Unit-8 Physical safety

• 1. Life span issues
• 2. Life style
• 3. Mobility & health status
• 4. Communication ability
• 5. Environmantal factors
• 6. Cognitive awareness
• 7. Sensory/Preception alterations
• 8. Emotional state

• Morse fall scale
• Hendrich II fall Risk Model

• Risk for injury
• Risk for falls

• Prevention
• Use of Restraints

• Scalds & burns- prevent at home and hospitals
• Fire- if there is a fire use RACE or SAVE
• Falls- never leave a weak/dizzy client alone

• Physical
• Chemical
• Emotional

• To prevent cl from hurting self or others, for safety
• Never a substitue for nursing care
• If applied,
• Inform family
• Check cl at least every 30 mins
• Remove every 2 hours and check circulation movement and sensation.
• Document time, reason, cl response, education, and care.
• Reasses every shift prn

use of medication

threats and verbal abuse

• Alternatives to restraints
• Client Response
• Communication of data

• Correct underlying problems
• Pay attention to tubing
• Minimize combativeness
• Minimize fall risk & wandering
• Bed /chair alarm

• Client falls
• Improper use of equipment
• Failure to provide enough monitoring (failure to rescue)
• Failure to communicate

• Common legal problems
• Purpose of cl records
• Types of Documents
• Chart forms
• Guidelines for recording/reporting

• Narritive- organize using DAR, Data, Action, Response
• Sourse oriented (SOMR)
• Problem Oriented (POMR)
• Charting by exception- WNL, WDL
• Critical pathways- mapping where the cl should be
• computer/informatics

SOAPIE, PIE

• Subjective
• Objective
• Assessment
• Planning
• Implementaion
• Evaluation

• Problem
• Intervention
• Evaluation

• SBAR
• Situation
• Background
• Assessment
• Recommend

First inital, last name, title

draw line through, write error or ME above, date & inital it.

Write Late entry, if someone charted before your time

do not mention litigations in charts

• unexpected incidents causing or risking death or serious injury.
• Many involve an in depth investigation