Podcast
Questions and Answers
Which of the following factors contributes to an unsafe patient environment?
Which of the following factors contributes to an unsafe patient environment?
What is the purpose of Fall Assessment Rating Scales?
What is the purpose of Fall Assessment Rating Scales?
Which practice is essential for preventing falls in patients?
Which practice is essential for preventing falls in patients?
Which of the following is a recommended strategy for monitoring patients to ensure safety?
Which of the following is a recommended strategy for monitoring patients to ensure safety?
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Which option is NOT considered a restraint alternative?
Which option is NOT considered a restraint alternative?
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What should be included in a care plan for a patient at risk of falling?
What should be included in a care plan for a patient at risk of falling?
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What is a critical safety consideration when monitoring sedated or unconscious patients?
What is a critical safety consideration when monitoring sedated or unconscious patients?
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Which intervention helps to create a safe environment for fall-risk patients?
Which intervention helps to create a safe environment for fall-risk patients?
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What is the recommended maximum duration to keep a restraint off a patient?
What is the recommended maximum duration to keep a restraint off a patient?
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Which of the following must be documented when a restraint is placed on a patient?
Which of the following must be documented when a restraint is placed on a patient?
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What is the first action to take if a patient falls?
What is the first action to take if a patient falls?
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According to fire safety procedures, what does the 'R' in R.A.C.E stand for?
According to fire safety procedures, what does the 'R' in R.A.C.E stand for?
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How often should a patient in restraints be checked?
How often should a patient in restraints be checked?
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Which of the following actions should NOT be taken when a patient is in restraints?
Which of the following actions should NOT be taken when a patient is in restraints?
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In case of a fire, what is the second step in the R.A.C.E procedure?
In case of a fire, what is the second step in the R.A.C.E procedure?
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What is included in the healthcare provider's order for restraints?
What is included in the healthcare provider's order for restraints?
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What is the primary purpose of using assistive devices during patient transfer?
What is the primary purpose of using assistive devices during patient transfer?
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Which position is recommended to promote lung expansion for patients with severe dyspnea?
Which position is recommended to promote lung expansion for patients with severe dyspnea?
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What is a crucial step in preventing patient injuries during mobility assistance?
What is a crucial step in preventing patient injuries during mobility assistance?
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In which position should a patient be placed to best support proper body alignment and prevent foot drop?
In which position should a patient be placed to best support proper body alignment and prevent foot drop?
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When utilizing a lateral position for patient care, what is the recommended angle to prevent pressure ulcers?
When utilizing a lateral position for patient care, what is the recommended angle to prevent pressure ulcers?
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What is essential to explain to patients when planning for mobility assistance?
What is essential to explain to patients when planning for mobility assistance?
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Which of the following positions helps prevent aspiration during meals?
Which of the following positions helps prevent aspiration during meals?
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In which position is a pillow placed under the patient’s leg to promote relaxation and knee flexion?
In which position is a pillow placed under the patient’s leg to promote relaxation and knee flexion?
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Study Notes
Client Safety
- The Joint Commission - evaluates and accredits healthcare organizations in the US
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Factors Contributing to Unsafe Patient Environment:
- Age and Ability to Understand: Adapt communication style based on patient's age and learning style.
- Impaired Mobility: Consider bed-bound patients, lack of balance, etc.
- Communication: Ensure effective communication with the patient.
- Pain and Discomfort: Acknowledge patient's pain and address it to minimize agitation and restlessness.
- Delayed Assistance: Respond promptly to call lights, bed alarms, and patient requests.
- Equipment: Verify equipment functionality and use it correctly.
Fall Assessment Rating Scales
- Numerical rating system (0-10) to assess a patient's fall risk.
- Higher the number, the greater the risk of falls.
Preventing Falls
- Individualized Care Plan: Based on fall-risk assessment.
- Call Light: Place within reach and respond promptly.
- Fall-Risk Alert Wristbands: Be aware of these visual cues.
- Safe Environment: Adequate lighting, low bed positions, clean/decluttered floor, items within patient reach.
- Location: Place high-risk patients near the nursing station.
- Frequent Rounds: Conduct hourly rounds.
- Assistive Devices: Utilize canes, walkers, or crutches and keep them readily available.
- Sedated or Unconscious Patients: Keep bedside rails up.
Restraint Alternatives
- Vests, Jackets, or Bands: Strapped to the bed, chair, or wheelchair to prevent movement.
- Monitors: Chair or bed monitors with pressure-sensitive alarms that activate at the nursing station when weight is no longer detected.
- Soft Devices: Bolsters to prevent slipping between or through side rails.
Restraints
- Also referred to as "protective devices," "safety reminder devices," or "Posey's."
- Last resort - use least restrictive methods first.
- Require a healthcare provider order with specific details: date, time, type, location, alternatives used, reason, duration, and signature.
Restraint Guidelines
- Patient Assessment Every 30 Minutes: Skin for redness/chafing, extremities for warmth and color.
- Removal Every 2 Hours: Offer fluids, assist with toileting, change patient position, assess extremities for edema, capillary refill, sensation, and function.
- Documentation: Record all actions on the appropriate flow sheet.
Patient Fall Actions
- Check for Injuries: Bleeding, level of consciousness, hip fracture, joint deformities, paralysis, or weakness.
- Call for Help.
- Vital Signs: Take and document.
- Code Blue: For unconsciousness, unstable vital signs, breathing difficulties, or lack of pulse.
- Assistance To Bed: Follow facility policy.
- Notify Healthcare Provider: Explain the fall, provide current patient condition, and be prepared to take orders for X-rays and other tests.
- Incident Report: Complete according to facility policy. Document patient findings, vital signs, assistance to bed, and provider notifications.
Fire Safety: R.A.C.E.
- Rescue: Evacuate patients from immediate danger.
- Alarm: Sound the fire alarm using facility procedures.
- Confine: Limit the fire's spread to one room or area.
- Extinguish: Attempt to extinguish the fire if safe to do so (check for safety, and if the client can assist).
Preventing Injury during Transfers
- Policy Knowledge: Familiarize yourself with facility policies.
- Staff Assistance: Obtain appropriate assistance from one or more staff members.
- Plan and Request Help: Plan ahead and clearly communicate assistance needs.
- Environment Preparation: Declutter the transfer area.
- Patient Explanation: Explain the transfer process to the patient.
- Assistive Devices: Utilize assistive devices for patient safety.
- Body Mechanics: Maintain proper body mechanics and alignment.
- Smooth Movements: Use smooth, controlled motions during lifting.
Bed and Patient Positions
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Semi-Fowlers: Head of bed elevated at 15-30 degrees (typically 30).
- Prevents regurgitation and aspiration during enteral feeding.
- Promotes lung expansion in patients with dyspnea or on mechanical ventilation.
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Fowlers: Supine with head of bed at 45-60 degrees.
- Facilitates procedures (nasogastric tube insertion, suctioning).
- Improves chest expansion and ventilation.
- Encourages drainage after abdominal surgery.
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High Fowlers: Supine with head at 60-90 degrees.
- Maximizes lung expansion by lowering the diaphragm.
- Reduces aspiration risk during meals.
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Supine or Dorsal Recumbent: Lies on back with head and shoulders elevated, forearms supported.
- Foot support prevents foot drop and maintains body alignment.
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Prone: Lies flat on abdomen and chest, head turned to one side, back aligned.
- Pillow placed under leg for comfort and ankle dorsiflexion.
- Promotes drainage after throat or oral surgery (short-term use only).
- Helps prevent hip contractures following lower extremity amputation.
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Lateral or Side Lying: Lies on side, weight distributed on dependent hip and shoulder, arm flexed.
- Pillows under head, neck, upper arms, and legs for alignment.
- Comfortable sleeping position.
- Regular turning to prevent pressure ulcers (30-degree lateral position for high-risk patients).
- Lateral Semi-prone Recumbent: Halfway between lateral and prone positions, weight on anterior ileum, humerus, and clavicle.
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