NURSING PATIENT CARE POLICY & PROCEDURE
April 30, 2015
June 20, 2016
Nursing Manual (Red)
Policy #: 13.16P
Title: Basic Care – Inpatient Pediatrics
(Birth-18 years of age)
Basic Care – Pediatrics focuses on maximum promotion of patient comfort and
II. POLICY SECTIONS
A. Presence and Respect
B. Vital Signs
C. Growth Parameters
E. Activities of Daily Living
These practices are to be followed in the care of all pediatric inpatients. Additional
unit practices may accompany these. As always, care should be individualized and
based on patient needs and nursing judgment. This document does not attempt to
address all assessment practices (e.g., pain, skin, mental status, functional status) but
rather to define a basic level of care.
A. Presence and Respect
1. Introduction to the Patient and Family
a. Caregivers (Registered Nurses and Nursing Assistants) introduce
themselves (providing name and title) and explain their role to their
b. Patient and family are oriented to the role of the Primary Nurse, Associate
Nurse, Patient- and Family-Centered Care (PFCC) and the PFCC folder.
c. Patient and family are introduced to the expectations of the patient care
area (visitation, bedtime, security, ID bands, time of rounds, etc.).
d. Primary/Associate Nurse, Team Nurse, Nursing Assistant and MD names
are written on the dry erase board in the patient’s room.
e. Patients are initially addressed by their first name and approached on an
age and developmentally appropriate level. Patients are asked about their
name preference and their “All About Me” posters.
2. Presence of Staff
a. Each RN, during the shift, will implement “5 minutes at the bedside” with
each patient/family member. This will include:
i. Providing an overview of the day’s planned diagnostic tests, lab tests,
and procedures scheduled for that shift/day. This will also be updated
on the white board.
ii. Asking the patient/family what their goals are for the day and how to
best align the patient’s goals with the medical plan of care.
iii. Assessing and clarifying family level of participation in daily cares of
iv. Instructing the family how to contact the RN. Indicate when the
patient and family can expect to see RN next (i.e. “I will be back in 1
hour to check your IV”).
v. Listening, validating, and clarifying patient/family perceptions and
b. Patients are observed hourly, including before the end of each shift, to
assure safety and identify unmet needs.
c. Call lights should be answered within 30 seconds at the nurse’s station. A
caregiver contacts the patient and family, in their room, within 5 minutes
to arrange for care of needs.
d. Caregiver assignments are entered into the Nurse Call System by the end
of shift report.
e. There is a defined process whereby the patient’s needs continue to be
assessed during change of shift report.
f. In transitioning from nurse to nurse, during change of shift, face to face
introductions and safety checks (including line reconciliation) and hand-
off report are completed at the bedside. Staff ensures that patient/family’s
immediate needs are met before leaving the room.
g. A Primary Nurse must be identified within 24 hours of the patient’s
admission with entry into Health Link, on the assignment board, and on
the white board in patient’s room.
3. Presence of Family and Friends
a. Caregivers recognize that the family is the constant in a child’s life and
ensure that key family members remain central to the child’s care
throughout the hospitalization.
b. Parent/guardian may be present during treatments or procedures.
c. Visiting hours are unrestricted for parents/guardians/primary supports.
Refer to UWHC Hospital Administrative Policy 7.33, Guidelines for
Participation of Patients’ Primary Supports and Guidelines for Visitors.
d. Overnight guests will be accommodated in accordance with UWHC
Hospital Administrative Policy 7.33, Guidelines for Participation of
Patients’ Primary Supports and Guidelines for Visitors.
e. Recognize that the family cannot always be at the child’s bedside and may
call to check on their child. Therefore, a numeric code will be established
upon admission to preserve confidentiality of patient information. Parents
will be provided with this number, and will be told to provide it when
calling for information. It will be explained to the family that no
confidential information will be given over the phone without the numeric
code. Calls may be forwarded to the patient’s room if family is present.
4. Compassion and Respect
a. The patient and family are treated with respect and courtesy.
i. Respect differences in culture, values, lifestyles, coping skills and
health care practices. Refer to the U-Connect site on cultural
congruence for health care providers.
ii. Respect and protect patient and family confidentiality.
iii. Respect personal privacy. Knock prior to entering a patient’s room
and ensure that patients are always covered modestly when in public
places or when door to room is open.
B. Pediatric Early Warning Signs
Pediatric Early Warning Signs (PEWS) should be documented every 4 hours,
with a change in condition, and upon admission from the ED by ED RN, for
every AFCH General Care and IMC patient.
C. Vital Signs
Patient vital signs are assessed on admission, then every 4 hours, unless a
different schedule for vital signs is stated in the provider’s orders.
ξ EXCEPTION: Patients undergoing video EEG where an undisturbed
sleep pattern is preferred.
When choosing the method of measurement, the nursing staff will assess the
patient’s developmental level, level of cooperation, diagnosis, acuity and status
change. Post operative vital signs are every 1 hour x 2, every 2 hours x 2 and then
every 4 hours unless stated differently according to provider order.
a. Temperature may be measured by axillary, oral, temporal or rectal route,
based upon nursing assessment, admitting diagnosis and provider.
b. For patients admitted with a history of fever, a likely infectious disease,
or a clinical change in status and unable to have an oral temperature
measured, a rectal temperature is recommended except as identified in
c. In addition, except as identified below, rectal temperature is the
recommended method for temperature assessment for infants and toddlers
(up to three years) when axillary does not correlate, e.g.; skin temperature
is cool. Axillary temperature greater than 37 degrees C should trigger a
rectal temperature to correlate for that child.
ξ Hematology or oncology diagnosis
ξ Bowel, perineal, rectal surgery, or anal atresia
ξ Premature infants
d. Document route used.
2. Heart Rate
a. Heart rate is measured by apical auscultation for one full minute on
b. Subsequent heart rates:
i. Children less than 5 years of age: an apical auscultation is obtained by
counting one full minute.
ii. Children 5 years of age or older: a radial pulse or apical auscultation is
obtained. The radial pulse can be counted for 15 seconds and then
multiplied x 4 for heart rate. Nursing assessment or provider order
may designate auscultation as the only method due to patient need or
3. Respiratory Rate
a. Respiratory rate is measured by auscultation for one full minute on
b. Subsequent respiratory rates:
i. Children less than 5 years of age: respiratory rate and rhythm is
obtained by auscultation for one full minute.
ii. Children greater than or equal to 5 years of age, respiratory rate and
rhythm is auscultated or observed for one full minute. Nursing
assessment or provider order may designate auscultation as the only
method due to patient need or diagnosis.
4. Blood Pressure
Best Practice for Pediatrics is to obtain blood pressure in right upper
extremity unless contraindicated.
a. Blood pressure is measured manually or electronically using an
appropriate sized cuff.
b. Measuring the diameter of a child or adolescent’s upper right arm is the
gold standard for choosing the appropriate blood pressure cuff.
c. Measure the halfway mark between elbow and shoulder for cuff
d. The width of the bladder of the cuff should cover at least 40% of the arm
circumference at the midpoint of the upper arm.
e. The cuff bladder length should cover 80-100% of the circumference of the
f. The bladder of the cuff should not overlap itself around the arm.
g. Document the site that the blood pressure was taken and cuff size that was
h. Document child’s position and activity when taking blood pressure.
1. Pain is a common experience for children when hospitalized. Pain can be due
to pre-existing conditions, surgical/other procedures or interventions that
occur during the hospitalization.
2. If a procedure causes pain in an adult patient, it should be assumed it is
painful to a child, even if they are not able to report that pain. If pain can be
anticipated, it should be prevented, or interventions should be included to
reduce the pain experience.
3. Pain screening, assessment and reassessment requirements are detailed in
Policy 8.76, Pain Management.
a. Upon admission, each patient will be given (or confirm that they received
at a prior hospitalization) age appropriate comfort items.
b. Pain parameters and pain relief goals are assessed and documented with
the assistance of parents/caregivers as needed.
c. Use of age/developmentally appropriate, validated tools to assess pain is
required. Nurses and parents should collaborate to determine the most
appropriate pain scale for each patient. Once the scale is identified, it
should be used consistently unless the patient’s condition changes
resulting in a necessary change in the pain scale. Pain scales used at
AFCH include: NPASS, NIPS, FLACC-R, FPS-R, and NRS, mild-
d. Evidence shows pain is best controlled with a combination of
pharmacological and nonpharmacological therapies. Families often know
what therapies have or have not worked for their child in the past. Non-
pharmacological therapies may include comfort items brought from home,
techniques used at home, as well as techniques and devices with evidence
to show benefit available at AFCH. A combination of tools may provide
the best outcome. A list of currently available techniques is included in the
pediatric pain flow sheet. Documentation of use of all pharmacological
and non-pharmacological therapies is expected and available on the flow
sheet. Expected outcomes of therapies should be explained.
e. Regardless of the methods of pain control being used, unrelieved pain is
defined as not meeting the patient’s goals for 2 readings over a 4-hour
period. Multiple steps can be completed to rectify this situation.
i. Discuss pain goals with patient and family to ensure the goals
are realistic and achievable.
ii. Consult with service managing care if pain relief continues to
iii. Remind the primary team that pain consults (Acute Pain
Service of Inpatient Pain Consult Service) are available to help
support teams when pain is difficult to manage.
f. Policy 1.17, IV Patient Controlled Analgesia (PCA) includes all
requirements for the use of PCA therapy. PCA by Proxy is discouraged,
but can be used when appropriate.
g. Policy 8.92, Epidural and Intrathecal (Neuraxial) Analgesia includes all
requirements for the use of this therapy.
E. Growth Parameters
Patient’s growth parameters will be measured on admission and as needed per
nursing assessment/provider order.
a. Weight is measured in kilograms on admission and more frequently as
NOTE: Daily weights will be obtained on all cardiac, nephrology and
failure to thrive patients as well as those less than 2 years of age.
b. Electronic scale is used.
c. Patients less than 3 years of age may be weighed on infant scale.
d. Wheelchair scale is available for wheelchair-dependent patients (P5, P8
and Pediatric Specialty Clinics).
e. The amount of clothing that may be worn by the patient being weighed is
i. Less than 1 year of age: no diaper or clothing
ii. 1-2 years of age: dry diaper only
iii. Greater than 2 years of age: dry diaper (if applicable), no shoes or
a. Height/length is measured in centimeters on admission and weekly
thereafter, or as ordered by provider.
b. Length measurements (using the length board) will be plotted in the 0-36
months growth chart.
c. Standing height measurements will be taken using the stadiometer.
i. Remove items that interfere with accurate height/length measurement:
shoes, hats, head coverings, and hair ornaments.
3. Head Circumference
a. Head circumference is measured in centimeters on all patients less than 2
years of age on admission, and more frequently due to diagnosis
(intracranial pathology), length of stay (greater than 1 week) or provider
order. Head circumference should be obtained weekly on infants.
b. Tape measure is placed around the largest part of the head (the frontal-
occipital circumference), passing it over the forehead just above the
eyebrows and ears.
4. Abdominal girth
a. Abdominal girth is measured based on nursing judgment with NG
feedings or GI diagnosis and/or provider order. Frequency will depend
upon the order.
b. The measurement is taken in centimeters by encircling the abdomen over
the middle of the umbilicus.
AFCH caregivers are aware of Child Abduction Responses in accordance with
UWHC Hospital Administrative Policy 8.54, Code Pink Infant/Child Abduction
1. Patient Safety
a. All rooms will have suction set up. Additional equipment will be based
upon patient need or provider order.
b. Patients are assessed upon admission for potential risk and environmental
factors that could lead to injury.
c. The GRAF-PIF Fall Risk Assessment will be done upon admission, with
transfer to another unit (done by receiving unit), and daily for children
greater than 12 months of age. HFFY #6200, Preventing Falls While in the
Hospital - Pediatrics, will be given to the family when the patient is
identified as being at high risk for falls.
d. Initiate measures to promote individualized patient safety.
e. The patient’s identification band will only be located on the patient’s body
and must be there at all times according to UWHC Hospital
Administrative Policy 7.31, Patient Identification.
f. Least restrictive restraints are used in accordance with Nursing Patient
Care Policy 13.23AP, Application of Physical Restraint (Adult &
g. Side rails are used in accordance with Nursing Patient Care Policy
13.23AP, Application of Physical Restraint (Adult & Pediatric).
h. High-sided cribs are used for children whose activity level necessitates
additional safety measures to control activity.
i. Crib rails are maintained in the high position when the patient is
j. Parents will be instructed about the proper use of side rails upon
admission. Parents will also be instructed to keep crib rails at least ½ way
elevated when sitting next to their child’s crib.
k. Padded side and crib rails will be used for any child at risk for injury due
to activity, medical condition (such as seizures or combativeness) or
l. Beds/cribs will have brakes in locked position.
m. Cribs are recommended for children less than two years of age.
n. Electric beds will be plugged into wall sockets.
o. Ambulatory patients will have their feet appropriately covered with non-
skid footwear when out of bed.
p. Children will be supervised at all times, when out of their room, by parent
q. Children will be accompanied by staff and family if appropriate to all
diagnostic procedures. Refer to Nursing Patient Care Policy 14.32, Escort
of Pediatric Inpatients to Tests and Procedures.
r. When patients leave the unit they must notify their RN or designee
identifying the time they are leaving, with whom, their destination, and
time of return. They must notify the RN or designee of their return.
s. Hand-off will be completed in accordance with Hospital Administrative
Policy 8.88, Hand-Off Communication and Hospital Administrative
Policy 7.36, Emergency Response Teams.
t. An emergency medication card (code card) will be at the foot of the bed of
all patients. The code card is available in the clinical record. To access,
click on the Patient Summary activity and search for the Pediatric Code
Card report. This report can be added to the tool bar with the wrench.
Enter the patient’s dosing weight.
u. Upon discharge, verify who the patient is being discharged to and compare
with the approved list obtained upon admission. Verification must be
documented in the clinical record. All patients will then be escorted out of
the building by RN or designee (NA, or volunteer) in accordance with
Nursing Patient Care Policy 14.12AP, Discharge of the Inpatient (Adult &
v. Cardiac monitoring is conducted in accordance with Nursing Patient Care
Policy 1.31, Caring for Adult and Pediatric Patients Requiring Cardiac
2. Patient Room and Equipment
a. Patients and families are oriented to room environment, including use of
bed or crib, bed exit alarm system, nurse call system, TV, phone,
bathroom and Guide for Patient and Visitors binder. In addition, the food
service system will be reviewed.
b. Patient room is kept clean and organized.
i. All dirty linens are in bags in the nurse server.
ii. Dirty equipment is taken to Soiled Utility Room
iii. Patient bathroom is kept clean, with all body fluids disposed of
c. Label and ensure safety of patient personal equipment, such as glasses and
d. Patients with tracheostomies have a spare correct-sized tracheostomy tube,
one size smaller than the current tracheostomy, scissor, appropriately
marked suction catheter, and resuscitation bag with tracheostomy adaptor
at the bedside. Children with tracheostomies are placed on a
cardiorespiratory or cardiac monitor with respiratory alarms engaged when
e. When in use, monitor alarms are set with appropriate limit parameters as
defined by provider notification parameter orders and connected to an
external alarm except when the caregiver is working directly with the
patient. Alarm settings are verified at the beginning of each shift.
f. No personal electrical equipment will be used unless approved by Plant
Engineering or authorized personnel.
g. All ventilators will be plugged into red emergency outlets according to
UWHC Hospital Administrative Policy 8.14, Guidelines for
Administration of Continuous Invasive and Non-Invasive Respiratory
h. Personal protective equipment and resuscitation bag/mask are kept in
3. Medication Administration
a. All medications must be scanned, followed by scanning of the patient’s ID
band, prior to administration.
ξ EXCEPTION: Areas that do not have scanning capabilities (i.e., OR
and PACU) and during Health Link downtime. Refer to Policy 6.37
Inpatient Health Link Downtime and Recovery.
b. High alert medications are administered in accordance with UWHC
Hospital Administrative Policy 8.33, High Alert Medication
c. Any catheters exiting the body (e.g., G-tube, J-tube, central line, epidural)
are labeled and identified.
d. Patients will be monitored for the first 5 minutes after the initiation of a
PCA and with every syringe change to ensure correct delivery.
4. Intravenous Catheters
a. For insertion, use, maintenance, replacement and discontinuation of
intravascular catheters, please refer to the following Policies and
ξ Nursing Patient Care Policy 1.23, Continuous Peripheral
Intravenous Therapy (Adult and Pediatric)
ξ Nursing Patient Care Policy 7.11P, Care of the Intubated
Patient (Pediatric and Neonatal)
ξ Nursing and Patient Care Policy 1.56 AP, Central
Vascular Access Device Use, Maintenance and Removal
(Adult & Pediatric).
b. All infusing peripheral intravenous (PIV) sites are to be assessed and
documented hourly. PIVs should be dressed in such a way to allow
maximum visualization of the site.
c. Port sites are visualized hourly when vesicants are infusing. When non-
vesicants are infusing, check site every 8 hours and PRN for pain,
d. All pediatric patients receiving infusions are to be managed using an IV
G. Activities of Daily Living
1. Activity and Play
a. Continuance of home schedule and routines is encouraged whenever
b. Care for the patient will incorporate both the patient’s chronological age
and developmental level.
i. Provide developmentally appropriate information that allows the
patient and family to understand and participate in the plan of care.
ii. Provide the patient with play activities that support growth and
development. Facilitate the involvement of the Child Life program
and the Hospital School, as appropriate.
iii. Respond to the patient’s emotional needs for warmth, physical contact,
comfort, and social playtime.
c. Toy safety is assessed for appropriateness, based upon the patient’s age
and developmental level.
d. Dirty toys are taken to the playroom and placed in the appropriate bin for
proper cleaning in accordance with Hospital Administrative Policy 13.19,
Toy Cleaning Procedure.
e. School is available and encouraged for school-age children. Refer to
Hospital Administrative Policy 7.46, Hospital School for the School Age
f. Parent agreement for isolation is used. Parents who opt out of isolation
procedures while visiting are not to use the unit kitchens, playrooms, or
g. Child Life is available for play, assistance in patient coping and procedural
2. Intake and Output
a. Age-appropriate diet is provided.
i. NO BOTTLE PROPPING (infants and toddlers) is allowed: Infants
will be held during bottle feedings by staff or a family member.
ii. Anticipate choking hazards with food (infants and toddlers).
b. Patient intake and output (I&O) is totaled and documented a minimum of
every 8 hours unless ordered or directed to be done more frequently.
i. EXCEPTION: I&O is documented every 2 hours and totaled every 8
hours for all infants.
ii. EXCEPTION: Patients receiving chemotherapy are totaled every 4
iii. EXCEPTION: The output of all chest tubes is totaled and
documented every 4 hours.
c. For breast milk, see Nursing Patient Care Policy 8.28P, Human Milk
Collection and Storage
a. A complete or partial bath is provided and documented daily unless there
is a medical reason prohibiting it.
b. Hand hygiene is performed with the patient before meals and after
c. Patients with diapers are checked every 2-4 hours while awake and every
4 hours at night. The perineal area is cleansed with each diaper change.
d. Toileting reminder/assistance is offered for those with impaired abilities
(e.g., head injury) or when developmentally appropriate.
e. Perineal care is provided for patients incapable of cleaning themselves and
after incontinent episodes.
f. Hair care is offered and documented daily. Shampoo is done as needed.
g. Oral care (brush teeth or swab) is offered and documented twice a day or
more frequently as directed or warranted by patient condition. For the
ventilated patient refer to Nursing Patient Care Policy 7.11P, Care of the
Intubated Patient (Pediatric & Neonatal).
h. Linens are changed every 72 hours or more frequently as needed.
ξ EXCEPTION: Linens are changed daily for all Hematopoietic Stem
Cell Transplant patients.
4. Sleep and Rest
a. Patient cares are organized to provide periods of optimal rest.
i. Infants are put to sleep on their back. The American Academy of
Pediatrics recommendations for safe sleep are followed until infants
are able to roll over independently.
ii. Morning and/or afternoon naps are planned and provided for all
patients, as needed.
b. Bedtime structure is encouraged for all patients. Determination of
bedtime will be made in collaboration with family. Stress importance of
keeping home bedtime routine and that children require more sleep during
times of illness. Quiet use of TV, phone, or video games, after 10 pm, is
based upon nursing and family discretion.
Scales used at the bedside for patient assessment:
Children’s Hospital of WI Sedation Scale (Pediatrics 2002; 109: 236-243)
6 = Unresponsive (GA)
5 = Arouses, but not to consciousness with painful stimulus
4 = Arouses slowly to consciousness with sustained painful stimulus (deep sedation)
3 = Arouses to consciousness with moderate stimulation
2 = Drowsy, arouses easily to consciousness with verbal stimulation
1 = Spontaneously awake without stimulus
0 = Anxious, agitated
V. UWHC CROSS REFERENCES
A. Health Facts For You (HFFY) 6200, Preventing Falls While in the Hospital –
B. Hospital Administrative Policy 6.37, Inpatient Health Link Downtime and
C. Hospital Administrative Policy 7.31, Patient Identification
D. Hospital Administrative Policy 7.33, Guidelines for Participation of Patients’
Primary Supports and Guidelines for Visitors
E. Hospital Administrative Policy 7.36, Emergency Response Teams
F. Hospital Administrative Policy 7.46, Hospital School for the School Age Patient
G. Hospital Administrative Policy 8.14, Guidelines for Administration of Continuous
Invasive and Non-Invasive Respiratory Support
H. Hospital Administrative Policy 8.33, High Alert Medication Administration
I. Hospital Administrative Policy 8.54, Code Pink Infant/Child Abduction Policy
J. Hospital Administrative Policy 8.76, Pain Management
K. Hospital Administrative Policy 8.88, Hand-Off Communication
L. Nursing Patient Care Policy 8.92, Epidural and Intrathecal (Neuraxial) Analgesia
M. Hospital Administrative Policy 13.19, Toy Cleaning Procedure
N. Nursing Patient Care Policy 1.17AP, IV Patient Controlled Analgesia (PCA)
O. Nursing Patient Care Policy 1.23 AP, Continuous Peripheral Intravenous Therapy
(Adult & Pediatric)
P. Nursing Patient Care Policy 1.31AP, Caring for Adult & Pediatric Patients
Requiring Cardiac Monitoring
Q. Nursing and Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric).
R. Nursing Patient Care Policy 7.11P, Care of the Intubated Patient (Pediatric and
S. Nursing Patient Care Policy 8.28P, Human Milk Collection and Storage
T. Nursing Patient Care Policy 13.23AP, Application of Physical Restraint (Adult &
U. Nursing Patient Care Policy 14.12AP, Discharge of the Inpatient (Adult &
V. Nursing Patient Care Policy 14.32P, Escort of Pediatric Inpatients to Tests and
A. Curley, M., Moloney-Harmon, P. (2001). Critical Care Nursing of Infants and
Children (2nd Ed.). W.B. Saunders, Co.
B. National High Blood Pressure Education Program Working Group on High Blood
Pressure in Children and Adolescents (2004). The fourth report on the diagnosis,
evaluation and treatment of high blood pressure in children and adolescents.
C. Task Force on Sudden Infant Death Syndrome (2011). SIDS and Other Sleep-
Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping
Environment. Pediatrics, 128(5), 1030-1039. doi; 10.1542/peds.2011-2284
D. Wong, D., Wilson, D., (Eds) . (2014). Nursing Care of Infants and Children (10th
Ed.). Mosby, Inc.
E. Foote, JM, Kirouac, N., & Lipman, TH. (2015). PENS position statement on
linear growth of children. Journal of Pediatric Nursing. 30(2), 425-426.
VII. REVIEWED BY
Clinical Nurse Specialist, General Pediatrics
Clinical Nurse Specialist, Universal Care Unit
Clinical Nurse Specialist- Hematology/Oncology, Neurology, ENT, Plastics
Clinical Nurse Specialist- Pediatric Pain
Nurse Manager, Hematology/Oncology, Neurology, ENT, Plastics
Director, Pediatric Nursing
Nursing Patient Care Policy and Procedure Committee, April, 2015
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer