325 week 2
Safety (Chapter 4)

Safety Considerations include:
Falls risk
Fire, electrical, radiation

Assess falls risk
Braden scale example
Assessment of:
Age, fall history
Medical problems
Gait and balance
Use of assistive devices
Seizure disorder
Neurological and cardiovascular

Nursing Interventions for falls include:
Side rails
Call bell within reach
Night time low lighting
Bed or wheelchair, low and locked
Floor clutter free
Bed alarms

Restraints are a last resort method to control patient. Always try other diversionary tactics. Position changes, etc.

*Cultural considerations - Restraints can be perceived as disrespectful in Asian cultures and as persecution or imprisonment to war survivors.

Related to anesthesia, electrical
No smoking must be enforced
Oxygen located in most rooms
Check inspection dates for equipment
Fire safety doors
RACE – rescue, alarm, confine, extinguish:
Remove patient
Turn off oxygen
Close doors, fire safety doors
Place wet towels

*Cultural considerations – Buddhists burn incense for healing, Hindus light a candle as an eternal flame at the time of death, Orthodox Jews light candles for the Sabbath. Teach patients and family about fire risk. Contact religious leaders, chaplain to try and find a way to honor their wishes while maintaining safety.

Fire extinguishers
A – Wood, paper, plastics
B – Flammable liquids, gasoline, paint, anesthetic gas
ABC – for any type of fire

Make sure patient is safe to approach, live wires
CPR if no pulse
Notify emergency personnel
Vital signs and skin burn assessment if pulse

Educate patient and family
Caution: Radioactive material on door
Wear a radiation exposure dosimeter
Wear lead apron and protective gloves when administering care
Rotate care providers
Visitors protective gear, 30 minutes a day, 6 feet away
If the material falls out don’t touch

***When teaching client should be able to return demonstration. In order to be reimbursed the documentation must reflect this. Ex. Patient instructed on the use of an MDI (metered dose inhaler) pt acknowledged understanding and returned demonstration.

Should be used only as a last resort
Labeled Prescription only, order required
Least restrictive used
Order states type of restraint medical surgical (reassess q 24 hrs) or behavioral (reassess q 2-4 hours), time limitations, face to face
Remove for ROM q 2 hrs, position, potty, palate (I&O)
Evaluate and document every 2 hours skin integrity, pulses, color, sensation (5ps)

Can result in:
Pressure ulcers
Neurovascular impairment
Altered sensory perceptions
Altered thought processes
Humiliation, fear, anger

Roll belt

Seizure Precautions:
Keep rails padded, bed low, locked, side lying, O2 , suction available,
In the event of a seizure:
If out of bed, guide to floor
Place pillow under head
Clear environment of harmful objects
Do not restrain or place anything in the mouth!
Roll to side recovery position as soon as able
Maintain airway
Use O2 and suction as necessary
Seizures 1-2 minutes,
Status epilepticus - 10 minutes or several back-to-back over 30 min.

After seizure:
First ABC!
Airway - clear
Breathing - Assess respiratory rate and pattern
Cardiovascular – Assess color and pulses
Assess for injury
Postictal state, loc
Assess for bladder or bowel incontinence

Body mechanics (Chapter 10)

Before moving a patient assess if help will be needed.
Tighten stomach, tuck pelvis and bend at the knees
Keep weight of patient to be lifted close
Avoid twisting
A draw sheet can help move the patient

Proper patient body alignment is important
Pressure ulcers can develop in 24 hours
Change patient position often
Inspect and assess patient position often
Be aware of conditions such as diabetes or malnutrition, which can increase risk of skin breakdown
Note fluid balance status, dehydration and edema can increase risk of breakdown
Incontinence and sweating can cause skin breakdown
Inactivity can induce muscle atrophy, decreased bone mass
Contractures and footdrop can occur in just a few days
Know the patients ROM abilities to avoid injury
Learn the patient’s sensory perception so to avoid injury
Know the patient’s baseline vital signs to avoid hypotensive episodes
Make sure patient is cognitively able to participate in transfers and positioning

Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, Missouri: Mosby Elsevier.

Making an occupied bed