Chapter 12: Nursing Client Safety and Fall Prevention

Client Safety

• Client safety is a major nursing responsibility, and preventing injury is a priority
• Factors that affect clients' ability to protect themselves include:
  • Mobility
  • Cognitive and sensory awareness
  • Emotional state
  • Ability to communicate
  • Lifestyle and safety awareness

Preventing Falls

• Older adult clients are at increased risk for falls due to:
  • Decreased strength
  • Impaired mobility and balance
  • Improper use of mobility aids
  • Environmental hazards
  • Endurance limitations
  • Decreased sensory perception
• Other clients at increased risk include those with:
  • Decreased visual acuity
  • Generalized weakness
  • Urinary frequency
  • Gait and balance problems
  • Cognitive dysfunction
• Nursing actions to prevent falls include:
  • Complete a fall-risk assessment for each client at admission and at regular intervals
  • Individualize the plan for each client according to the results of the assessment
  • Encourage clients to speak up and take an active role in their health care
  • Create a culture of checks and balances to avoid errors
  • Use protocols for responding to dangerous situations
  • Adopt quality care priorities from the National Quality Forum

Seizures

• A seizure is a sudden surge of electrical activity in the brain
• Partial seizures (focal seizures) are due to electrical surges in one hemisphere of the brain
• Generalized seizures involve both hemispheres of the brain
• Status epilepticus (a prolonged seizure) is a medical emergency
• Seizure precautions include:
  • Making sure rescue equipment is at the bedside
  • Ensuring rapid intervention to maintain airway patency
  • Inspecting the client's environment for items that could cause injury
  • Advising caregivers and family not to put anything in the client's mouth during a seizure
• During a seizure:
  • Stay with the client and call for help
  • Maintain airway patency and suction PRN
  • Administer medications
  • After the seizure, determine mental status and measure oxygenation saturation and vital signs

Seclusion and Restraints

• Seclusion and restraints are used for the physical protection of the client or the protection of other clients or staff
• Restraints can be physical (devices that restrict movement) or chemical (sedatives or medications)
• Inappropriate uses of seclusion or restraints include:
  • Convenience of the staff
  • Punishment for the client
  • Clients who are extremely physically or mentally unstable
• Restraints should:
  • Never interfere with treatment
  • Restrict movement as little as necessary
  • Fit properly and be as discreet as possible
  • Be easy to remove or change

Nursing Responsibilities for Clients in Restraints

• Explain the need for the restraints to the client and family
• Know the location of exits, alarms, fire extinguishers, and oxygen shut-off valves
• Review the manufacturer's instructions for correct application
• Assess skin integrity and provide skin care according to the facility's protocol
• Offer food and fluid, and provide a means for hygiene and elimination
• Monitor vital signs and provide range-of-motion exercises of extremities

Fire Safety

• Fires in health care facilities are usually due to problems with electrical or anesthetic equipment, or from smoking
• All staff must:
  • Know the location of exits, alarms, fire extinguishers, and oxygen shut-off valves
  • Review the manufacturer's instructions for correct application
  • Know the evacuation plan for the unit and the facility
• Fire response follows the RACE sequence:
  • Rescue and protect clients in close proximity to the fire
  • Alarm: Activate the facility's alarm system and report the fire's details and location
  • Contain/Confine: Close doors and windows, and turn off any sources of oxygen and electrical devices
  • Extinguish: Use the appropriate fire extinguisher to put out the fire

Fire Extinguishers

• Classes of fire extinguishers:

  • Class A: Combustibles (paper, wood, upholstery, rags, other types of trash fires)
  • Class B: Flammable liquids and gas fires
  • Class C: Electrical fires

• To use a fire extinguisher, use the PASS sequence:

  • Pull the pin
  • Aim at the base of the fire
  • Squeeze the handle
  • Sweep the extinguisher from side to side, covering the area of the fire### Priority Actions for Client Safety

• The nurse's priority action is to eliminate safety hazards from the client's environment to prevent falls and ensure client safety.

Responding to a Fire in a Client's Bathroom

• If a nurse discovers a small paper fire in a trash can in a client's bathroom, the priority action is to remove the client to safety and activate the alarm.
• Next, the nurse should obtain a class C fire extinguisher to extinguish the fire, as it is the most appropriate type of extinguisher for electrical fires.
• The nurse should also place wet towels along the base of the door to the client's room to prevent the fire from spreading.

Preventing Falls in Healthcare Facilities

• Nurses must evaluate clients for risk factors of falls and implement preventative measures accordingly.
• Programs to prevent falls are essential in settings that provide services to older adult clients.

Risk Factors for Falls

• Decreased strength
• Impaired mobility and balance
• Improper use of mobility aids
• Unsafe clothing
• Environmental hazards
• Endurance limitations
• Decreased sensory perception
• Decreased visual acuity
• Generalized weakness
• Urinary frequency
• Gait and balance problems (cerebral palsy, multiple sclerosis)
• Cognitive dysfunction
• Adverse effects of medications (orthostatic hypotension, drowsiness)

Nursing Actions to Prevent Falls

• Complete a fall-risk assessment for each client at admission and at regular intervals.
• Individualize the plan for each client according to the results of the fall-risk assessment.
• Use risk assessment tools to evaluate clients and their environment for safety.
• Encourage clients to speak up and take an active role in their health care and in preventing errors.
• Create a culture of checks and balances to avoid errors when working in stressful circumstances.
• Communicate risk factors and plans of care to clients, family, and other staff.
• Use protocols for responding to dangerous situations.
• Respond to call lights in a timely manner.
• Use fall-risk alerts (color-coded wristbands).
• Provide regular toileting and orientation of clients who have cognitive impairment.
• Orient clients to the setting to make sure they know how to use all assistive devices (grab bars) and can locate necessary items.
• Place clients at risk for falls near the nurses' station.
• Provide hourly rounding.
• Keep the bed in the low position and lock the brakes for clients who are sedated, unconscious, or otherwise compromised.
• Keep the side rails up for clients who are sedated, unconscious, or otherwise compromised.

Importance of Preventing Falls

• Medicare and Medicaid no longer reimburse for treating injuries resulting from falls.
• Safety is freedom from injury, and providing for safety and preventing injury are major nursing responsibilities.

Client Safety

• Avoid using full side rails for clients who get out of bed or attempt to get out of bed without assistance.
• Provide nonskid footwear and nonskid bath mats for use in tubs and showers.
• Use gait belts and additional safety equipment when moving clients.
• Keep the floor clean, dry, and free from clutter with a clear path to the bathroom.
• Keep assistive devices nearby after validation of safe use (e.g., eyeglasses, walkers, transfer devices).
• Educate the client and family about safety risks and the plan of care.
• Lock the wheels on beds, wheelchairs, and carts to prevent them from rolling during transfers or stops.
• Use electronic safety monitoring devices (e.g., chair or bed sensors).

Seclusion and Restraints

• Use seclusion or restraints for the shortest duration necessary and only if less restrictive measures are not sufficient.
• Communicate risk factors and plans of care to clients, family, and other staff.
• Respond to call lights in a timely manner.
• Use fall-risk alerts (e.g., color-coded wristbands).
• Provide regular toileting and orientation of clients who have cognitive impairment.
• Know the facility's disaster plan, understand the chain of command and roles, and use common terminology when communicating with the team.

Incident Reporting and Safety Data

• Identify and document incidents and responses according to the facility's policy.
• Use equipment only after adequate instruction and safety inspection.
• Keep the bed in the low position and lock the brakes.
• Keep bedside tables, overbed tables, and frequent-use items (e.g., telephone, water, facial tissues) within reach.

Documentation

• Document precipitating events and behavior of the client prior to seclusion or restraints.
• Document alternative actions to avoid seclusion or restraints.
• Document time of application and removal of the restraints.
• Document type of restraints and location.
• Document the client's behavior while in restraints.
• Document type and frequency of care (e.g., range of motion, neurologic checks, removal, integumentary checks).
• Document condition of the body part in restraints.
• Document the client's response at removal of the restraints.
• Document medication administration.