menaka stf -report with...
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SENIOR TRAINING FELLOWSHIP (STF)
1. NAME : Mrs. N. Menaka Raghuraman
2. DEPARTMENT : COLLEGE OF NURSING
CHILD HEALTH NURSING DEPARTMENT
3. YEAR OF STF : 2014
4. OBJECTIVES STATED IN THE APPLICATION FOR STF:
� To observe the physical set up of the pediatric oncology unit i.e.
inpatient and outpatient services, bone marrow transplant unit.
� To observe the services and best practices by pediatric oncology unit
nurses.
� To learn the policies, protocols and the standards for providing
nursing care to children with cancer.
� To learn the specific skills required for a pediatric oncology nurse in
relation to assessment, chemotherapy administration, care of central
venous access, supportive care, emergency management, counseling,
palliative care and end of life care.
� To learn the trends and other innovative approaches used in the
pediatric oncology unit.
� To observe the in service and educational programme conducted for
the nurses in the pediatric oncology unit.
5. CENTER VISITED FOR STF: Royal Children’s Hospital
Brisbane, Queensland.
MENTOR: Ms. Rachel Edwards
Nurse educator, Pediatric oncology
6. SHORT DESCRIPTION OF TRAINING:
INTRODUCTION
Royal Children’s Hospital (RCH) at Brisbane is a 168 bed multi-specialty
tertiary referral and teaching hospital for the State of Queensland.
PHYSICAL SET UP
The pediatric oncology unit houses two different wards - Banksia ward with
14 beds, Turner ward with 10 beds and a day care unit .The bone marrow
transplant unit which is attached to the Banksia ward has 3 beds. The unique
feature is that all the above patient care areas are considered as immune
compromised patient care areas and are restricted for entry of general public.
Children having infections or known to have had contacts with infected family
members are isolated appropriately from the non-infectious children.
The patient care area is child and family friendly, with well equipped play
room and parent lounges. The walls are decorated with beautiful paintings.
Relevant printed texts and pictures with information related to care of children
with cancer are displayed for staff (E.g. hand washing, safe handling of cytotoxic
agents, central venous access device management bundle etc...)
TEAM MEMBERS OF PEDIATRIC ONCOLOGY UNIT:
MEDICAL:
Medical director for pediatric oncology/hematology is the head of the unit.
The team of doctors functioning in the unit includes senior specialist (consultant),
Fellows (preparing to become senior specialist), registrars and resident doctors.
NURSING:
The executive nursing director is the head of the nursing services in the
hospital. The nursing directors in charge for pediatric oncology/hematology units
directly report to the executive nursing director. A team of nurses including nurse
practitioners, nurse educators, clinical nurse consultants, liaison nurses ,research
nurses, nurse unit managers, clinical nurse facilitators shift coordinators, staff
nurses ,nursing assistants, and bone marrow transplant unit nurse co-coordinators
work under the guidance of the nursing directors. As per the staffing policy in the
oncology ward the nurse patient ratio is 1:2. There are total of 25 staff nurses
working in the oncology day care unit.
ALLIED HEALTH:
Apart from the nursing team many other health professional also render care
to these children who are either admitted in the wards or visit the day care unit.
Social worker counsels the child and family after thorough assessment of the
family and social structures.
Welfare workers assess the financial need of the family and help them to access
to resources such as free accommodation or subsidized medical benefits.
Occupational therapist orients the child and family members about the disease
condition, investigations required and treatment modalities. They engage the
hospitalized children with meaningful activities.
Physiotherapist provides physical therapies as per the need of the child.
Speech therapist helps children with speech difficulties and feeding problems
Dietician assesses the nutritional status of the child and recommends the
appropriate dietary supplements required.
Music therapist provides solace and diversion to the child and family members by
singing and playing instruments of the family’s choice.
MISSELANEOUS
Many volunteers and nongovernmental organizations support the family
financially as well as provide diversion to children during hospitalization (E.g.
Leukemia foundation, Clown doctors, working wonders, Red kite, Make a wish
etc.).
PATIENT CARE IN DAY CARE UNIT
Every day (Monday to Friday) 25-30 children visit the oncology day care
unit to receive health care services. It was quite amazing to see the system of
patient care in the day care unit. The day care unit is designed in such a way that
the child register first, then the triage nurse carry out initial assessments such as
measuring the height, weight, vital signs, and collects necessary nursing history
and she ties the ID band to the child . Then the child along with family members
consult the doctor, blood samples are collected for investigation, dressing of the
central venous access is done or the port is accessed as per need. Once the blood
results are ready the child undergoes the recommended chemotherapy
administration. Bone marrow aspiration and intrathecal chemotherapies are done in
the minor theatre of day care unit under general anesthesia (GA) on Tuesdays and
Thursdays of the week. Followed by the painful procedures done under GA
children are wheeled to the recovery room and closely monitored until they are
conscious & stable.
GUIDELINES, POLICIES, STANDARDS, & PROCEDURES:
The pediatric oncology unit has printed as well as online guidelines and
policies for patient care services. Standards for nursing care are
available in the unit exclusively for oncology nursing practice in
the State of Queensland. A record of all common procedures
carried out in the unit are available in the patient care areas.(E.g.
Central line dressing, heparin flush of central line, blood sampling
from central venous line, and needling a chemoport etc..)
CYTOTOXIC DRUG PREPARATION, STORAGE, ADMINISTRATION,
AND DISPOSAL
Cytotoxic drugs are prepared in pharmacy by the pharmacist in the low
pressure room under the biological safety cabinet. The pharmacist wears cytotoxic
specific personnel protective equipment and follows reverse barrier techniques.
After the counter checking by the senior pharmacist the syringes of loaded
medicine are put in to purple bag, labeled and sealed. Then it is brought to the
patient care area and stored at 2-8degree centigrade in the chemotherapy storage
refrigerator. In the clinical area two specially trained chemotherapy nurses check
the protocol, follow all the rights of medication administration, wear the PPE
(purple impermeable apron with full front cover and full sleeves, nitrile purple
gloves,N95 face mask, goggles, and inner shoes)to administer drugs. Most of the
time nurses wear clean purple gloves but follow aseptic non touch technique. All
the disposable items used for cytotoxic drug preparation and administration are
segregated into purple bins lined with purple colored alginate bags. Sharps are
discarded into disposable purple colored sharp containers .The urine, stools, and
vomitus of the child are considered as cytotoxic waste for 7 days following
chemotherapy administration and disposed with special care. The bedpans and
urinals are sterilized after each use by placing in to a sterilizer machine kept in the
dirty utility room.
CENTRAL VENOUS ACCESS DEVICE (CVAD) MAINTENANCE
BUNDLE
CVAD maintenance bundle consist of hand hygiene, scrub the hub, aseptic
non touch technique (ANTT), dressing, and patency. The oncology unit nurses are
specially trained to follow the bundle to prevent CVAD related infections. The
nurses who have completed the training successfully are recognized as CVAD
HERO. The CVAD HEROES are also trained to repair the damaged or broken
central venous catheters using the repair kit provided by the pharmaceutical
company. Nurses who have attended workshops on antibiotic therapy are called
ANTI BIOTIC CHAMPIONS.
STAFF DEVELOPMENT PROGRAMME AND SKILL TRAINING
Graduate nurse to work in the pediatric setting need to undergo a special
pediatric nursing course for one month. Then if she is interested to work in the
oncology unit she needs to undergo the chemotherapy course that consists of 3
modules and practical sessions for 3 months. After the successful completion of the
course the staff nurse is permitted to function independently in the unit. The
clinical facilitators train the new graduate nurses as well as the other nurses to
practice procedures like central line dressing on the Chester model available in the
wards. The clinical facilitators periodically assess the procedures done by the
nurses and gives evaluation. The oncology nurse educators are responsible for the
chemo course training and development of the nurses.
Every week on Thursday noon education meetings are conducted to share
the topic of interest with the oncology team members. Advanced workshops are
conducted once in 3 months for senior clinical nurses to upgrade their knowledge
and skills. CPR training is given to all the staff periodically by the respective nurse
educator. Every clinical area has a reading room with relevant study materials.
DISTRACTION PROGRAMME
An organization called Tender loving care for kids (tlc for kids.com)
recommends and supports the ‘Distraction Programme’, in the pediatric oncology
unit. The treatment room has distraction boxes which contain attractive play items
that divert the child’s mind during the procedure. Every child is given a gift after
the planned procedure in appreciation of the child’s cooperation.
RING THE BELL
Children those who have successfully completed the treatment ring the bell kept in
the day care waiting area. They write their comments with signature in the memory
making diary which gives a moment of hope to the other children and their
families currently on treatment.
PALLIATIVE CARE TEAM
Palliative care team plans and organizes the care for children referred under them.
They provide care to children admitted in the ward as well as make home visits
along with the community health nurse working for that area. The family is given a
home care kit with necessary medical supplies to continue the care at home. This
kit includes a syringe pump to administer necessary medication as continuous
infusion through subcutaneous line. This assistance helps family members in
adequate symptom management such as pain, nausea and vomiting. The parents
and siblings are given adequate counseling and support. Palliative care guide is
available for parents as well as for health professionals.
EDUCATION MATERIAL FOR FAMILY AND CHILD:
Every family is given a “Going home book’, to help them to learn about cancer
and home care.
A magnet sticker with information about danger signs and contact numbers in case
of emergency is given to the family at the time of discharge.
Organizations such as Leukemia Foundation, Children Oncology Group(COG)
has made lot of attractive teaching materials with the interest to equip the child and
parents with adequate knowledge to enable them to cope through the treatment
process.
SCHOOL VISITS:
The Liaison nurses make school visits to meet the teachers and the classmates of
children who are on chemotherapy or just completed treatment and rejoined the
school. The Liaison nurse educates the teacher and children in simple terms to
ensure the safety of the children when they are attending the school.
RCH SCHOOL:
According to the policy of the state of Queensland, RCH has a higher secondary
school to continue the education for the hospitalized stable children as well as their
siblings. The teachers are very friendly with the students and teach in a play way as
well as use variety of AV aids.
CLINICAL TRIALS
In collaboration with the Children Oncology Group (COG) based in United States
currently more than 44 clinical trials are going on in RCH. The aim of these
clinical trials is to improve the cancer treatment and the survival rate of children
with cancer in the future. All the team members play a vital role in conducting the
clinical trials.
RCH TUMOUR BANK:
The tumor bank collects and stores leukemia samples and solid tumor specimens.
These samples are given free of cost to the multiple research centers in the world to
carry out the clinical trials to ensure disease specific treatment for cancer in the
future.
7. PLANS TO IMPLEMENT OBJECTIVES ON RETURN TO CMC
� To share the new ideas obtained from RCH with colleagues during the in
service education programme.
� To encourage the unit staff nurses to read the pediatric oncology related text
books given by the friends from RCH and to conduct periodic in service
education programmes.
� To apply the innovative ideas to modify our patient care area as child
friendly to some extent possible.
� To formulate policies, procedures and protocols related to chemotherapy
handling (preparation storage, administration, safe disposal and spill
management) in consultation with other team members.
� To write down the procedure for central venous access device (Peripheral
line, PICC line, Hickman line, and chemo port ) management
� To improve the skills of nurses related to CVAD care by providing them the
opportunity to practice on the manikin
� To enhance the existing educational and counseling programme for child
and family members (Training of the OT along with the chemo nurses to use
teaching materials)
� To assist in planning an ideal pediatric oncology unit for the future pediatric
specialty hospital
� To prepare orientation programme for new staff nurses joining the pediatric
oncology unit.
� To prepare a course for training of pediatric oncology nursing in line with
the hospital policies.
� To educate and train pediatric oncology unit nurses in all the above aspects.
CONCLUSION:
It was a wonderful opportunity for me to observe and learn the system of
functioning in the oncology unit at RCH. I was amazed to see the rich resources
such as manpower, patient care related materials, infrastructure and the financial
assistance rendered to the children with cancer. This experience was an eye opener
to learn about the cytotoxic safety measures. Though it is not possible to practice
all that I have observed I am sure that I will try my level best to apply some of the
ideas that I have learned to improve the quality of care to children in our hospital.
All the team members of the pediatric oncology unit at RCH were very caring and
friendly throughout my stay and sincerely supported me in achieving my learning
objectives. In the nursing show case conducted by nurses in RCH I was given an
opportunity to present about nursing experiences from India and also about the
heritage of CMC, Vellore. I was fortunate to have fellowship with Mr. Brain Lee,
senior member of friends of Vellore. I also had an opportunity to visit the
Queensland University of technology-school of nursing.
Menaka Raghuraman Date: 12.04.2014