Safe Environment- Environmental Hazards

a device which is worn on the leg and signals when the leg is in a dependent position such as when its over the side rail or on the floor

the reduction and spread of microorganisms

a clients environment includes all of the physical and psychosocial factors that influence or affect their life and survival

the federal agency responsible for the enforcement offederal regulations regarding the manufacture, processing and distribution of food, drugs and cosmetics and to protect consumers from the sale of impure or dangerous substances

ingestion of bacterial toxins produced in food ex) staph and clostridia

third prong in a plug that carries stray electrical current back to the ground

• is hot dry skin
• rectal temp is above 105*

• exposure to extreme cold
• the bodies core temp falls below 95*

• the process by which resistance to an infectious disease is produced
• can produce active or passive immunity

• a CLEAN technique aimed at the reduction and prevention of the spread of microbes
• ex) handwashing, gloves, cleaning, disinfection

any microorganism capable of producing illness

• mask; protection from droplet or airborne precautions
• goggles; to prevent infection from splashing or spraying
• gown; barrier protection and contact precautions, also is fluid resistant
• gloves; non-sterile are worn when touching blood, bodily fluids and contaminated items

any substance that impairs health or destroys life when ingested, inhaled or otherwise absorbed by the body

a harmful chemical or waste material discharged into water, soil or air

a device used to immobilize a client or extremity and that restricts the movement or normal access to a pts body

• blood, all bodily fluids, secretion, excretions, nonintact skin and mucous membranes.
• teir 1- is designed for all pts in any setting regardless of dx or presumed infection
• teir 2- applies with droplet nuclei, droplet and contact precautions

the complete elimination or destruction of all microorganisms

• sterilization or elimination of all microorganisms including pathogens and spores
• an object is considered contaminated if it comes in contact with an object that is not sterile

• basic needs are met
• physical hazards are reduced
• sanitation is maintained
• pollution is controlled
• skin integrity is maintained
• nervous system, cell structure andfx are also maintained

• lifestyle risks; Etoh, drugs and smoking
• impaired mobility; inability to get out of the way of danger
• sensory/ communication deficit; no sensation, blind or deaf
• lack of knowledge of safe practice

• decreased muscle strength, fx, mobility and ROM
• decreased reflexes and ability to respond to multiple stimuli
• decreased perception to hot or cold
• decreased peripheral vision

• physical safety from environmental hazards
• biological safety from pathogens

• the transmission of pathogens is reduced
• the bodies normal defense mechanisms are supported
• the inflammatory process is working
• the skin and mucous membranes are intact

healthcare workers are continuously at risk for exposure to infectious microorganisms

• hands are visibly soiled
• before and after client contact
• after contact w a source of microorganism ex blood, bodily fluid, mucous membranes, non intact skin or equipment
• before the performance of invasive procedures
• after removing gloves

• Physical- hand rails, clutter
• Mechanical- defective equipment
• Thermal- fire, heat or cold
• Chemical- poison, meds or carbon monoxide
• Radiation- XR, sun exposure
• Ecological- air, land or water pollution

• orient clients and families to surroundings and explain procedures
• encourage family and friends to stay or use sitters
• assign a confused or disoriented client to a room near the nurses station
• eliminate bothersome tx as soon as possible
• use relaxation techniques

• side rails on beds
• safety bars in toilets and showers
• call bells
• fall risk assessments

• sense of loneliness that may stem from the disruption of social relationships and limited sensory contact
• feelings of rejection, guilt, undesirability and uncleanliness

• LI-reasons must be clearly stated; must be part of the clients medical tx; all less restrictive interventions must be tried first
• DG- must have an MD order; the type of restraint and reason must be given; they must be re-ordered every 24h

• anything in the chain of infection can affect a pts biological safety
• causative agents such as bacteria, fungi, viruses, protozoa and rickettsiae
• break the chain by identifying and treating causative agent; eliminate reservoirs of infection; proper attire; elimination of means of transmission; aseptic technique and to recognize high risk pts

• hand are washed b\t clients, after contact with blood, body fluids, secretions, excretions and after contact w equipment or articles that may have become contaminated by them; and immediately after gloves are removed
• gloves are worn when touching blood, body fluids, secretion, excretions, non intact skin, mucous membranes or contaminated items; gloves should be removed and the hands washed between pts
• Masks, eye protection or face shields are worn if client care activities may generate splashes or sprays of blood or bodily fluid
• gowns are worn if the soiling of clothes is likely from blood or bodily fluid, wash hands after gown removal
• client care equipment is properly cleaned and reprocessed; single use items are properly discarded
• contaminated linen is placed in a leakproof bag and is handled as to prevent skin mucous membrane exposure
• all sharps are discarded in a puncture resistant container

• Airborne; droplet nuclei < 5 microns (TB, Varicella) require a private room, negative pressure air flow w at least 6 exchanges/h and a mask or respiratory protection device
• Droplet; droplets > 5 microns (rubella, strep and pneumonia) require a private room and a mask
• Contact; colonization or infection with a multi-drug resistant organism (herpes, scabies) require a private room, gloves and a gown

• protects the clients from immediate injury (R-escue)
• reports the exact location of the fire (A-ctivate the alarm)
• contain the fire (C-onfine the fire)
• put out the fire if possible (E-xtinguish)

• close windows
• shut off O2
• unplug electrical items
• close doors

• maintaining good working order of equipment
• grounding electrical equipment
• education of family and pt abt possible hazards

• dx-Impaired mobility
• intervention- use of wheelchair/walker

• assess ABC's
• terminate exposure (remove visable material from nose and mouth)
• identify the amt/ type of substance ingested
• call poison control
• if instructed, induce vomit vomiting via ipecac and h2o
• if directed, save vomit for lab
• place the pt on their side to prevent aspiration of vomit
• never induce vomiting on an unconscious pt or w harsh chemicals

No, this pt does not meet the requirement for physical restraint, b/c the pt is confused there are other measure that should be taken to ensure the safety of the pt and his roommate such as being put in a room closer to the nurses station, checked on more frequently or asking the roommate to notify you in case of change in the pt.

No, the use of restraints requires problems solving and knowledge application unique to professional nursing.

• C- glaucoma, cataracts
• E- impaired mobility

• C-cerumen accumulation
• E- impaired hearing

• C- dizziness, vertigo
• E- increased risk for falls

• C- xerostomia (drymouth)
• E- difficulty w speach & eating, halitosis

• C- peripheral neuropathy
• E- impaired impulses to brain

• C- aphasia, ventilators
• E- frustration, inability to communicate

• Inadequate quality or quantity of stimulation
• E- regression, restlessness and panic
• NI- screening, safety and promotion of meaningful stimulation

• Pt receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore
• E- disorientation and mood swings
• NI- environmental control and adequate sleep

• placing call bell, phone and personal belongings within pts reach
• frequent checking in on the pt
• assessing need for side rails for support
• adequate lighting

increased opacity of the lens that causes a clouding over the eye

impaired near vision

• a degeneration of the retina that causes a decrease in central vision.
• like a clouded circle in the center of your vision
• a common cause of blindness

a decrease in vision due to and increased pressure on the optic nerve.

dizziness

• cotton mouth
• dry mouth

age related hearing loss

numbness and pain in the limbs caused by nerve damage.

• use two identifiers to confirm that you have the right pt.
• never use room number as one, pts tend to wander

mucous membranes that line the cheeks

cleaning of the patients genital area

a series of massage strokes that use light touch

deliberate release of viruses or bacteria to cause illness or death in people, plants or animals

toxic chemicals that are used to cause damage to people

• basic needs are met
• physical hazards reduced
• pollution is controlled sanitation is maintained
• skin integrity is maintained
• staff safety
• nervous and immune function
• "feeling safe"

• increase or decrease stimulation
• ambulation
• decrease noise level
• group tasks together
• soft lighting

• improve accuracy of pt identification
• improve effectiveness of communication among caregivers
• increase safety of medication administration
• reduce the risk of health care associated infections
• accurately and completely reconcile medications across the care continuum
• reduce harms from falls