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Spring 2010 1

A.C.E.S. AAAAdvanced

CCCClinical

EEEEducation with

SSSSimulation

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Spring 2010 2

ACES Policy and Procedure Review and Sessions

Week 1— Admission/Assessment/Codes Complete the worksheets for the a.m. session using the key points and/or handouts listed below

1. Admitting a Patient—Key points

2. Use of Free Float- Key Points

3. Nursing Assessment & Reassessment-Key Points

4. Patient Care Plans/Focus Problem Lists-Key Points

5. D.A.R. Charting Resource—Handout

6. Discharge of Patient from the Hospital Against Medical Advice (Form)

7. Rapid Response Team Protocol (RRT)-Key Points

8. Initiating a CODE BLUE-Key Points

9. Crash Cart Contents—Handout

10. AMBER ALERT-Key Points

11. CODE RED– Fire Policy-Key Points

12. CODE GRAY—Physical Assistance-Key Points

13. (Draft) Post Mortem Care-Key Points

14. Organ and Tissue Donation—policy

15. POLST FORM (Form)

16. Coroners Case—policy

A.M. Session - See Matrix

Teams will present on completed worksheets:

1-Emergency Codes

2-Code Cart and Code Team

3-Fire Evacuation Carries/Demonstration

4-AMA/AMBER Alert

5-Post-Mortem Organ Donation/Coroner Case

P.M. Session—Clinical simulation scenarios—rotations assigned day of class

Anaphylaxis Scenario

CHF Scenario

RRT Scenario

Quiz

Evaluation

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Spring 2010 3

WEEK 1

SKILLS STATION MATRIX AND SIMULATION MATRIX

Time All Groups Together

0800-0830 Welcome/Intro/Expectations

0830-0915 Pretest

0915-0930 Break

0930-1000 Team Assignments/ DAR Charting Worksheet

TEAM Presentations

Group

1

1000-1030

Group

2

1030-1100

Group

3

1100-1130

Group

4

1130-1200

Group

5

1245-1315

Emergency

Codes (2)

Code Cart/

Code Team

Evacuation-

Carries (5)

AMA/

AMBER Alert

Organ Donation/

Coroner Case

1200-1245 Lunch on your own

1315-1345 Group Review—Kronos / Fire Drill

1345-1430 Group 1 Group 2 Group 3

1430-1515 Group 2 Group 3 Group 1

1515-1600 Group 3 Group 1 Group2

Anaphylaxis CHF RRT

1600 –1620 Quiz

1620 –1630 Evaluations

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Spring 2010 4

Policy Title: Admitting a Patient

For complete policy, go to Policies and Procedures (Admission & Discharge) on Memorial’s Intranet

Purpose: To provide guidelines for admitting a patient

Key Points:

• All patients admitted to YVMH must have doctors orders for care

• If direct admit, the patient will be escorted to the floor by a Registration Service Represen-

tative.

• The nursing staff (nurse techs/RN) assists patient with changing into gown, weighs patient,

obtains current vital signs and assists patient with getting into bed. Patient is oriented to

use of bed, call lights, phone, bathroom, and visiting hours and visitation policy.

• An admission assessment is performed by the RN/LPNII (JCAHO requires an RN focused

assessment), who notifies the Physician as appropriate.

• The nurse must assess the patient within the first half hour after their arrival on the unit

for the chief complaint/focus problem and document as soon as possible.

• The Nursing Admission Assessment should be completed as soon as possible and docu-

mented completely within eight hours of admission.

• Documentation on the Home Medication Reconciliation Record will begin on admit and be

completed in Soarian within 24 hours– the unit Pharmacist may assist in completion.

• Do not provide water to a patient until there is a specific diet order

** Additional info: Patient may be admitted for:

Short Stay = patient here for less than 24 hours—time begins at end of procedure.

Observation = patient may remain for up to 48 hours—time begins when patient arrives to

unit/floor (or from end of anesthesia + 6 hours)

ACES

Policy and Procedure Review

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Spring 2010 5

Free Float Responsibilities 2/2010

The Free Float's main responsibilities include assisting nurses when they are having difficulty completing their as-

signments in a timely manner. This may include items from the following list:

1. Respond to Rapid Responses/Code Blue (cover patients for the nurse involved in the code)

2. Assist with in-patient transfers

3. Pass medications

4. Assist with blood transfusions

5. Assist with RN skills: ex. dressing changes, catheter insertions

6. Double check insulin and heparin

7. Pick up a group of patients without notification (i.e. sick nurse)

8. Transport patients to CT/Radiology if requiring a nurse to monitor.

9. Assist with patient care and transfers

10. Call physicians for orders, clarification

11. Assist in consolidating patients to make room for surgeries and admits

12. Check in surgery patients returning to floor from PACU

13. Assist in Day Surgery to prepare patients for surgery

14. Assist physicians with procedures (i.e. chest tube insertion, biopsy, paracentesis, thoracentesis,

etc.)

15. Assist in ED as second pair of hands

16. Able to assist with all RN responsibilities when needed by floor staff

17. Assess, pass meds, and complete DAR note on one(1) patient from each nurse on days when staff-

ing is below Matrix

18. Admissions (history and physical assessments)

19. Discharges

20. Sign off orders

Free Floats are limited: 1 per shift to cover hospital wide, and can be reached by Vocera

Free Floats communicate DIRECTLY with the Primary Nurse prior to and following care of a patient.

Assessments and charting:

The Primary RN completes: the Head to Toe chapter, Fall Risk chapter, and Braden Scale chapter. It

remains the responsibility of the Primary RN to complete the admit on their patient.

The Free Float can complete: the admission chapter, patient factor chapter, patient history chapter,

and the medication chapter. Time permitting the free float may fill in the Kardex and/or print off the

medication reconciliation sheet for the chart.

The Free Float can complete an admission for an LPN II, (including assisting with Kardex, medication

reconciliation, and completing a DAR note) if the Shift Coordinator or RN supervising the LPN II is un-

able to complete.

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Spring 2010 6

Policy: Nursing Assessment and Reassessment

For the complete policy, go to Policies and Procedures –General Nursing, on Memorial’s Intranet

Purpose: To provide guidelines for assessment standards for patients at YVMH

Key Points:

• On Admit: Nursing Admission Assessment is performed by admitting nurse upon admis-

sion and must be documented as early in shift as possible or within (8) eight hours.

This also includes:

Patient History/ Fall Risk/Braden Scale

On Pediatric unit - include Growth and Development

Medication Reconciliation Form is completed within 24 hours

• The admission assessment evaluates physical, psychosocial, environmental, self-care, edu-

cational, spiritual, pain (including pain score/goal), cultural and discharge needs. This as-

sessment helps prioritize which interdisciplinary health care team members will assist

with the patient’s needs (i.e. referrals that may be needed).

• Each Shift:

1) Nurses complete and document a Head-Toe-Assessment (i.e. Shift Assessment)

which reviews all systems, including Braden Scale (Fall Risk)

2) Complete a DAR note ( D=Data, A=Action, R=Response) in Clinical Notes on each

problem that deviates from the patient’s normal state or baseline. The DAR should

paint a picture of the patient’s condition and should address the focus problems.

3) Review and update the focus problems on patient’s KARDEX (pain, falls, skin,

diagnosis, etc.). Documentation of Focus problems on the Kardex should include:

Date initated

Priority

Signature

Date resolved

• Reassessments are driven by the focus problem list and any changes inpatient condition

• Please see policy for unit specific assessment and reassessment requirements.

• Vital signs are obtained per unit protocol and based on patient’s condition.

ACES

Policy and Procedure Review

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Spring 2010 7

Policy: Patient Care Plans/Focus Problem Lists

For the complete policy, go to Policies and Procedures on Memorial’s Intranet

Purpose: To show the purpose of the Patient Care Plans/Focus Problem Lists and

inform nurses of their responsibility to complete them.

Key Points:

• Care Plans/Focus Problem lists are based on the nursing process. It is the responsibility of

the nurse to document these on the Kardex.

• Care Plans/Focus Problem lists are individualized for each patient’s needs and communi-

cates the patient’s needs to all healthcare team members.

• Care Plans/Focus Problems are assessed and documented on admission and at least every

8 hours.

• Any unresolved focus problems at time of discharge require patient education, ie. wound

care, use of pain meds, potential for falls, and/or need for referrals.

• The Kardex, along with the Care Plans/Focus Problem lists are part of the patient’s perma-

nent record.

ACES

Policy and Procedure Review

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Spring 2010 8

Policy: Multidisciplinary Documentation of Patient Care - Focus Problem Charting

For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet

Purpose: To outline the standards expected for proper patient documentation.

Key Points:

• The patient’s record is private and confidential. Only Health Care Providers directly in-

volved in care will have access. Because of this, providers must sign off computer termi-

nals anytime they leave the terminal site

• All patients must have at least one problem documented on the Focus Problem List on ad-

mission. The admitting RN/LPNII initiates the focus problem list based on the Admit As-

sessment and patient care guidelines. As subsequent assessments are done by care team

members (i.e. Nursing, CRM, PT, RT etc.) the focus problem list will be added to, updated,

reassessed and reprioritized.

• Change of shift report is given from the Focus Problem List

• All Focus Problems must be addressed each shift both on the Kardex and as a Clinical Fo-

cus Note/DAR Note (using the Data, Action, Response format for charting).

• Vital signs and pain assessments/reassessments are obtained and documented per unit

policy into the patient’s chart. I& O is entered into the computer charting at 0600, 1400,

and 2200.

• Allergies are documented on admission and updated /corrected as additional information

is obtained.

• Physician Orders should be reviewed by the Primary RN throughout the shift and evalu-

ated to ensure correct processing comparing MAK, Soarian and the Kardex.

• 24 hour Chart Checks:

- An additional chart check is performed by the night shift RN, who reviews the last 24

hours of physician orders to ensure correct processing.

- The 24 hours chart check should not be completed by the same RN who signed off the

order originally. Another RN should review.

- Following review and correction of the orders, the nurse will draw a green line across

the order sheet and sign after the last order, including date and time. Document ‘24

hour chart check’ has been completed.

Continued following page -

ACES

Policy and Procedure Review

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Spring 2010 9

Late Entries:

Additional documentation may be added to Soarian for the first 24 hours post discharge.

After 24 hours post discharge, any late entry may be made on the Progress Note and given to Health

Information Management (Medical Records dept.) to be scanned into the electronic Medical Record.

Late entry note must include:

1. Documenting “Late Entry “ at the beginning of note.

2. Date and time of actual note entry.

3. Date and time of event/occurrence being charted on.

4. Patient name and encounter number (eight digit account number).

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Spring 2010 10

DAR is a form of focus charting and the DAR stands for Data-Action-Response. DAR documen-

tation is based upon the nursing process. Routine nursing tasks and assessment data is docu-

mented on flow sheets and check-lists.

Your focus is a nursing diagnosis, or in place of a nursing diagnosis you can use

a problem, sign or symptom (nausea, pain, etc), behavior, special need, an

acute change in the patient's condition or a significant event. Your progress

note is written in the DAR form.

D (Data) - includes subjective and objective information that describes the fo-

cus problem or describes observations at the time of significant events.

A (Action) - includes immediate and future nursing interventions performed,

and/or protocols and procedures initiated, based on your assessment of the

patient's condition and any changes to the care plan you deem necessary based

on your evaluation.

R (Response) - describe the patient's response to nursing or medical care. The

response is a statement that the Action Plan of Care outcomes have been at-

tained or are progressing toward attainment.

Here are examples of DAR charting related to a focus problem:

Focus: Risk for infection related to surgical incision sites

D (data): Incision site in front of left ear extending down and around the ear

and into neck--approximately 6 inches in length--without dressing. Site without

redness or swelling, bluish discoloration below left ear. Jackson-Pratt drain in

left neck below ear secured in place with suture. J-P drain half full.

A (action): J-P emptied (40 ml serosanguinous fluid). Instructed patient on S&S

of infection (redness, swelling, pain, green/foul drainage).

R (response): J-P drain suction reestablished. Patient states understands signs

and sx of infection.

Focus: Delayed surgical recovery

D (data): Patient reported dizziness after trying to get OOB to use the bath-

room.

A (action): Assisted patient back in bed and placed on bedpan. Reviewed use of

call light and to call for assistance to get up. Taught patient how to dangle legs

and get OOB slowly. Also taught coughing and deep breathing exercises, turning

in bed, and use of antiembolism stockings.

R (response): Patient voided 200ml in bedpan. Coughing and deep breathing

appropriately. Lungs clear bilaterally. Antiembolism hose in place.

D. A. R.

Charting

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Spring 2010 11

Focus: Acute pain related to surgical incision

D (data): Patient reports pain at surgical incision as 7/10 on 0 to 10 scale.

A (action): Incision assessed. Sutures intact, no redness swelling or drainage

noted. Morphine 2mg IV given at 2335 per post op orders.

R: (response) Patient reports pain as 3/10 at 2400. Pt. resting with eyes closed.

from page 678 of Portable RN: The All-in-One Nursing Reference, third edition, published by

Lippincott, Williams & Wilkins, 2007

Examples of DAR notes related to patient condition or significant event:

D (data): Patient reports vagin*l bleeding started yesterday and passing clots. –Four maxi

pads saturated with dark red drainage and 8 quarter clots in 60 minutes. BP 102/68, P 108, R

24, T 34.1C, SpO2 98%RA

A (action): Status reported to Dr. Miller. IV started with 18g. angiocath, 1000 ml of 0.9% Nor-

mal Saline hung @ 200 ml/hr per orders. Continue to monitor bleeding and pad count and

vital signs. Dr. Miller will see the patient in one hour.

R (response): Patient understands rationale for IV fluids and continuous monitoring. BP

120/72, P 88, R. 20, T. 34, SpO2 99% RA.

D (data): Bladder distended 2 fingers above pubis. Patient has not urinated since foley cathe-

ter removed @ 1800. Patients reports abdominal discomfort above pubis 8/10 when pal-

pated.

A (action): Patient assisted to toilet but remains unable to void. Dr. Johnson notified and or-

ders received. # 14 straight catheter inserted without difficulty per orders.

R (response): Drained 700 mL of clear yellow urine per straight cath. No distention noted

above pubis. Patient reports no bladder discomfort when palpated.

D (data): Patient's temperature at 1305 was 101.5 (oral). B/P 120/80, P-88, R-20. Patient in no

acute distress.

A (action): Dr Smith contacted and orders received: blood cultures X 2, CBC and portable

chest X-ray. After blood cultures drawn, patient given Tylenol 500 mg p.o.at 1400.

R (response): 1500 patient's temperature was 99.8 (oral). Awaiting lab and X-ray results . Will

continue to monitor .

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Spring 2010 12

A patient has had cholecystectomy this morning and is now admitted to your floor for pain

control:

D (data): Pt is sitting at edge of bed grimacing, c/o pain in mid-abdominal region and right up-

per quadrant. Pt is crying, describes pain as “sharp” and rates pain as 9/10 on the 0-10 pain

scale. Pt relates “I need something for pain now.” Pt denies nausea but complains of feeling

“bloated and full of gas.” Incision evaluation: wound edges red with dime sized serosangi-

nous drainage noted. Hypoactive bowel sounds all 4 quadrants. V/S: Bp-145/93, HR-102, R-

14, T-98.7

A (action): Pt given medication for pain: Demerol 75 mg IM left ventral gluteal muscle. Pt re-

positioned on right side with pillows to help splint wound. Encouraged to take slow deep

breaths to relax and move legs to help move gas.

R (response): Rechecked patient at 30 minutes. Pt states pain is “much better” and rates pain

at level 3/10 on 0-10 pain scale. Pt resting with eyes closed. Call light within reach. Pt in-

structed to call for assistance if she needs to get up to bathroom (commode). Will continue to

monitor for changes.

So:

The Data portion is what is going on...(and sometimes what is not going on, to show that you

are checking the whole patient).

Action: What you did about it.

Response: What was the response of your action?

If the situation warrants add— "will monitor or continue to monitor" to show that you intend

to stay on top of the situation.

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Spring 2010 13

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Spring 2010 14

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Spring 2010 15

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Spring 2010 16

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Spring 2010 17

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Spring 2010 18

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Spring 2010 19

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Spring 2010 20

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Spring 2010 21

Policy: Rapid Response Team (RRT) Protocol

For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet

Purpose: Provide guidelines for calling RRT and the protocol to implement when an RRT is

activated.

Key Points:

The RRT is called when a patient begins to deteriorate and the nursing staff feels they need assistance by resource staff to evaluate and stabilize the patient or reverse a de-teriorating condition. It is important for nurses to recognize the s/s of a deteriorating patient which may include:

• Staff concern or worry

• HR <40 or >130

• SBP <90

• O2 sat <90%

• O2 sat declining with supplemental O2 • Increased work of breathing • Change in LOC / mental status (including agitation & restlessness) • Urine output to < 50 ml in past 4 hours • Physician request

• An RRT can be called when a patient’s primary nurse wants help in evaluating a patient by dialing 8123 and stating Rapid Response and Pt. Room #.

• Primary Nurse should stay with patient and give report to RRT team on arrival at patient bedside .Primary RN will be knowledgeable of the patient and have the chart at the bed-side including current labs, EKG, study reports, and H&P .

• Primary RN will notify the physician of the patient’s status, treatment, and response using the SBAR tool.

• The RRT is a multidisciplinary team (Critical Care Nurse, Resp.Therapy, Pharmacist, Nrsg

Supervisor, etc) that responds ASAP to assist the primary care nurse with patient evalua-

tion and treatment.

• Documentation following an RRT includes 2 forms: The Primary Nurse RRT Form, filled out by the patient’s primary nurse, and the RRT Team Form, filled out by the RRT Team members (found in Memorial Forms Catalog). Specific documentation is outlined in the policy.

ACES

Policy and Procedure Review

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Spring 2010 22

Documentation:

• Primary RN will document date, location, time called, time arrived, situation, code status, current VS (including O2 sat, supplemental O2, pain level) on the Rapid Response form.

• RRT nurse will complete the rest of the Rapid Response Form every time the RRT is activated, routing the completed sheet to the RRT PI leader and physician for review and forwarded to the Performance Improvement office where data will be abstracted .

• RT will document on a respiratory DAR sticker with interventions and chart on the respiratory flow sheet if applicable.

• Primary RN - An interdepartmental transfer form will be completed by the Pri-mary RN.

• Peer Review Tool will be given to persons involved in the response by the RRT. These will be completed and sent to the Performance Improvement Depart-ment

The RRT will accompany the primary RN to assess the patient. and:

A. Stabilize the patient’s airway and administer oxygen.

B. Place patient on heart monitor if not already in place.

C. Begin ACLS protocol if a symptomatic arrhythmia detected.

D. Establish IV access if one not in place. Consider placing second line and drawing blood for lab if possible

E. Follow RRT protocol regarding basic interventions (see below)

F. Transfer patient to ACU or CCU as indicated by patient’s condition.

RRT PROTOCOLS:

1. Arrhythmia

• Ensure IV access EKG

• Supplemental oxygen Treat according to ACLS guidelines

• Initiate Code Blue if appropriate

2. Hemodynamic Consider if post-op or potential for bleeding • Trendelenburg position (if no head injury) CBG CBC • Ensure IV access & Consider 2nd IV line EKG INR • Supplemental oxygen Aptt • Consider fluid bolus according to medical hx: 250ml-1000ml

3. Respiratory • RT to assess & treat per RT protocol CBG • Ensure IV access Consider ABG and/or PCXR • Supplemental oxygen Consider bipap • If on opiate analgesia: Stop continuous PCA & administer Narcan 0.4mg IVP x1

4. Neurological • Glasgow Coma Scale CBG • Ensure IV access Consider ABG • Supplemental oxygen

5. Urinary Output • Bladder scan • Foley catheter and/or Irrigate pre-existing Foley

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Spring 2010 23

6. Febrile • Tylenol 650mg PO or PR PRN fever >101F (38.3C)

7. Acute Seizures • CBG • Maintain airway • For adults only: Lorazepam (Ativan) 1mg IV x1 for clonic-tonic seizure activity

lasting longer than 2 minutes (if not allergic) ** Call Code Blue if seizure activity continues longer than 2 minutes after giving

Lorazepam **

8. Chest Pain

• Ensure IV access & Consider 2nd IV line

• Supplemental oxygen

• EKG

• Aspirin 325mg PO/PR x1 (if not contraindicated: allergy, surgery this admission, warfarin

• or aspirin ordered, or active bleeding)

• Nitroglycerin 1 spray or 0.4mg tablet SL PRN chest pain – may repeat every 5 mins x 2

• Consider Troponin and/or CPK

9. Anaphylaxis: - Ask physician about: • Diphenhydramine (Benadryl) 50mg IV x1 Epinephrine 0.3mg SQ x1 • Cimetidine (Tagamet) 300mg IV over 20mins x1 • Methylprednisolone (Solumedrol) 125mg IV x1

10. Hypoglycemia • If CBG less than 60 or symptomatic of hypoglycemia: • Able to take PO: 1. Give 1 tube of Instaglucose, ½ cup juice or regular pop 2. Re-

check CBG in 15 mins. • NPO w/ IV access: 1. Give ½ amp D50W IV & recheck CBG in 15 mins. • NPO w/o IV access: 1. Give Glucagon 1 mg IM & recheck CBG in 15 mins.

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Spring 2010 24

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Spring 2010 25

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Spring 2010 26

Policy: Initiating a Code Blue

For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet

Purpose: Provide guidelines to be followed for a Code Blue event

Key Points:

• The Code Blue is initiated when staff assesses the need for emergency interventions

(Airway, Breathing, Circulation) to save the life of a patient. There are 4 phases to a Code

Blue with each phase and team duties carefully outlined in the policy.

• 1- Initial Response: To call a Code Blue dial: 8123 (the priority emergency line in the hos-

pital) and tell the Operator “Code Blue, Room #____, or location.” Basic Life Support

(CPR) is begun by staff and continues until directed by the Code Team.

• 2- Unit Response: The first person available brings the Crash Cart and the patient records

to the room. Primary RN remains with pt. providing care (CPR), and history/report until

excused by Code Team. Other duties of Primary Nurse include: clears room of second pa-

tient as needed, checks O2/suction, notifies physician/family/clergy when released by

Code Team—Shift Coordinator/Nurse Supervisor can assist as needed.

• 3- Code Team Response: The Code Team consists of: a Team Leader (Critical Care Shift

Coordinator/or Physician Responder)- Nursing Supervisor/Chaplain (provide emotional

support and communication), Emergency Department RN (defibrillation/meds), Critical

Care Shift Coordinator (may be team leader/assigns scribe), IV Therapy nurse (IV insertion/

assist with medication administration), Medical Technician (lab draws/ISTAT) Respiratory

Therapist (airway/O2), Pharmacist (assist/or administer meds), Primary nurse (see above),

Security Guard (as directed by Team Leader), and Transport Tech (duties as directed by

Team Leader).

• 4- Post Code Activities: Code Blue Record (on top of code cart) is completed by the Criti-

cal Care Coordinator or assigned staff. Respiratory Care are notified to replace resuscitator

mask in patient room. Crash Cart is taken to the pharmacy for replacement by the Trans-

port Tech.

ACES

Policy and Procedure Review

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Spring 2010 27

ACTIVATION OF CODE BLUE AND RAPID RESPONSE DURING

SYSTEM FAILURE

EMERGENCY CELL PHONES AVAILABLE IN UNIT LOCK BOXES

Person identifying Code Blue or RRT identifies a person

to activate emergency cell phone tree, in the following order:

ED 952-68892-

Respiratory 952-08333-

Nursing supervisor 961-18864-

Coordinator ICU 969- 00535-

Pharmacy 952-9195

Lab 952-31117-

Security (If needed send runner to

operator to page them via 2 way radio)

Give the location of the event

Personal identifying

Code Blue or RRT

yell5”Code Blue, I

need help.” NAC or

Unit Secretary is

designated to be:

Runner #1

Runner #1...goes to

the ED to report the

location of the event.

EMERGENCY CELL PHONES NOT AVAILABLE

Runner #1...goes

to ICU to notify

coordinator of

event location.

Runner # 1..locates

the nursing

supervisor and they

both report to the

event.

ED shift coordinator designates

Runner #2 to notify the following

Staff in the order listed.

1. Pharmacy

2. Laboratory

Runner #2... returns to ED

The coordinator designates

Runner #3 then reports to the

event.

Runner #3...goes to the

operator to have them page

security via 2-way radio.

ALL TEAM MEMBERS PRESENT

The Nursing Supervisor makes the decision when runners # 1 and # 3 and Security are no longer

needed.

The RN calls the family and physician as soon as phone available.

Note: A copy of this policy is kept on all Code Blue carts and in the Disaster Manual.

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Spring 2010 28

What’s Inside the Crash Cart?

DRAWER CONTENTS

1

Pharmacy

Medications

Adenosine, Epinephrine

Amiodarone, Glucagon

Atropine Midazolam

Calcium Chloride Magnesium Sulfate

Dextrose Naloxone

Sodium Bicarbonate

Diphenahydramine Vasopressin

2

IV Equipment

500ml bag of NS, 5 saline flushes, 10ml &12ml syringes, IV

pump tubing, sterile towel & sterile gloves, assorted IV

catheters, tourniquet, blood tubes for lab draw, tegaderm

dressing, 2x2 gauze, povidone-iodine & chlorseptic swab-

sticks.

3

Nursing

Equipment

Yankhauer suction, Salem Sump NG tubes, tubing, NG con-

nector & strips, Suction catheter kits, Yellow face masks,

Yellow isolation gown, ECG pads, Defibrillation pads, Blood

pressure cuff, Stethoscope, water soluable lube, 60ml cathe-

ter-tip syringe (cone tip)

4

Respiratory

Infant, Pediatric & Adult Ambu bags, Towel roll, Adult non-

rebreather mask, Infant & Pediatric O2 masks, Oxygen tub-

ing/connectors, Oral airways in assorted sizes, Wrapped intu-

bation tray & blades for intubation

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Spring 2010 29

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Spring 2010 30

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Spring 2010 31

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Spring 2010 32

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Spring 2010 33

Policy: AMBER ALERT: For Missing Infant or Child

For complete policy, go to Policies and Procedures (Administrative) on Memorial’s Intranet

Purpose: To outline YVMH staff protocol in the event an infant or child is ab-

ducted from the hospital

Key Points:

• Amber Alert is announced to alert all hospital personnel that an infant/child is discovered

to be missing—this also requires an immediate coordinated hospital response with Yakima

Police Dept.

• Dial 8123– state “AMBER ALERT”, (Location/Room Number) and age of child if over one

year of age/ Operator notifies Nursing Supervisor and calls 911

• Each staff member and the Yakima Police Department response is outlined in the policy

• When a “AMBER ALERT” is called, it is the responsibility of all employees to stop and de-

tain, if possible, any individual with an infant/child, large bag, box / backpack or other large

object within the hospital, or attempting to leave the hospital.

• When detained, escort to Admitting Main Lobby to meet with Security.

• If unable to detain, then obtain and document a description of the individual(s) and vehi-

cle—and direction heading and notify Security, person in charge and /or YPD—911.

ACES

Policy and Procedure Review

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Spring 2010 34

Policy: Fire Policy

For complete policy, go to the Red Emergency/Disaster Binder in your Department

Purpose: To provide the safest care to both patients, visitors and staff in the

event of a fire within the hospital setting

Key Points:

• If you see smoke, smell something burning, or suspect there is a fire, follow the

R.A.C.E. plan: R- Remove, A - Alarm, C - Contain, E - Extinguish/Evacuate

• Call the hospital switchboard to report fire – Dial 8123

• Remain calm – Do not yell “Fire.” Alarms frighten patients, be sure to reassure patients/

persons in the immediate area and explain procedure for evacuation (or drill).

• In the event of a fire, there are two points of evacuations:

1) Point of Origin (those in the immediate vicinity of fire) -see algorithim

2) Away from the Point of Origin (those away from the vicinity of fire)-see algorithim

• In the event of an evacuation, complete a Transfer form for each patient and attach it to

the patient’s gown.

• Once room evacuated, close door and place pillow, upside down garbage can, or mark X on

door to indicate evacuation.

• Remember to account for patients/visitors and staff once evacuation of department com-

plete. Check in with Incident Command upon evacuation to report patient/visitor status.

• There are 3 types of extinguishers. Each extinguisher is labeled—use the appropriate ex-

tinguisher for the type of fire.

• If the fire can be extinguished, use the P.A.S.S. acronym:

P—Pull, A—Aim, S—Squeeze, S— Sweep

ACES

Policy and Procedure Review

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Spring 2010 35

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Spring 2010 36

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Spring 2010 37

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Spring 2010 38

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Spring 2010 39

Policy: CODE GRAY: Physical Assistance Needed

For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet

Purpose: To maintain control of a patient or visitor who becomes threatening to

others or themselves

Key Points: 4 phases to the policy

• 1- Initial Response: The calling of the “Code Gray”: Dial 8123 ( the priority emergency line

in the hospital) and telling the Operator “Code Gray, Room #___, or location.”

• All trained personnel shall respond immediately

• 2- Planning: Forming of strategy while other staff members arrive. Identify a “Person in

Charge”(primary communicator) and a “Traffic Control Person”(directs those arriving)

• 3- Crisis Management: Only one person actually talks to the individual. Statements are

direct, to the point, but not rude. Expectations and consequences are made clear. Physi-

cal interventions are executed quickly and without excess force.

• 4- Debrief: Immediately after event a concise ‘debrief’ should take place to see what was

effective or not and check –in with staff involved to be sure they are able to return to

work.

ACES

Policy and Procedure Review

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Spring 2010 40

Policy: Post-Mortem Care (DRAFT ) Page 1 of 2

For complete policy, go to Policies and Procedures (General Nursing) and (Emergency) on Memorial’s

Intranet

Purpose: Guidelines for notification of family/healthcare professionals after

death of a patient with steps for preparation and transport of a body.

Key Points:

Notify Nursing Supervisor (Vocera: state, “Nursing Supervisor”) who will notify or ask the

nurse to notify the following individuals:

• Call the attending physician (inquire if there is to be an Autopsy).

• Notify significant family member as designated in the patient record.

• Call the funeral home (family choice or funeral home on-call).

• Notifies the organ procurement agency of all deaths within one hour.

• Will notify Coroner when appropriate (see policy on Coroner cases).

• Information desk (during business hours) so they are removed from the inpatient list.

• Radiation oncologist if patient has radio active implant.

• All consulting physicians on the case at the earliest appropriate time.

The Nurse should provide the Nursing Supervisor with:

- Patient’s weight (Funeral Home needs this for transport of body).

- Whether patient was in a RESTRAINT anytime during the 24-hours preceding

death. This must be reported to the Department of Health.

If possible, determine if an autopsy is planned, prior to patient’s death. (Complete Form

#0264: Authorization for Autopsy) Original goes into chart, copy to Mortician or morgue and

copy to Pathologist. Notify Nursing Supervisor for assistance to transfer the body, unobtru-

sively to the hospital morgue if an autopsy is to be performed.

Note: It is preferable for the physician to discuss an autopsy with family and to secure the au-

thorization signatures. If the physician is not available, a registered nurse may witness the au-

thorization. The Nursing Supervisor will notify the Pathologist on weekends and holidays of a

pending autopsy.

ACES

Policy and Procedure Review

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Spring 2010 41

Policy: Post-Mortem Care (DRAFT) Page 2 of 2

Key Points (continued):

• Determine if the necessary legal paperwork is complete for tissue or organ donation.

(Form #0273: Consent for Organ and Tissue Donation and Form #0105: Organ Tissue

Donor Information to Funeral Home/Donor Inquiry).

• Determine if there are any cultural, religious, or ethnic beliefs that will influence the

postmortem care of the body

• Gently close the eye lids. Wash body parts soiled by blood, urine, feces, or other drain-

age. The mortician will provide a complete bath. Place an absorbent pad under the pa-

tient’s buttocks, clean gown on the patient, and brush or comb the patient’s hair. Place a

clean sheet over the body leaving the arms exposed at the side for family to touch if they

would like. Keep the patient's head elevated at all times with the hands placed naturally

at the sides or resting on the abdomen. Patient's dentures: should be placed in patient’s

mouth if preparing the body for the family—otherwise not required.

• Remove unneeded equipment from the room—exception = following Code/Trauma may

leave equipment for family to see that everything possible was done for patient.

• Offer to call hospital or other chaplain for family members.

• Do not remove indwelling catheters, IVs—may tie off, mortician /coroner will remove

• Keep patient identification band in place.

• Do not delay providing postmortem care and notifying the family so they may begin

funeral arrangements.

• A focus note is required to record event and specific observations (quality of pulse, respi-

ration, etc.) prior to patient’s death. Nursing documentation after death should include:

• Name of Physician notified

• Funeral home called and WHO requested it

• Detailed accounting of disposition of personal effects

• Record of support offered to family

• Enter Discharge by Death into the Soarian system.

• The Nursing Supervisor will notify the County Coroner of any death that meets criteria as

a Coroner’s Case.

ACES

Policy and Procedure Review

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Spring 2010 42

General Nursing Policy and Procedure Manual

Admission & Discharge

Organ and Tissue Procurement

PURPOSE:To identify individuals for organ and tissue donation.

POLICY:

1. In compliance with Washington State and Federal Laws, it is the policy of Yakima Valley

Memorial Hospital to honor voluntary consent for organs and tissues for transplantation

and to secure appropriate informed consent.

2. The Hospital recognizes the importance of allowing those who wish to have the maximum

opportunity to give, providing solace to the grieving family by giving life and happiness to

others at the time of tragedy. The principles of voluntary giving are upheld while allowing

autonomy to families of potential donors.

3. Yakima Valley Memorial Hospital recognizes LifeCenter Northwest, Northwest Tissue Cen-

ter, and Sight Life as the designated regional organ and tissue procurement agencies.

PROCEDURE:

1. The Nursing Supervisor will notify the procurement agency on all deaths or imminent

deaths to determine donor suitability.

• Non-ventilated patients: 1-888-266-4466

• Ventilated patients: 1-888-543-3287

• On all coroner cases, release for donation must be pursued prior to fam

ily approach. The donation agency will contact the coroner regarding

release for donation. The legal next-of-kin should then be provided with

the appropriate donation options. Individuals who may approach the

donor family must be trained by the Donation Agency. The staff will ex

ercise discretion and sensitivity of the circ*mstances, beliefs, and de

sires of the families of potential donors.

2. A determination is to be made regarding necessity of notifying the coroner if the cause

of death could result in a criminal action per hospital policy (if injury occurred outside of

Yakima County, coroner of county in which injury occurred must be notified as well as

Yakima County Coroner):

•Homicide l Unknown or doubtful causes

•Suicide l Drug related incident

•Trauma l Death within 24 hours of admission

•Accident (unless seen by MD within last 36 hours)

3. It is solely the responsibility of the donation agency to obtain release from the coroner

for donation. Hospital staff should contact the coroner per hospital policy in reference to

all cases that fall under that jurisdiction. However, all discussions with the coroner regard-

ing donation will be pursued by the donation agency.

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Spring 2010 43

4. These requests shall be documented on the Organ/Tissue Donor Information to the Fu-

neral Home/Donor Inquire Form. If a patient is not a designated donor, a consent form for

organ and tissue donation shall be signed by the legal next-of-kin. In the case of solid organ

donation, LifeCenter will be responsible for completing either a witnessed telephone con-

sent or a written consent with the family. This disclosure form along with a copy of the le-

gal document attached to it will be placed in the patient's chart. A signed donor card,

driver's license legal document or donor registry entry is a legal document of documenta-

tion of donation wishes may also be used as a legal document

1. LifeCenter Northwest Organ Procurement Agency; Ventilated patients; meeting imminent

death criteria.

2. A LifeCenter Northwest coordinator will facilitate the organ donation process in all phases.

The coordinator will travel to Yakima Valley Memorial Hospital to evaluate patient suitabil-

ity for donation.

3. Organ donation will be limited to all medically suitable patients (as determined by LifeCen-

ter) who have been declared brain dead in accordance with the "Declaration of Brain

Death Policy" approved by the Medical Staff, or who will probably suffer cardiac arrest

within 60 minutes after withdrawal of life support.

4. In the case of a brain dead donor, the time brain death is declared is the official time of

death.

5. In the case of tissue or cornea donation, all tissues to be donated are to be specified on

the consent form. The original signed consent is to be kept with the chart. In the case of

solid organ donation, LifeCenter Northwest will be responsible for completing either writ-

ten consent or a witnessed telephone consent with the family.

6. Washington State Law identifies the following persons (in descending order of priority) as

legal next-of-kin:

• Legal Guardian

• Durable power of attorney of health care

• Spouse

• Adult son or daughter 18 years or older

• Parent

• Adult brother or sister 18 years or older

• Any other person authorized to do so

7. The Nursing Supervisor and Spiritual Care is to be notified that donation is being consid-

ered so that emotional and spiritual support may be given.

ORGAN DONORS:

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Spring 2010 44

5. In the case of donation after cardiac death (DCD), the time of cardiac death will be the offi-

cial time of death. For withdrawal of life support in a DCD case, the hospital staff should

follow Yakima Valley Memorial's policy for "Withholding and Withdrawing Treatment."

LifeCenter staff members will not participate in the process of withdrawal of life support.

Determination of the location of withdrawal of life support is the responsibility of the hos-

pital and/or the donor family members. For pronouncement of death in a DCD case, it is

important to keep the warm ischemic time of the organs to a minimum. Therefore, a phy-

sician must be available at the bedside at the time of withdrawal of life support, in order to

pronounce the cardiac death as soon as cardiac death is evident.

6. Notify admitting department of time of brain death (all charges from that point on go to

the procurement agency). Notify admitting department to make a new face sheet, chip,

and ID bracelet, with new admission number.

7. The LifeCenter Northwest coordinator will remain on site to assist with the donor manage-

ment and the recovery of the organs for transplant.

8. For brain death donors, the hospital will provide (at minimum) the following staff to assist

with the donor case:

ICU

a.Bedside Nurse

b.Physicians

OR

a.Anesthesiologist (Anesthesia will not be needed in DCD cases)

Northwest Tissue Services & Sightlife Eye Bank - All deaths

Families that are unable to make a decision about cornea or tissue donation while on site

are encouraged to go home and discuss donation with additional family members, etc. Ex-

plain to them that a Donor Coordinator will contact them by phone later to further discuss

their options. If the family wished to donate, a witnessed telephone consent will be ob-

tained by the recovery agency. Get a phone number from the family where they can be

reached.

Organ and Tissues Procurement Agencies Phone Numbers:

LifeCenter Northwest Organ Procurement - (ventilated) 1-888-543-3287Northwest Tissue

Services and Sihtlife Eye Bank - (non-ventilated) 1-888-266-4466

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Spring 2010 45

Effective Date: 08/31/1982

Prepared by:

Approved by: Nursing Policy and Procedure Committee Date: 08/01/1982, 09/23/2008

Reviewd by: Nursing Policy and Procedure Committee Date: 09/19/2003, 08/22/2006, 09/23/2008

Revised by: Nursing Policy and Procedure Committee Date: 05/05/1988, 08/02/1993, 12/02/1994, 12/05/1997, 01/05/1998, 02/05/1999, 08/01/2000, 06/01/2005, 10/19/2007, 09/23/2008

Approved by: Nursing Policy & Procedure Committee Date: 06/01/2005, 10/19/2007, 09/23/2008

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Spring 2010 46

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Spring 2010 47

Emergency Department

Emergency

Coroner Cases

PURPOSE:

To notify the Yakima County Coroner of all suspected coroner cases.

POINTS OF EMPHASIS

All suspected coroner cases (see attached sheet) shall be reported to the Yakima County

Coroner at the time of death in the Emergency Department (ED). This can be done by the

Nursing Supervisor, ED Physician, or the Shift Coordinator in the ED.

1. Contact Coroner at his office, 575-4369, or call Sheriff's Department at 575-4080 and ask

that he be paged.

2. Coroner will decide if autopsy is needed and at what facility it will be done, at YVMH or

one of the funeral homes. Body will be transported to appropriate facility.

3. Contact the House Supervisor regarding organ donation. Nurse Supervisor or Chaplain

requests permission from the family.

4. If an organ donation is to be made, House Supervisor/Chaplain will contact Northwest

Organ Procurement Agency (N.O.P.A.) for further arrangement and patient management

requirements

Under existing State Law, the County Coroner has jurisdiction of bodies of all deceased

persons, as follows:

1. Who come to their death SUDDENLY WHEN IN APPARENT GOOD HEALTH WITHOUT

MEDICAL ATTENDANCE WITHIN THE THIRTY SIX HOURS PRECEDING DEATH.

2. Where the circ*mstances of death indicate death was caused by UNNATURAL OR UNLAW-

FUL MEANS.

3. Where death occurs under SUSPICIOUS CIRc*msTANCES.

4. Where a Medical Examiner's (Coroner's) autopsy or post mortem or inquest is to be held.

5. Where death results from UNKNOWN OR OBSCURE CAUSES.

6. Where death occurs WITHIN ONE YEAR FOLLOWING AN ACCIDENT.

7. Where death results from a KNOWN OR SUSPECTED ABORTION, whether self-induced or

otherwise.

Where a death is caused by ANY VIOLENCE WHATSOEVER.

CORONER CASES (REPORTABLE DEATHS):

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Spring 2010 48

9. Where death apparently results from:

A.DROWNING

B.LIGHTENING

C.HANGING

D.STARVATION

E.TETANUS

F.BURNS

G.RADIATION

H.STRANGULATION

I.ELECTROCUTION

J.EXPOSURE

K.SUFFOCATION

L.GUNSHOT WOUNDS

M.ALCOHOLISM

N.SMOTHERING

O.STABS

P.CUTS

Q.NARCOTICS

R.OTHER ACCIDENTS

10. Where death is due to PREMATURE OR STILL BIRTH.

11. Where death is due to a violent CONTAGIOUS DISEASE OR SUSPECTED CONTAGIOUS DIS-

EASE WHICH MAY BE A PUBLIC HEALTH HAZARD.

12. Where death results from:

A.ALLEGED RAPE

B.CARNAL KNOWLEDGE SODOMY

13. Where death occurs in a jail or prison.

14. When a body is FOUND DEAD, OR IS NOT CLAIMED BY RELATIVES OR FRIENDS.

Effective Date: 09/30/1991

Prepared by: Julia Patten

Approved by: Date: 09/01/1991

Reviewd by: Alan Collinsworth/Interim ED Director/Memorial Date: 09/09/1996, 01/10/2002, 05/10/2003, 12/15/2003, 11/27/2006

Revised by: Betty Baird/ED RN/Memorial Date: 11/27/2006

Approved by: ED Policy & Procedure Committee Date: 11/27/2006

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FAQs

What is the 10 item adverse childhood experiences questionnaire? ›

The short, 10-item screening version of the ACE (ACE-10) assesses the exposure to 10 types of ACEs (emotional, physical and sexual abuse, emotional and physical neglect, and five household dysfunctions: parental separation/divorce, household physical violence, household substance abuse, household mental illness or ...

What are the 10 ACEs of trauma? ›

What are the 10 ACES of Trauma?
  • Physical Abuse. Causing physical harm to a child by hitting, kicking, punching, scratching, beating, burning, throwing, or stabbing. ...
  • Sexual Abuse. ...
  • Verbal Abuse. ...
  • Physical Neglect. ...
  • Emotional Neglect. ...
  • Mental illness. ...
  • Substance Addiction. ...
  • Imprisonment.
Dec 14, 2021

How to score the ACE questionnaire? ›

Administering, Scoring, and Interpreting the ACE

The answer choices are Yes or No. Each affirmative answer (Yes) is assigned 1 point. ACE score is determined by adding up all the points. An ACE Score of 0 suggest that the person reported no exposure to childhood trauma.

Is an ACE score of 7 high? ›

Is an ACE score of 7 high? Yes. A score higher than 6 puts an individual at a heightened risk for the health concerns associated with adverse childhood experiences.

What is a bad ACE score? ›

Adults with an ACE score of 4 or more are 1220% more likely to attempt suicide, 1003% more likely to use injected drugs, 460% more likely to have recent depression, and 390% more likely to have lung disease. Adults with an ACE score of 2 or more are 400% more likely to consider themselves an 'alcoholic.

What are the 5 adverse childhood experiences? ›

Overview of ACEs
  • domestic violence.
  • parental abandonment through separation or divorce.
  • a parent with a mental health condition.
  • being the victim of abuse (physical, sexual and/or emotional)
  • being the victim of neglect (physical and emotional)
  • a member of the household being in prison.

What type of trauma is ACEs? ›

Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance use problems.

What are the 8 childhood traumas? ›

Types of Traumatic Events

Neglect and psychological, physical, or sexual abuse. Natural disasters, terrorism, and community and school violence. Witnessing or experiencing intimate partner violence. Commercial sexual exploitation.

What are the three types of ACEs abuse? ›

  • About the CDC-Kaiser ACE Study. ...
  • ACEs Definitions. ...
  • • Abuse. ...
  • o Physical abuse: A parent, stepparent, or adult living in your home pushed, ...
  • o Sexual abuse: An adult, relative, family friend, or stranger who was at least 5. ...
  • • Household Challenges. ...
  • o Substance abuse in the household: A household member was a problem drinker.

What is toxic stress? ›

However, stress that is prolonged, severe, or chronic, can cause significant problems with health and development. (Franke, 2014). Such stress, that itself creates additional challenges for a person's functioning, is toxic stress (Harvard University Center for the Developing Child, n.d.).

Who can administer ACEs? ›

The ACE survey should be administered in person by the individual's primary clinician or a staff person with whom the individual has a trusting relationship and who has some knowledge about the individual's life experience.

Is death of a parent an adverse childhood experience? ›

Adverse childhood experiences (ACEs) are potentially traumatic events that occur before age 18 such as experiencing maltreatment, neglect, or witnessing violence as well as parental death [8,20].

Do I have childhood trauma that I don't remember? ›

Be it a traumatic incident or a past experience, it may happen that the brain fails to recollect the memories that the body significantly remembers. "It's completely normal for memories of our childhood to be a bit fuzzy—after all, our brains don't always hold onto every detail from that time.

What are the four types of childhood trauma? ›

Psychological, physical, or sexual abuse. Community or school violence. Witnessing or experiencing domestic violence. National disasters or terrorism.

Do I have repressed memories? ›

Remembering a repressed memory “could begin with dream-like memories,” says psychologist Pauline Peck, PhD. It's “something that doesn't feel like a coherent narrative. You might have bits and pieces of a memory or have a strong felt 'sense.

What are the items in the adverse childhood experiences questionnaire? ›

ACE-IQ is designed for administration to people aged 18 years and older. Questions cover family dysfunction; physical, sexual and emotional abuse and neglect by parents or caregivers; peer violence; witnessing community violence, and exposure to collective violence.

What are the 10 ACEs that researchers have measured? ›

The 10 adverse childhood experiences (ACEs) assessed in the original ACE Study included physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, violence against a mother, parental divorce, household member having problems with substances, household member having problems with mental illness, ...

What are the items in the childhood trauma questionnaire CTQ? ›

CTQ scores on five scales: Physical Abuse, Sexual Abuse, Emotional Abuse, Physical Neglect and Emotional Neglect. 28 items cover: post-traumatic stress disorder, depression, eating disorders, addictions, suicide attempts, personality disorders and sexual problems.

What are the categories of the ACEs questionnaire? ›

Adverse childhood experiences (ACEs) are categorized into three groups: abuse, neglect, and household challenges. Each category is further divided into multiple subcategories. Participant demographic information is available by gender, race, age, and education.

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