Chapter 12-Client Safety Flashcards

1
Q

Nursing actions in client safety

A

It is the nurses responsibility to use risk assessment tools to evaluate clients in their environment for safety.

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2
Q

Falls

A

Older adult clients are at increased risk for falls

Others that are at risk our clients with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems, and cognitive dysfunction.

Adverse effects a certain medication‘s can increase risk for falls

Major Nursing Priority, programs to prevent falls, healthcare facilities actively prevent falls because Medicare and Medicaid no longer reimburses for treating injuries resulting from falls.

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3
Q

How to prevent falls

A

Complete a fall risk assessment

Make sure the client knows how to use and has call light

Respond to call lights in a timely manner

Use fall risk alerts such as yellow gowns and color-coded wristbands

Provide regular toileting and orientation

Adequate lighting

Making sure clients know how to use assistive devices

Put at risk clients near the nurses station

Make sure their items are within reach

Keep the bed in the lowest position

If a client is sedated or unconscious keep side rails up

Provide nonskid footwear and bathmats

Keep the floor clean, dry, free of clutter

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4
Q

Seizure Types

A
  1. Partial seizures/focal seizures due to electrical surges and one hemisphere of the brain
  2. Generalized seizures involve both hemispheres of the brain
  3. Status epilepticus is a medical emergency
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5
Q

Seizure precautions

A

Rescue equipment at bedside, including oxygen, oral airway, suction equipment, and padding for side rails.

Never leave the client alone when seizing

Make sure items are out of the way and don’t cause harm

Do not put anything in their mouth

Do not restrain a client during a seizure, lower bed to floor, protect their head, protect their privacy, put them on their side if possible.

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6
Q

During a seizure

A

Stay with a client, call for help

Maintain airway and suction as needed

Administer medication

Note duration, sequence, and type of movements

After seizure determine mental status, measure oxygenation saturation, measure vital signs. Explain what happened, provide comfort, understanding, and quiet environment.

Make sure to document any precipitating behavior and a description of events, and report to provider.

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7
Q

Seclusion and restraint

A

Should only be used as a last resort and require a doctors order

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8
Q

Restraint complications

A

Pneumonia, incontinence, pressure injuries

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9
Q

Types of restraints

A

Physical devices that restrict movement such as vest, belt, mitts, and limb.

Chemical devices such as sedatives, neuroleptic, or psychotropic medication to calm client.

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10
Q

Restraints should:

A

Never interfere with treatment

Restrict movement as little as is necessary

Fit properly and be discreet

Be easy to remove or change

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11
Q

Restraint prescription

A

Provider must prescribe seclusion or restraints in writing after a face-to-face assessment of the client.

In emergency situations nurses can place restraints on a client but the nurse must obtain a prescription from the provider as soon as possible usually within one hour.

The prescription must include the reason for the restraints, type of restraints, location of restraints, how long to use them, the type of behavior that warranted them.

Prescription allows only four hours of restraints for an adult, two hours for clients ages 9 to 17, and one hour for clients younger than nine years of age.

Providers are able to renew these prescriptions but only for a maximum of 24 hrs

Restaurant orders cannot be PRN

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12
Q

Nurse responsibilities for restraints

A

Explain the need for strains to the client and family explaining they are safe and temporary

Ask client or guardian to sign consent form

Assess skin integrity, offer food and fluid, provide means for hygiene and illumination, monitor vital signs, offer range of motion exercises.

Pad bony areas to prevent skin breakdown

Restraints should be tied to a movable part of the bed

Two fingers to make sure good circulation

Constantly reassess need for restraints

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13
Q

What to document about restraints?

A

Precipitating event/behavior

Alternative actions to avoid them

Time of application/removal

Type of restraint/location

Clients behavior while in restraints

Type and frequency of care

Condition of body part in restraints

Clients response to removal

Medication administration

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14
Q

Fire safety

A

All staff must know the location of exits, alarms, fire extinguishers, and oxygen shut off valves.

Make sure equipment does not block doors

Know the evacuation plan for the unit and facility

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15
Q

What is RACE?

A

R stands for a rescue and protect

A stands for alarm

C stands for contain/confine

E stands for extinguish

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16
Q

What is PASS?

A

P- pull the pin

A-aim at the base of the fire

S-squeeze the handle

S-sweep the extinguisher from side to side

17
Q

Classes of fire extinguishers

A

Class A is for combustible such as papers, Wood, upholstery, rags, other types of trash fires.

Class B is for flammable liquids and gas fires.

Class C is for electrical fires.