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Accreditation standards of medication management, infection control, assessment and plans of care
ADVANCES IN NURSING
Accreditation standards of medication management, infection control, assessment and plans of care
needs to know the height and weight of the patient. These will help determine any medication dosages for a pediatric patient. All of these should be determined from a basic patient assessment or be in the patient record. The second standard that is important for medication management is “medications are properly and safely stored.”1 Each organization has to have a list of approved medications. This is the formulary. The formulary is usually determined by a committee. Medications need to be stored so that their stability is maintained. They need to be refrigerated or they need to be kept at room temperature and those storage options need to be available for all medications. Medications also need to be placed somewhere where unauthorized persons cannot access them. Medications need to be stored in locked containers and in a locked room. The standard says that the room where medication is stored can also be under constant surveillance. Some hospital employees have a computer access card that unlocks medication room doors so only authorized personnel can access the medication storage area. Another aspect of the standard, “medications are properly and safely stored”1 is the recommendation that there will be a limited number of drug concentrations. This is to prevent errors. If multiple concentrations of medication are available, nurses can make a math error and potentially give the wrong dosage. A few years ago it was determined that drugs such as potassium injection can no longer be stored on the patient care units. Potassium was added to IV fluid by a nurse and there were medication errors that caused this standard to be written. The final part of this standard is that storage areas must be inspected. This can be done approximately once a quarter by pharmacy personnel. They enter the medication storage area and make sure that there is compliance with all storage standards. Pharmacy personnel can provide written reports to the Nurse Manager about their inspections and any problems that were identified can be corrected. The next medication management strategy or standard is that “emergency medications need to be available, controlled and are secure.”1 Emergency medications are decided by a hospital committee. The committee can be made up of hospital leadership and medical staff. All of these emergency medications need to be available in a unit dose which is age specific and ready to administer. This could include medications such as epinephrine or diphenhydramine. These emergency medications need to be kept in a sealed, locked container. The container needs to be kept in a locked medication room. These medications also need to be replaced according to the policy that is written by the hospital. The medications also need “to be safely and accurately administered.”1 There also needs to be a policy or procedure that tells the nurse how to report a reaction or an error. Serious drug reactions need to be reported to the Federal Drug Administration group in the United States, and errors need to be recorded for quality control programs and continuous improvement activities. Medication errors are an opportunity for the nurse manager or the nurse education specialist to teach a nurse how to make their practice safer.
Linda Sorensen
Abstract The Joint Commission for Accreditation of Healthcare Organizations specify standards of care. This article focuses on the standards of medication management and infection control. It also relays information on nursing assessment and plans of care.
Keywords accreditation standards; assessment; infection control; medication management; plans of care
This is content from a speech given at the First Joint Nursing conference at Ospedale Pediatrico Bambino Gesù in Rome, Italy. It is about hospital accreditation standards. The emphasis is on Medication Management standards and Infection Control standards. The focus will be how to implement those standards. Almost all of these standards require each hospital to have their own policy or procedure. This will be specified in the article. The final focus of the article will be on how nurses complete their assessment and develop a plan of care for individual patients and review examples of those plans. Medication Management is symbolized by the MM. “Patient specific information is readily accessible to those involved in the medication management system.”1 This is one of the important standards that has to be addressed. This standard specifies that a written policy includes patient specific information that the nurse must have access to in order to give medications. These are obvious things that are needed such as the age and the sex of the patient, what medications they are currently taking, what diagnoses they have, the reason for their hospitalization, if there are relevant laboratory values such as basic blood work or urinalysis. The nurse also needs to know about any allergies or sensitivities to medication. In some areas, such as in Pediatrics, the nurse also
Linda Sorensen is at the Department of Nursing, Mayo Clinic/Mayo Eugenio Litta Children’s Hospital, Rochester, MN USA Conflict of interest: none declared
PAEDIATRICS AND CHILD HEALTH 17:S1
S92
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN NURSING
When giving medication, the health care professional must verify that they have the correct medication with the original physician’s order and compare it against the medication label. The medication also needs to be examined to make sure that there isn’t any precipitate or any other contamination. The nurse also verifies that the patient has no contraindications to a medication. This could possibly be aspirin containing medication for a patient that has an allergy to aspirin. The nurse must also verify that the medication is being given at the proper time, that the dose is correct, and that it’s the correct route. At the time a new medication is given, the nurse must advise the patient or their family member of any potential adverse reaction. If the patient or family observes any reaction occurring after a new medication is given, they need to inform the nurse of the problem. Any concerns will need to be addressed with the ordering physician. Most documentation policies and procedures for medications require that the nurse documents the medication name, the dose given, the route used, and the time it was given. If a pain medication is given there also needs to be a reassessment of its effectiveness after its been given a chance to act. If the pain medication was not effective, the nurse has a responsibility to discuss that with the physician and potentially get a different order for analgesia. This next section will explain some of the infection control issues that can occur in hospitals. The infection control standards in English are documented as IC, “the risk of a health care-associated infection is minimized through a hospital wide infection control program.”1 The standard states that there has to be “systems in place that communicate… infection prevention and control issues.”1 Every year, nurses can be required to complete an infection control education program or watch a video about infection control in the hospital. Anyone who has patient contact should be required to complete some kind of infection control education every year. The education needs to be documented as completed or staff that are slow to complete it need to be counseled. There needs to be goals for “preventing healthcare associated infections within the hospital.”1 The prevention of transmission of infection can be prevented in several ways. Exposure can be limited and hand hygiene can be encouraged to minimize the risk of any transmission of infection. To limit exposure, patients are placed in isolation to protect other patients and staff. Standard precautions, the use of gloves and/or masks and face shields, are standard precautions whenever the nurse encounters bodily fluids. Isolation can be initiated immediately for any patient with a respiratory or diarrheal illness. Droplet isolation is used for respiratory illness and contact isolation for diarrheal illness. Children in most types of isolation need to be kept in their rooms. Parents and family members can also be restricted from public areas to prevent the spread of infection. Two diseases have become increasingly difficult in the United States. One is MRSA which is Methcillin Resistant Staphylococcus Aureus and the other is VRE which is Vancomycin Resistant Enterococcus. Both of these are virulent organisms that can spread like an epidemic through a hospital.
PAEDIATRICS AND CHILD HEALTH 17:S1
The patient that has MRSA or VRE, should be placed in strict isolation immediately upon their admission so they aren’t mixing with the patients that have not been exposed to the disease previously, and all staff know that they must use personal protective equipment. An alcohol based hand sanitizer or soap and water can be used for hand hygiene. Staff can be taught to spread an alcohol based hand sanitizer over the hands for about 15 seconds. The Center for Disease Control in the United States suggests that this is typical cleansing that can occur between patient contact that doesn’t involve any contact with blood or body fluids. For any contact with blood or body fluids it is recommended that the nurse use soap and water for about one minute to clean their hands. Gloves need to be worn for any contact with patients that could involve blood or body fluids. Gloves in several sizes need to be provided in all patient rooms so that they are easily accessible for nursing staff. Initially, it was a difficult thing for nurses that have been taught that skin to skin contact with patients was preferred. All now believe that this is the only safe way to practice infection control. The risk of the transmission of infection needs to be minimized. This is done through making sure that any equipment that is used between patients is cleaned on a regular basis. There needs to be a system that insures that equipment that is used for multiple patients is cleaned at least every day. The date of each cleaning can be written on a card attached to the equipment. Personal protective equipment should be stocked in every patient room. This equipment includes a mask with an eye shield in case a nurse is going to be involved with something that could potentially splash, such as measuring urine; gloves; and special trash bags for anything that is contaminated with blood. All of these ways help us to minimize any risk of transmission of infection between patients or to the nurse. The next section is about how patients are assessed and how plans of care are developed from an assessment. The first thing that the nurse is responsible for when any patient is admitted to the hospital is completing a baseline assessment. Each hospital sets a standard about how soon this must be accomplished. The assessment should usually be completed within a few hours of the patient’s arrival at the hospital. The RN baseline assessment includes: the patient’s past history, the reason for their visit, spiritual or cultural issues, advance directives, nutrition, abuse or neglect screening, use of adaptive devices, the ability to complete activities of daily living, and the need for patient or family education. After the initial baseline assessment is completed, the nurse is responsible to continue with general assessments. The standard for that assessment is determined by the type of patient care unit. In a general pediatrics unit, the nurse can complete a general assessment on their patients at least twice per day. This can be done once in the morning and again in the evening. In an intensive care unit this can be done every four hours. In a rehabilitation unit, a daily assessment may be all that is necessary because this type of patient is very stable. The nurse needs to assess all the systems of the patient and this assessment leads to a plan of care that’s individualized for that patient. The areas assessed include pain, skin, the IV site, tissue perfusion, respiratory, sensory perceptual, activity or S93
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN NURSING
mobility, anxiety or coping, safety, home health maintenance, nutrition and fluid, and elimination and output. This assessment can be documented for each particular system by the nurse indicating whether the criteria for the assessment was met or not met. Here is an example: there is a child with an infected leg and their mobility is being assessed. Mobility would probably not be met for this child. Skin integrity would probably be not met. And under pain, depending on the particular time of day, that assessment would either be met or not met. The nurse assesses whether that person is able to be up and about without any assistive devices. In the case of mobility, because of potential pain or swelling in the leg, in this example it is assessed that the child’s mobility is not usual. He’s not walking around by himself and therefore the mobility assessment is not met. In the case of the same child, skin integrity also may be not met. This may be because there is redness, swelling, or potentially drainage from a particular lesion on that child’s leg. Pain may also occur with infection and depending if the child has been recently medicated, pain will be met or not met. The plan of care is developed from the nurse’s assessment. In the case of this child with the infected leg, when mobility is assessed, the nurse chooses particular interventions that will help that child deal with his problems with mobility. One thing the nurse might do would be to ask the physician if it would be appropriate to ask for a physical therapy consult. The nurse may find a wheelchair for the child and ensure that the wheelchair has a place that the leg can be elevated or help the child learn how to use crutches or a walker in order to intervene in the problems of mobility. For skin integrity, the leg lesion would be assessed to make sure that it is not getting any worse. The diameter of the leg would be measured and any dressing change would be included in the plan of care. The same child would also have pain addressed in his care plan. Pain interventions could include giving analgesia and this would be according to the physician’s order. Child life specialists, developmental and preparations specialists in the children’s hospital, could be consulted. They might help the child get their mind off their pain through diversion, teaching them how to cope with dressing changes, or providing some kind of activity, play, or craft to do. Positioning could also be included in the care plan. This could include elevating the leg to help prevent pain. A neurovascular assessment would also be completed. This includes assessing the color, the warmth, sensation, and the ability for the child to move their toes and perhaps the other joints of that leg. This assesses whether or not the leg is healing or getting worse. Another example is of a nurse’s assessment after an appendectomy. The nurse completes a multi-system assessment. In this case, pain is either met or not met. Skin alterations are probably not met because there has been an appendectomy that includes an incision and therefore an interruption in the usual skin integrity. Respiratory may be met or not met. Nutrition and elimination is either met or not met. These would be the four main areas that would be considered when designing a care plan for a child that had an appendectomy. PAEDIATRICS AND CHILD HEALTH 17:S1
The assessment leads a nurse to a particular plan of care for a child after an appendectomy. For the respiratory assessment, it may be found by listening to the lungs that the child has some post operative atelectasis. The interventions would include ways to get the child to use their lungs by turning, coughing and deep breathing on a regular schedule, making sure that they get up to walk several times in a 24 hour period and perhaps by providing some type of respiratory exercise that the child perform. Ways a nurse can get a younger child to do respiratory exercise is to provide them with bubbles, or to give them a pinwheel to blow on, or give them a straw and a cotton ball and tell them that they will have a cotton ball race by blowing through a straw. It’s extremely important after any kind of surgery that lung assessment is done thoroughly, at least every shift, so the nurse knows whether these interventions are working or not. Another area that can be a problem after general surgery is nutrition and elimination. In general, after surgery there will be physician orders that start with the child not being able to eat or drink at all. The diet starts with sips, which means small amounts of liquid, and eventually leads up to a general diet. Dietary choices are important for children. Liquids in the form of frozen popsicles, juice, or pop are going to be much more interesting to them than broth or tea. The nurse also would include an assessment of bowel sounds and find out whether or not the child has had a bowel movement recently and how often they usually have one. The nurse records accurate intake and output to make sure the child is staying hydrated and is also urinating in reasonable amounts. A daily assessment of weight helps the nurse to determine hydration. Patients also need to be assessed to determine what type of patient and family education is needed. In order to determine a plan of care for patient/family education, the nurse assesses their potential for barriers to learning. If the child doesn’t speak English or if his family doesn’t speak English, language is going to be a barrier to them. If the child is very young, they may not comprehend what is being told to them and therefore teaching is directed to their parents. The assessment also includes cultural issues or religious issues that need to be understood before the patient or family can be educated. The patient or family’s learning preference also needs to be determined. Does the patient or family like to read about things, learn by listening, or would they would prefer a demonstration? When education is documented, the nurse includes who was taught, the topic, whether or not the patient or family member learned, and what teaching method was used. Using the example of the infected leg, assume that the final diagnosis for this child was osteomyelitis. Is the family capable of taking care of this patient at home? Will they need home care agency support? If they do, a nursing referral would be completed, with the patient’s permission, to a homecare agency. Would this family do better with an outpatient pediatric infusion therapy center, or a home hospital, or are there other caregivers or family members that might be helpful to provide care? If this family is able to give three weeks of intravenous (IV) antibiotics at home there are many things that need to be taught. Teaching would include IV device care, the medication S94
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN NURSING
technique or how to give the medication, what the purpose of the medication is, and if there are particular side effects that the family should be concerned about and if there are any other signs or symptoms the family should report to their doctor. In the appendectomy example, the family would be taught about any signs or symptoms of infection and tell them who they should call if they have any problems once they’re dismissed. They also need information about activity: if they can resume their usual activity such as lifting, going to school, or playing sports; if they are allowed to bathe or shower, and if there is any particular care for the incision. In general, if an incision has steri strips the patient and family are told that these do not have to be removed and will peel off on their own. Patients are also told that bathing isn’t a problem and that the incision shouldn’t be soaked in a bath. The things that are documented about any part of an education plan is whether or not the education is started, whether the patient and family verbalize that they understood the education, whether or not they demonstrated an understanding, if they need any reinforcement of the education that we have provided, or if the education wasn’t needed at all. Education
PAEDIATRICS AND CHILD HEALTH 17:S1
might not be needed for a nurse who is the parent of an ill child. If the child of a nurse was hospitalized and needed some specific types of home care, the nurse might already know the information and stop the nurse from giving us all the details about signs and symptoms of infection because that would be part of their knowledge base. This article has been written to give nurses some insight into how to deal with the standards for medication management and infection control and how patients are assessed to provide plans of care during a hospitalization and for the education needed at home to cope with the rest of their illness. It is recommended that a thorough review of the current literature from the Joint Commission Hospital Accreditation Standards be completed for complete information about these topics.
REFERENCE: 1 Joint Commission on Accreditation of Healthcare Organizations. Hospital accreditation standards. Oakbrook Terrace, IL: Joint Commission Resources, Inc.; 2005.
S95
© 2007 Elsevier Ltd. All rights reserved.
Accreditation standards of medication management, infection control, assessment and plans of care
needs to know the height and weight of the patient. These will help determine any medication dosages for a pediatric patient. All of these should be determined from a basic patient assessment or be in the patient record. The second standard that is important for medication management is “medications are properly and safely stored.”1 Each organization has to have a list of approved medications. This is the formulary. The formulary is usually determined by a committee. Medications need to be stored so that their stability is maintained. They need to be refrigerated or they need to be kept at room temperature and those storage options need to be available for all medications. Medications also need to be placed somewhere where unauthorized persons cannot access them. Medications need to be stored in locked containers and in a locked room. The standard says that the room where medication is stored can also be under constant surveillance. Some hospital employees have a computer access card that unlocks medication room doors so only authorized personnel can access the medication storage area. Another aspect of the standard, “medications are properly and safely stored”1 is the recommendation that there will be a limited number of drug concentrations. This is to prevent errors. If multiple concentrations of medication are available, nurses can make a math error and potentially give the wrong dosage. A few years ago it was determined that drugs such as potassium injection can no longer be stored on the patient care units. Potassium was added to IV fluid by a nurse and there were medication errors that caused this standard to be written. The final part of this standard is that storage areas must be inspected. This can be done approximately once a quarter by pharmacy personnel. They enter the medication storage area and make sure that there is compliance with all storage standards. Pharmacy personnel can provide written reports to the Nurse Manager about their inspections and any problems that were identified can be corrected. The next medication management strategy or standard is that “emergency medications need to be available, controlled and are secure.”1 Emergency medications are decided by a hospital committee. The committee can be made up of hospital leadership and medical staff. All of these emergency medications need to be available in a unit dose which is age specific and ready to administer. This could include medications such as epinephrine or diphenhydramine. These emergency medications need to be kept in a sealed, locked container. The container needs to be kept in a locked medication room. These medications also need to be replaced according to the policy that is written by the hospital. The medications also need “to be safely and accurately administered.”1 There also needs to be a policy or procedure that tells the nurse how to report a reaction or an error. Serious drug reactions need to be reported to the Federal Drug Administration group in the United States, and errors need to be recorded for quality control programs and continuous improvement activities. Medication errors are an opportunity for the nurse manager or the nurse education specialist to teach a nurse how to make their practice safer.
Linda Sorensen
Abstract The Joint Commission for Accreditation of Healthcare Organizations specify standards of care. This article focuses on the standards of medication management and infection control. It also relays information on nursing assessment and plans of care.
Keywords accreditation standards; assessment; infection control; medication management; plans of care
This is content from a speech given at the First Joint Nursing conference at Ospedale Pediatrico Bambino Gesù in Rome, Italy. It is about hospital accreditation standards. The emphasis is on Medication Management standards and Infection Control standards. The focus will be how to implement those standards. Almost all of these standards require each hospital to have their own policy or procedure. This will be specified in the article. The final focus of the article will be on how nurses complete their assessment and develop a plan of care for individual patients and review examples of those plans. Medication Management is symbolized by the MM. “Patient specific information is readily accessible to those involved in the medication management system.”1 This is one of the important standards that has to be addressed. This standard specifies that a written policy includes patient specific information that the nurse must have access to in order to give medications. These are obvious things that are needed such as the age and the sex of the patient, what medications they are currently taking, what diagnoses they have, the reason for their hospitalization, if there are relevant laboratory values such as basic blood work or urinalysis. The nurse also needs to know about any allergies or sensitivities to medication. In some areas, such as in Pediatrics, the nurse also
Linda Sorensen is at the Department of Nursing, Mayo Clinic/Mayo Eugenio Litta Children’s Hospital, Rochester, MN USA Conflict of interest: none declared
PAEDIATRICS AND CHILD HEALTH 17:S1
S92
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN NURSING
When giving medication, the health care professional must verify that they have the correct medication with the original physician’s order and compare it against the medication label. The medication also needs to be examined to make sure that there isn’t any precipitate or any other contamination. The nurse also verifies that the patient has no contraindications to a medication. This could possibly be aspirin containing medication for a patient that has an allergy to aspirin. The nurse must also verify that the medication is being given at the proper time, that the dose is correct, and that it’s the correct route. At the time a new medication is given, the nurse must advise the patient or their family member of any potential adverse reaction. If the patient or family observes any reaction occurring after a new medication is given, they need to inform the nurse of the problem. Any concerns will need to be addressed with the ordering physician. Most documentation policies and procedures for medications require that the nurse documents the medication name, the dose given, the route used, and the time it was given. If a pain medication is given there also needs to be a reassessment of its effectiveness after its been given a chance to act. If the pain medication was not effective, the nurse has a responsibility to discuss that with the physician and potentially get a different order for analgesia. This next section will explain some of the infection control issues that can occur in hospitals. The infection control standards in English are documented as IC, “the risk of a health care-associated infection is minimized through a hospital wide infection control program.”1 The standard states that there has to be “systems in place that communicate… infection prevention and control issues.”1 Every year, nurses can be required to complete an infection control education program or watch a video about infection control in the hospital. Anyone who has patient contact should be required to complete some kind of infection control education every year. The education needs to be documented as completed or staff that are slow to complete it need to be counseled. There needs to be goals for “preventing healthcare associated infections within the hospital.”1 The prevention of transmission of infection can be prevented in several ways. Exposure can be limited and hand hygiene can be encouraged to minimize the risk of any transmission of infection. To limit exposure, patients are placed in isolation to protect other patients and staff. Standard precautions, the use of gloves and/or masks and face shields, are standard precautions whenever the nurse encounters bodily fluids. Isolation can be initiated immediately for any patient with a respiratory or diarrheal illness. Droplet isolation is used for respiratory illness and contact isolation for diarrheal illness. Children in most types of isolation need to be kept in their rooms. Parents and family members can also be restricted from public areas to prevent the spread of infection. Two diseases have become increasingly difficult in the United States. One is MRSA which is Methcillin Resistant Staphylococcus Aureus and the other is VRE which is Vancomycin Resistant Enterococcus. Both of these are virulent organisms that can spread like an epidemic through a hospital.
PAEDIATRICS AND CHILD HEALTH 17:S1
The patient that has MRSA or VRE, should be placed in strict isolation immediately upon their admission so they aren’t mixing with the patients that have not been exposed to the disease previously, and all staff know that they must use personal protective equipment. An alcohol based hand sanitizer or soap and water can be used for hand hygiene. Staff can be taught to spread an alcohol based hand sanitizer over the hands for about 15 seconds. The Center for Disease Control in the United States suggests that this is typical cleansing that can occur between patient contact that doesn’t involve any contact with blood or body fluids. For any contact with blood or body fluids it is recommended that the nurse use soap and water for about one minute to clean their hands. Gloves need to be worn for any contact with patients that could involve blood or body fluids. Gloves in several sizes need to be provided in all patient rooms so that they are easily accessible for nursing staff. Initially, it was a difficult thing for nurses that have been taught that skin to skin contact with patients was preferred. All now believe that this is the only safe way to practice infection control. The risk of the transmission of infection needs to be minimized. This is done through making sure that any equipment that is used between patients is cleaned on a regular basis. There needs to be a system that insures that equipment that is used for multiple patients is cleaned at least every day. The date of each cleaning can be written on a card attached to the equipment. Personal protective equipment should be stocked in every patient room. This equipment includes a mask with an eye shield in case a nurse is going to be involved with something that could potentially splash, such as measuring urine; gloves; and special trash bags for anything that is contaminated with blood. All of these ways help us to minimize any risk of transmission of infection between patients or to the nurse. The next section is about how patients are assessed and how plans of care are developed from an assessment. The first thing that the nurse is responsible for when any patient is admitted to the hospital is completing a baseline assessment. Each hospital sets a standard about how soon this must be accomplished. The assessment should usually be completed within a few hours of the patient’s arrival at the hospital. The RN baseline assessment includes: the patient’s past history, the reason for their visit, spiritual or cultural issues, advance directives, nutrition, abuse or neglect screening, use of adaptive devices, the ability to complete activities of daily living, and the need for patient or family education. After the initial baseline assessment is completed, the nurse is responsible to continue with general assessments. The standard for that assessment is determined by the type of patient care unit. In a general pediatrics unit, the nurse can complete a general assessment on their patients at least twice per day. This can be done once in the morning and again in the evening. In an intensive care unit this can be done every four hours. In a rehabilitation unit, a daily assessment may be all that is necessary because this type of patient is very stable. The nurse needs to assess all the systems of the patient and this assessment leads to a plan of care that’s individualized for that patient. The areas assessed include pain, skin, the IV site, tissue perfusion, respiratory, sensory perceptual, activity or S93
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN NURSING
mobility, anxiety or coping, safety, home health maintenance, nutrition and fluid, and elimination and output. This assessment can be documented for each particular system by the nurse indicating whether the criteria for the assessment was met or not met. Here is an example: there is a child with an infected leg and their mobility is being assessed. Mobility would probably not be met for this child. Skin integrity would probably be not met. And under pain, depending on the particular time of day, that assessment would either be met or not met. The nurse assesses whether that person is able to be up and about without any assistive devices. In the case of mobility, because of potential pain or swelling in the leg, in this example it is assessed that the child’s mobility is not usual. He’s not walking around by himself and therefore the mobility assessment is not met. In the case of the same child, skin integrity also may be not met. This may be because there is redness, swelling, or potentially drainage from a particular lesion on that child’s leg. Pain may also occur with infection and depending if the child has been recently medicated, pain will be met or not met. The plan of care is developed from the nurse’s assessment. In the case of this child with the infected leg, when mobility is assessed, the nurse chooses particular interventions that will help that child deal with his problems with mobility. One thing the nurse might do would be to ask the physician if it would be appropriate to ask for a physical therapy consult. The nurse may find a wheelchair for the child and ensure that the wheelchair has a place that the leg can be elevated or help the child learn how to use crutches or a walker in order to intervene in the problems of mobility. For skin integrity, the leg lesion would be assessed to make sure that it is not getting any worse. The diameter of the leg would be measured and any dressing change would be included in the plan of care. The same child would also have pain addressed in his care plan. Pain interventions could include giving analgesia and this would be according to the physician’s order. Child life specialists, developmental and preparations specialists in the children’s hospital, could be consulted. They might help the child get their mind off their pain through diversion, teaching them how to cope with dressing changes, or providing some kind of activity, play, or craft to do. Positioning could also be included in the care plan. This could include elevating the leg to help prevent pain. A neurovascular assessment would also be completed. This includes assessing the color, the warmth, sensation, and the ability for the child to move their toes and perhaps the other joints of that leg. This assesses whether or not the leg is healing or getting worse. Another example is of a nurse’s assessment after an appendectomy. The nurse completes a multi-system assessment. In this case, pain is either met or not met. Skin alterations are probably not met because there has been an appendectomy that includes an incision and therefore an interruption in the usual skin integrity. Respiratory may be met or not met. Nutrition and elimination is either met or not met. These would be the four main areas that would be considered when designing a care plan for a child that had an appendectomy. PAEDIATRICS AND CHILD HEALTH 17:S1
The assessment leads a nurse to a particular plan of care for a child after an appendectomy. For the respiratory assessment, it may be found by listening to the lungs that the child has some post operative atelectasis. The interventions would include ways to get the child to use their lungs by turning, coughing and deep breathing on a regular schedule, making sure that they get up to walk several times in a 24 hour period and perhaps by providing some type of respiratory exercise that the child perform. Ways a nurse can get a younger child to do respiratory exercise is to provide them with bubbles, or to give them a pinwheel to blow on, or give them a straw and a cotton ball and tell them that they will have a cotton ball race by blowing through a straw. It’s extremely important after any kind of surgery that lung assessment is done thoroughly, at least every shift, so the nurse knows whether these interventions are working or not. Another area that can be a problem after general surgery is nutrition and elimination. In general, after surgery there will be physician orders that start with the child not being able to eat or drink at all. The diet starts with sips, which means small amounts of liquid, and eventually leads up to a general diet. Dietary choices are important for children. Liquids in the form of frozen popsicles, juice, or pop are going to be much more interesting to them than broth or tea. The nurse also would include an assessment of bowel sounds and find out whether or not the child has had a bowel movement recently and how often they usually have one. The nurse records accurate intake and output to make sure the child is staying hydrated and is also urinating in reasonable amounts. A daily assessment of weight helps the nurse to determine hydration. Patients also need to be assessed to determine what type of patient and family education is needed. In order to determine a plan of care for patient/family education, the nurse assesses their potential for barriers to learning. If the child doesn’t speak English or if his family doesn’t speak English, language is going to be a barrier to them. If the child is very young, they may not comprehend what is being told to them and therefore teaching is directed to their parents. The assessment also includes cultural issues or religious issues that need to be understood before the patient or family can be educated. The patient or family’s learning preference also needs to be determined. Does the patient or family like to read about things, learn by listening, or would they would prefer a demonstration? When education is documented, the nurse includes who was taught, the topic, whether or not the patient or family member learned, and what teaching method was used. Using the example of the infected leg, assume that the final diagnosis for this child was osteomyelitis. Is the family capable of taking care of this patient at home? Will they need home care agency support? If they do, a nursing referral would be completed, with the patient’s permission, to a homecare agency. Would this family do better with an outpatient pediatric infusion therapy center, or a home hospital, or are there other caregivers or family members that might be helpful to provide care? If this family is able to give three weeks of intravenous (IV) antibiotics at home there are many things that need to be taught. Teaching would include IV device care, the medication S94
© 2007 Elsevier Ltd. All rights reserved.
ADVANCES IN NURSING
technique or how to give the medication, what the purpose of the medication is, and if there are particular side effects that the family should be concerned about and if there are any other signs or symptoms the family should report to their doctor. In the appendectomy example, the family would be taught about any signs or symptoms of infection and tell them who they should call if they have any problems once they’re dismissed. They also need information about activity: if they can resume their usual activity such as lifting, going to school, or playing sports; if they are allowed to bathe or shower, and if there is any particular care for the incision. In general, if an incision has steri strips the patient and family are told that these do not have to be removed and will peel off on their own. Patients are also told that bathing isn’t a problem and that the incision shouldn’t be soaked in a bath. The things that are documented about any part of an education plan is whether or not the education is started, whether the patient and family verbalize that they understood the education, whether or not they demonstrated an understanding, if they need any reinforcement of the education that we have provided, or if the education wasn’t needed at all. Education
PAEDIATRICS AND CHILD HEALTH 17:S1
might not be needed for a nurse who is the parent of an ill child. If the child of a nurse was hospitalized and needed some specific types of home care, the nurse might already know the information and stop the nurse from giving us all the details about signs and symptoms of infection because that would be part of their knowledge base. This article has been written to give nurses some insight into how to deal with the standards for medication management and infection control and how patients are assessed to provide plans of care during a hospitalization and for the education needed at home to cope with the rest of their illness. It is recommended that a thorough review of the current literature from the Joint Commission Hospital Accreditation Standards be completed for complete information about these topics.
REFERENCE: 1 Joint Commission on Accreditation of Healthcare Organizations. Hospital accreditation standards. Oakbrook Terrace, IL: Joint Commission Resources, Inc.; 2005.
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© 2007 Elsevier Ltd. All rights reserved.