB

• Check pulse• Infant: brachial

• Child: Carotid What is wrong with this picture?• Bed in high position• 2 people performing airway• No chest rise

AIRWAY• Airway person: at HOB

• Face mask: minimum 5L O2 (otherwise pt breathing in own CO2)

• AMBU: hook up to O2.

• Always assess for CHEST RISE

• MRSOPA• M= mask (size, seal, position)• R=reposition (head tilt chin lift, nostrils

toward sky)• S= suction• O= open mouth• P=pressure (squeeze ambu harder)• A= advanced airway (consider

intubation)

Code CartWhat drawers do I use?

Only 3 drawers are opened in a code

• 1. Top drawer-MEDICATIONS

• 2. Color drawer by weight (braslow tape)-SUPPLIES, FLUIDS

• 3. Bottom drawer-additional supplies (drawing up meds, saline flushes, intubation, etc)

Restraints and Seclusions

RESTRAINT AND SECULSION

A restraint is any manual method, physical or mechanical device,

material or equipment that immobilizes or reduces the ability of a

patient to move his or her arms, legs, body, or head freely; or a drug

or medication when it is used as a restriction to manage the patient’s

behavior or restrict the patient’s freedom of movement and is not a

standard treatment or dosage for the patient’s condition.

RESTRAINT AND SECULSION

A restraint DOES NOT include devices such a orthopedically prescribed

devices, surgical dressings or bandages, protective helmets, or other

methods that involve the physical holding of a patient for the purpose

of conducting routine physical examinations or tests, or to protect the

patient from falling out of bed, or to permit the patient to participate

in activities without the risk of physical harm (this does not include a

physical escort).

RESTRAINT AND SECULSION

Seclusion can only be used in emergency situations, if

needed, to ensure the immediate safety of the patient

exhibiting violent or self-destructive behavior (and others)

and less restrictive interventions have been determined

to be ineffective.

Quick Guide on what to do, First Try before using restraints

Less intrusive measure:•1:1 patient to staff

observation•Verbal intervention •Child life

involvement •Distraction•Verbal redirection

Less intrusive measure:• Positioning• Positive reinforcement• Music• Family involvement • Mittens or gloves• Securing/covering site

or area

Quick Guide on what to do if in medical restraintsEvery 2 hours, observation includes:

Behaviors

Restraints removed/ROM

Circulation/Skin checks

Toilet/hygiene offered

Fluids offered hourly, if applicable

Meals/snacks are offered at least three times a

day, if applicable

Vital signs are documented at least every 4 hours

Quick Guide on what to do for medical restraints

Orders are limited to:

• 4 hours for adults 18 years of age or older

• 2 hours for children and adolescents 9-17 years of age

• 1 hour for children under 9 years old

NOTE: These are guidelines for MEDICAL RESTRAINTS ONLY, BEHAVIORAL RESTRAINTS HAVE DIFFERENT CRITERIA FOR PATIENT SAFETY

Quick Guide on what to do• The restraint or seclusion order may only be renewed in

accordance with these limits for up to 24 hours unless superseded by state law that is more restrictive

• After 24 hours, and before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other Qualified License Personnel (if allowed by state) must see and assess the patient.

• Physical holding of a patient for the purpose of conducting physical examination or tests is permitted. However, patients do have the right to refuse.

What not to do

DO NOT:

• Tuck a patient’s sheets in so tightly that he/she cannot move.

• Use wrist holders/highly padded mitts or other types of devices.

• Use a side rail to prevent a patient from voluntarily getting out of bed.

• Place hand mitts and attach them to bedding.

• The use of PRN orders is prohibited for drugs or medications that are being used as restraints.

• Staff cannot discontinue an order and then restart it because that would constitute a PRN order.

What NOT to do

Example: When a trial period of observation out of restraints is initiated and

the patient again exhibits the symptoms that prompted the prior use of

restraints, and the patient is placed in restraints again, a new order would be

required. This episode cannot be considered as part of the original

episode/order as it would be considered a PRN order which is not permitted.

A temporary release they occurs for the purpose of caring for a patient’s needs, for example toileting, feeding, ROM, is not considered a discontinuation of the intervention.

Quality Monitoring

Evidence of prolonged restraints, as defined by the

organization, and, if possible, actions taken to reduce or

eliminate the use of restraints must be analyzed by the

treatment team and presented for management review.

Staff Training and Competence

All staff involved in restraints and seclusions are provided with

ongoing education and training to ensure patients are cared for in

a safe and therapeutic manner. Training is provided before

providing any restart and seclusion care as part of orientation and

subsequently on an annual basis. Due to the different skill levels

(Level I-IV) and responsibilities of those involved, there are

different levels of education and training.