Chapter 12-Client Safety Flashcards
Nursing actions in client safety
It is the nurses responsibility to use risk assessment tools to evaluate clients in their environment for safety.
Falls
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.
How to prevent falls
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
Seizure Types
- Partial seizures/focal seizures due to electrical surges and one hemisphere of the brain
- Generalized seizures involve both hemispheres of the brain
- Status epilepticus is a medical emergency
Seizure precautions
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.
During a seizure
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.
Seclusion and restraint
Should only be used as a last resort and require a doctors order
Restraint complications
Pneumonia, incontinence, pressure injuries
Types of restraints
Physical devices that restrict movement such as vest, belt, mitts, and limb.
Chemical devices such as sedatives, neuroleptic, or psychotropic medication to calm client.
Restraints should:
Never interfere with treatment
Restrict movement as little as is necessary
Fit properly and be discreet
Be easy to remove or change
Restraint prescription
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
Nurse responsibilities for restraints
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
What to document about restraints?
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
Fire safety
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
What is RACE?
R stands for a rescue and protect
A stands for alarm
C stands for contain/confine
E stands for extinguish
