Chapter 12 Client Safety Flashcards
Prevention of falls is a major nursing priority. Besides older clients, what are some other clients at increased risk for falls?
Visual acuity, generalized weakness, urinary frequency, gait and balance problems and side effects from medication.
What are some factors that affect a clients ability to protect himself?
Age, mobility, cognitive and sensory awareness, emotional state, ability to communicate, lifestyle.
How can nurses prevent falls?
Completing a fall-risk assessment upon admission and also regular while client is hospitalized.
Plans for falls should be individualized based on fall-risk assessment. What are some general measures to prevent falls?
Make sure client knows where the call light is, ensure enough lighting, place clients at risk for falls near nursing station, keep bed rails up for clients that are sedated or unconscious and provide client with nonskid foot wear
What is a seizure?
Sudden surge of electrical activity in the brain. It can occur at any time.
What are partial seizures or focal seizures?
Due to electrical surges in one part of brain.
What do generalized seizures involve?
The entire brain.
What are seizure precautions?
Measures to protect the client from injury should a seizure occurs.
What are some seizure precautions?
Ensure rescue elopement is at beside. Inspect environment for items that may cause harm in the event of seizure. Assist clients with history with ambulation and transferring. Do not put anything inside of the mouth. Do not restrain.
What should a nurse do in the event of a seizure?
Stay with client and call for help, administer medications as prescribed, note duration, sequence and type of movement. After a seizure asset mental status, oxygenation status and vital signs. Document in clients record.
Restraints can be either which two things?
Chemical or physical.
When is seclusion never allowed?
For convenience, punishment, clients who are extremely physically or mentally unstable and clients who can not tolerate deceased stimulation of a seclusion room.
Restraints should:
Never interfere with treatment, restrict
movement as little as necessary, fit properly and be discreet and be easily removed or changed
When all other less restrictive means have failed and a client still is able to do harm to themselves, what must occur in order for seclusion or restricting to be used?
Treatment must be prescribed by doctor in writing based on face to Dave assessment of client
What must a prescription for restraints or seclusion include?
The reason for restraint, type of restraint, location of restraint and how long the restraint by be used. Also type of behavior demonstrates by client that need the restraint.
