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Questions and Answers
What should caregivers and family do during a seizure?
What should caregivers and family do during a seizure?
How long can restraints be used for adults, clients ages 9 to 17, and clients younger than 9 years of age?
How long can restraints be used for adults, clients ages 9 to 17, and clients younger than 9 years of age?
What should be the priority action of a nurse observing smoke coming from under the door of the staff’s lounge?
What should be the priority action of a nurse observing smoke coming from under the door of the staff’s lounge?
What should a nurse do when caring for a client who has had a seizure?
What should a nurse do when caring for a client who has had a seizure?
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What action should a nurse take when caring for a client who has a history of falls?
What action should a nurse take when caring for a client who has a history of falls?
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What should a nurse do upon discovering a small paper fire in a trash can in a client’s bathroom?
What should a nurse do upon discovering a small paper fire in a trash can in a client’s bathroom?
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What are some factors that can increase the risk of falls in older adult clients?
What are some factors that can increase the risk of falls in older adult clients?
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What are some client groups at increased risk for falls?
What are some client groups at increased risk for falls?
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Medicare and Medicaid reimburse for treating injuries resulting from falls.
Medicare and Medicaid reimburse for treating injuries resulting from falls.
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_____ are essential for settings that provide services to older adult clients.
_____ are essential for settings that provide services to older adult clients.
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Match the following safety measures with their descriptions:
Match the following safety measures with their descriptions:
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What is the primary purpose of using fall-risk alerts, such as color-coded wristbands?
What is the primary purpose of using fall-risk alerts, such as color-coded wristbands?
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When providing hourly rounding, what should the nurse prioritize?
When providing hourly rounding, what should the nurse prioritize?
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What is the primary purpose of keeping the bed in the low position and locking the brakes?
What is the primary purpose of keeping the bed in the low position and locking the brakes?
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What should the nurse do when providing care to a client who has cognitive impairment?
What should the nurse do when providing care to a client who has cognitive impairment?
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Why is it important to provide adequate lighting in the client's environment?
Why is it important to provide adequate lighting in the client's environment?
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What should the nurse do when identifying and documenting incidents and responses?
What should the nurse do when identifying and documenting incidents and responses?
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Why is it important to orient clients to the setting and assistive devices?
Why is it important to orient clients to the setting and assistive devices?
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Which of the following is a major nursing responsibility in preventing falls?
Which of the following is a major nursing responsibility in preventing falls?
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What is the purpose of the National Patient Safety Goals?
What is the purpose of the National Patient Safety Goals?
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Which of the following is NOT a risk factor for falls in older adult clients?
Which of the following is NOT a risk factor for falls in older adult clients?
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Which client group is at an increased risk for falls due to cognitive dysfunction?
Which client group is at an increased risk for falls due to cognitive dysfunction?
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What is the primary goal of fall prevention strategies in healthcare settings?
What is the primary goal of fall prevention strategies in healthcare settings?
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Which of the following is a potential adverse effect of medications that can increase the risk of falls?
Which of the following is a potential adverse effect of medications that can increase the risk of falls?
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Which of the following is an environmental hazard that can increase the risk of falls?
Which of the following is an environmental hazard that can increase the risk of falls?
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Which of the following clients is at an increased risk for falls due to impaired mobility and balance?
Which of the following clients is at an increased risk for falls due to impaired mobility and balance?
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What is the primary reason why safety is a major nursing priority?
What is the primary reason why safety is a major nursing priority?
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What is the primary reason why healthcare facilities must actively prevent falls?
What is the primary reason why healthcare facilities must actively prevent falls?
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What should a nurse do to individualize a plan for a client who has orthostatic hypotension?
What should a nurse do to individualize a plan for a client who has orthostatic hypotension?
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Why is it important for nurses to create a culture of checks and balances when working in stressful circumstances?
Why is it important for nurses to create a culture of checks and balances when working in stressful circumstances?
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What should a nurse do to evaluate a client's risk for falls?
What should a nurse do to evaluate a client's risk for falls?
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What is the purpose of completing a fall-risk assessment for each client at admission and at regular intervals?
What is the purpose of completing a fall-risk assessment for each client at admission and at regular intervals?
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Why is it important for nurses to encourage clients to speak up and take an active role in their healthcare?
Why is it important for nurses to encourage clients to speak up and take an active role in their healthcare?
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What should a nurse do to report and document a client's allergies?
What should a nurse do to report and document a client's allergies?
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Why is it important for healthcare facilities to provide care that avoids exposure to allergens?
Why is it important for healthcare facilities to provide care that avoids exposure to allergens?
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When should a nurse consider using alternative actions to avoid seclusion or restraints?
When should a nurse consider using alternative actions to avoid seclusion or restraints?
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What type of fire extinguisher is used for electrical fires?
What type of fire extinguisher is used for electrical fires?
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What is an essential step in preventing falls in older adult clients?
What is an essential step in preventing falls in older adult clients?
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What is the primary purpose of using fall-risk alerts, such as color-coded wristbands?
What is the primary purpose of using fall-risk alerts, such as color-coded wristbands?
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What should a nurse prioritize when providing care to a client who has cognitive impairment?
What should a nurse prioritize when providing care to a client who has cognitive impairment?
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Study Notes
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.
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Assess your knowledge of client safety and fall prevention, including factors affecting client ability to protect themselves and risk factors for older adult falls.
