What percent of all reported hospital accidents do falls account for?
90%
Who is at an increased risk for falls due to decreased strength, impaired mobility and balance, and endurance limitations combined with decreased sensory perception?
Older adult clients
Besides older adult clients, who are other clients that may be at increased risks for falls?
Decreased visual acuity
Generalized weakness
Urinary frequency
Gait and balance problems
Cognitive dysfunction
Side effects of some medications
The may include sudden onset and violent clonic-tonic movements that result in injury
Seizures
How do you prevent injury from seizures?
Implement seizure precautions
What policies need to be understood when using restraints?
Federal, state laws and facility policies
When should restraints be used?
Only as a last resort
In consultation with the PCP
Only with an order stating why the restraint is necessary and for how long
What are physical restraints?
Any physical, manual, or mechanical method or device attached to a body to restrict movement
What are chemical restraints?
Medications used to control behavior
Why are chemical restraints especially dangerous in older adults?
Because the increased sedation, drowsiness, and/or otherwise impaired cognition may increase the risk of falling
What is use of restraints without an order considered?
False imprisonment - illegal
How soon must a face-to-face assessment by the PCP be done when a nurse uses restraints in an emergent situation?
Within 1 hour
What are appropriate nursing diagnoses in relation to falls?
Risk for falls
Risk for injury
Deficient knowledge
What assessment should be done on admission and at regular intervals to prevent falls?
Fall-risk assessment
What are ways in which to prevent falls?
Nonskid footwear
Floors free from clutter
Adequate lighting
Orient client to setting
Assistive devices nearby
Home safety surveys
Education of the client and family of POC
Reporting and documenting all incidents in order to prevent them in the future
Answer call lights promptly
Assign a client at risk for falls to a room close to the nurses' station
Keep the bed rails up and the bed in the lowest position
Lock wheels on anything that rolls
Use chair or bed sensors for clients at risk
To ensure good circulation to the area and allow for full RIM to the limb being restricted, what should be done with the restraints?
Remove or replace them frequently
Pad bony prominences and do neurosensory checks every __ hours to identify any neurological or circulatory deficits when using restraints
2
Where should the restraint be tied when the client is in bed?
The bed frame
How many fingers need to fit between the restraint and the client's body?
2
How loose should the restraint be?
Loose enough for range of motion
To help the client and family understand why restraints are being used, what should the nurse do?
Explain the need and situation
When should restraints be discontinued or limited?
At the earliest possible time while still ensuring the client's safety
When a client is on restraint orders, can the client be left unattended without the restraint on?
No
What are four things restraints should do?
Never interfere with treatment
Restrict movement as little as necessary to ensure safety
Fit properly
Be easily changed to decrease the chance of injury and to provide for the greatest level of dignity
What does the documentation for restraints include?
The behavior that makes the restraint necessary
Nursing interventions used prior to the placement of restraints
Client's LOC
Type of restraint used and location
Education/explanations to the client and family
Exact time of application and removal
Client's behavior while restrained
Type and frequency of care
Attempts to use alternate restraints with client's response
Client's response when the restraint is removed
When developing a plan of care for a client with a history of seizures, what should be assessed?
Frequency of seizures
Type and date of last seizure
Medication
Triggers or trends of the seizures
What rescue equipment needs to be at the bedside of a patient on seizure precautions?
Oxygen
Oral airway
Suction equipment
Saline lock for IV access if the client is at high risk for experiencing a generalized seizure
To reduce risk of injury, the client should be assisted in ___________ and ______________
Ambulation; transfer
What should all caregivers and family be advised to not do in the event of a seizure?
To not put anything in the client's mouth - except in status epilepticus when an airway is needed
How do you ensure a client's safety in the event of a seizure?
Do not restrain him
Lower him to the floor or bed
Protect his head
Remove nearby furniture
Provide privacy
Put him on his side if possible
Loosen clothing to prevent injury
Promote dignity of the client
After a seizure what should be done for the client?
Explain what happened
Provide comfort and understanding
Provide a quiet environment for the client to recover
When documenting a seizure, what should be included?
Precipitating behaviors
Description of the event
Report to the PCP
True or false: Use equipment only after a safety inspection and instruction of its use
True
When is equipment inspected?
Regularly by the engineering or maintenance department
By the user prior to use
Why is faulty equipment a hazard?
It can start a fire
Cause a shock
How is electrical equipment grounded and why?
Three-pronged plug and grounded outlet
To decrease the risk of electrical shock
When should outlet covers be used?
In environments with individuals at risk for sticking items into them
How should equipment be unplugged?
Using the plug - not the cord
What should be done with electrical equipment prior to cleaning?
Unplug it
What does JCAHO require all pumps to have to prevent an overdose of fluids or medications?
Free-flow protection
Do not overcrowd outlets and use extension cords only when absolutely necessary. If extension cords must be used in an open area, what should be done to the cord?
Tape the cords to the floor
The first response in the health care setting to fire is:
RACE
What does RACE stand for?
Rescue - protect and evacuate clients in immediate danger
Alarm - report the fire
Contain - contain the fire
Extinguish - extinguish the fire
What class of fire extinguisher is used for paper, wood, upholstery, rags or other types of trash?
Class A
What class of fire extinguisher is used for flammable liquids and gases?
Class B
What class of fire extinguisher is used for electrical fires?
Class C
What should be taught to the client for home fire safety?
"Stop, drop and roll"
Correct use and storage of oxygen
Emergency numbers near the phone
Stairs are well lit with nonslip tread
Family exit and meeting plan
Fire extinguishers and operable smoke and carbon monoxide detectors
In the event of fire, if possible, closing windows and doors, covering the mouth and nose with a damp cloth, and keeping the head as close to the floor as possible
What is the correct use and storage of oxygen in the home?
No open flames
Storing the container as instructed by the manufacturer
A nurse enters a client's room and discovers flames in the trash can. Identify the sequence of actions in response to a fire in a client care area.
RACE
Identify the order of priority for completion of each of the following interventions for a newly admitted client with a history of falls.
A. Survey the client's belongings
B. Complete a fall-risk assessment
C. Complete a physical assessment
D. Make arrangements for a home safety survey
E. Educate the family and client on the fall risks
A - 3
B - 1
C - 2
D - 5
E - 4
When doing an admission, the nurse surveys the personal belongings of an older adult client. The client's belongings include glasses, a hearing aid, cane, and a variety of medications. Identify a priority nursing diagnosis for this client based on this information.
D. risk for falls
What does ergonomics mean?
The factors or qualities in an object's design and/or use that contribute to comfort, safety, efficiency and ease of use
Prior to attempting to position or move a client, what type of assessment should the nurse do?
A mobility assessment
What does correct body alignment assist with?
Balance
What happens to the body's muscles when the body's center of gravity is stable?
No strain on the muscles
What happens to the body without correct body alignment?
Less control over balance
At increased risk for falls
How can you enhance balance?
Widen the base of support and ensure the center of gravity is within the base of that support
In which position is lateral with no support except for a pillow under the head, with the vertebrae straight without causing discomfort for the client?
Lying
When sitting and standing what is the best body alignment?
Head erect
Vertebral column straight and in S-shape from lateral view
Shoulder and hips parallel
In which position is the client lying supine with HOB elevated 45 - 90 degrees, and the knees may be slightly elevated?
Fowler's position
Which position allows for better chest expansion and ventilation and for better dependent drainage after abdominal surgeries?
Fowler's position
In which position is the client lying supine with HOB elevated 30 - 40 degrees, and the knees may be slightly elevated?
Semi-Fowler's position
Which position promotes lung expansion and decreases stress on the abdominal muscles?
Semi-Fowler's position
In which position is the client lying on his back with his head and shoulders elevated on a pillow?
Supine or dorsal recumbent position
In which position is the client lying flat on the abdomen with the head to one side?
Prone position
Which position promotes drainage from the mouth for clients with throat or oral surgery, but inhibits chest expansion?
Prone position
In which position is the client lying on his side with most of the weight on the dependent hip and shoulder. The arms should be flexed in front of the body with a pillow behind the back and hips to support the client and maintain the position.
Lateral or side-lying position
Which position is a good sleeping position, but the client must be turned regularly to prevent development of pressure ulcers on the dependent area?
Lateral or side-lying position
In which position is the client on his side halfway between lateral and prone positions with the lower arm behind the client while the upper arm is in front with the upper leg flexed?
Sims' or semi-prone position
Which position is a comfortable sleeping position for many clients and promotes oral drainage?
Sims' or semi-prone position
In which position is the entire bed tilted with the HOB lower than the foot of the bed?
Trendelenburg position
Which position is used during postural drainage and facilitates venous return?
Trendelenburg position
In which position is the entire bed tilted with the foot of the bed lower than the HOB?
Reverse Trendelenburg
Which position promotes gastric emptying and prevents esophageal reflux?
Reverse Trendelenburg
What needs to be assessed when determining need for transfer assistance and/or use of assistive devices?
Assess the client's ability to help with transfers
Determine the need for additional personnel or assistive devices
Assess and monitor the client's proper use of mobility aids
Include assistance or mobility aids needed for safe transfers and ambulation in POC
What are some appropriate nursing diagnoses for client positioning or immobility?
Risk for injury
Risk for impaired skin integrity
Impaired physical mobility
Risk for activity intolerance
For an immobile client when should position changes occur?
Every 1 to 2 hours or per facility/agency protocol or provider's orders
What do you assess to determine if there is an accumulation of secretions in the lungs?
Respiratory status
What should the nurse encourage the client to do to reduce stasis of secretions in the lungs and fully expand the lungs, which decreases the risk of pneumonia or respiratory complications?
Turn, cough and deep breathe or do incentive spirometry every 2 hours
What should be assessed regularly to determine increased risk for thrombosis -specifically in the lower extremities?
Circulatory status
What should the nurse encourage the client to do to promote circulation and prevent stasis?
Leg exercise
Ambulation
Fluids
Position changes
How can the risk of orthostatic hypotension be reduced?
By ambulating the client as soon as possible to increase venous return
Assist with transfers and ambulation to prevent falls
What types of treatments, ordered by the PCP, to decrease venous return and risk of thrombosis?
Medications - platelet inhibitors or anticoagulants
Intermittent pneumatic compression cuffs (IPCs) or sequential compression devices (SCDs)
Therapeutic elastic stockings
What do IPCs or SCDs do?
Increase venous return through external pressure
What to therapeutic elastic stockings do?
Exert external pressure on muscles promoting venous return
What is the center of gravity?
The center of a mass
Where is the body's center of gravity?
The pelvis
How is the center of gravity lowered?
Bend the hips and knees
True or false: Twisting the spine or bending at the waist minimizes risk for injury
False
Which direction should you face when moving a client?
The direction you are moving
Is it safer to push or pull from the center of gravity?
Pull
A client is being admitted to the surgical unit postoperatively with strict orders for no ambulation for 4 days. What assessments should be done to evaluate the risk for complications?
Skin
Circulatory
Respiratory
A postoperative client should be in a Semi-Fowler's position. The nurse determines the position is incorrect because
B. the HOB is at 50 degrees
Place the following steps in a mobility assessment in the correct sequence.
- Exercise tolerance
- Moving from supine to sitting on the side of the bed
- Gait
- Range of motion
Range of motion
Moving from supine to sitting on the side of the bed
Gait
Exercise tolerance
Which of the following positions promotes drainage from the mouth for clients with throat or oral surgery but inhibits chest expansion?
C. Prone position
What is asepsis?
The absence of illness-producing microorganisms
How is asepsis maintained?
Through the use of aspetic technique
What is the primary behavior associated with aseptic technique?
Hand hygiene
The use of precise practices to reduce the number, growth, and spread of microorganisms from an object or area. It is also know as "clean technique". What type of asepsis is this?
Medical asepsis
When is medical asepsis used?
Oral medication administration
Nasogastric tube management
Providing personal hygiene
The use of precise practices to eliminate all microorganisms from an object or area. Also known as "sterile technique". What type of asepsis is this?
Surgical asepsis
When is surgical asepsis used?
Parenteral medication administration
Insertion of urinary catheters
Surgical procedures
What is the number one measure to reduce the growth and transmission of infectious agents?
Good hand washing
What are the three essential components of good hand washing?
Soap or a chemical that contains an antimicrobial agent
Water
Friction
When are healthcare workers required to wash their hands?
Before and after every client contact
After removing gloves
After contact with body fluids
When hands are visibly soiled
After using the restroom
How long does the CDC recommend the handwashing time should be?
10 - 15 seconds to remove transient flora
Up to 2 min when hands are more soiled or in contact with high risk areas
What are additional examples of practices that reduce the growth and spread of microorganisms?
Changing linens daily
Cleaning floors and the client's bedside stand
Separating clean linen from contaminated materials into different areas
What helps control the contact and spread of microorganisms to both the PCP and the client?
The use of masks, gloves, gowns and protective eyewear
Why should items never be placed on the floor in the client environment, even soiled laundry?
Because the floor is considered grossly contaminated
Why should linens not be shaken out in the client environment?
To avoid raising dust which can be irritating to those in the environment
When a soiled item is moist, what type of bag should it be put in?
A plastic bag
What are things a PCP should do to prevent spread of microorganisms?
Follow facility/agency protocols for isolation and protection
Wash hair frequently and keep it short or pulled back to prevent contamination of the care area or client
Not wear artificial nails and keep the nails short and clean
Use hand lotion to prevent drying, chapping, and lesions on the hands
Not wear rings with grooves or stones that are difficult to clean
What are practices that maintain a sterile field?
Avoid coughing, sneezing or talking directly over a sterile field
Air movement should be controlled by special ventilation
Only sterile items may be in the sterile field
Do not reach across or above a sterile field
Items to be added to a sterile field must be held a minimum of 6 inches above the field
Keep all surfaces dry
Discard any sterile packages that become wet
What area of the sterile field is actually considered unsterile?
The outer wrappings and 1-inch edge of the packaging
What are the steps to opening a sterile package?
1. open the farthest edge away from you
2. open the side flaps
3. open the edge closest to you
How should sterile solutions be poured?
1. remove the bottle cap
2. place the bottle cap face up on the surface
3. hold the bottle with the label in the palm of the hand so that the solution does not run down the label
4. pour a small amount of the solution into an available receptacle (1 to 2 ml)
5. pour the solution onto the dressing or site without touching the bottle to the site
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it's important that the nurse
B. place a mask on the client to limit the spread of microorganisms into the surgical wound
A nurse is teaching a group of personal care assistants that the most effective way to decrease the spread of infection by
D. basic handwashing
While wearing sterile gloves, a nurse can touch any
A. object on the sterile field
Match each of the following practices to the best example.
A. medical asepsis practice
B. standard precautions
C. sterile field maintenance
D. contamination
1. a nurse wears gloves when emptying a bedpan each time
2. a nurse drops a sterile dressing on the floor
3. a nurse keeps her sterile hands above her waist
4. a nurse wipes off the client's bedside table
A - 4
B - 1
C - 3
D - 2
Which of the following statements are true of surgical asepsis and a sterile field? (select all that apply)
- The nurse should turn her back on the sterile field if she needs to cough
- The 1 inch edge around a sterile field is considered sterile
- A sterile item can touch another sterile item without contaminating it
- Sterile items must remain above the waist
- Surgical asepsis is also called "sterile technique"
- A sterile item can touch another sterile item without contaminating it
- Sterile items must remain above the waist
- Surgical asepsis is also called "sterile technique"
