9.1 Lap / Safety / Test3

Front 1

K.T.

Asphyxiation

Back 1

- A lack of oxygen due to interrupted breathing

Front 2

K.T.

Burn

Back 2

Excessive exposure to thermal, chemical, electrical, or radioactive agents.

Front 3

K.T.

Chemical restraint

Back 3

Medications such as neuroleptics, anxiolytics, sedatives, and psychotropic agents used to control socially disruptive behavior. The purpose of restraints is to prevent the client from injuring self or others.

Front 4

K.T.

Electric Shock

Back 4

- Occurs when a current travels through the body to the ground rather than through electric wiring, or static electricity that builds up on the body.

Front 5

K.T.

Physical restraint

Back 5

Any manual method or physical or mechanical device, material, or equipment attached to the client’s body; they can not be removed easily and they restrict the client’s movement.

Front 6

K.T.

Safety monitoring device

Back 6

Electronic devices that are available to detect when clients are attempting to move or get out of a chair or bed.

Front 7

K.T.

Scald

Back 7

A burn from a hot liquid or vapor, such as steam.

Front 8

2. Discuss factors affecting safety. P. 670 (Kozier)

Back 8

The ability of people to protect themselves from injury is affected by such factors as age and development, lifestyle, mobility and health status, sensory-perceptual alterations, cognitive awareness, psychosocial state, ability to communicate, safety awareness, and environmental factors.

Front 9

2. Discuss how safety is impacted by Lifestyle:

Back 9

unsafe work environments; residence in neighborhoods with high crime rates; access to guns and ammunition; sufficient income to buy safety equipment or make necessary repairs; access to illicit drugs (may also be contaminated by harmful additives) Risk-taking behavior is a factor in some accidents.

Front 10

2. Discuss how safety is impacted by Mobility and health status

Back 10

People who have impaired mobility due to paralysis, muscle weakness, and poor balance or coordination are obviously prone to injury. Stroke, spinal cord

Front 11

2. Discuss how safety is impacted by Sensory-Perceptual Alterations

Back 11

Accurate sensory perception of environmental stimuli is vital to safety. People with impaired touch perception, hearing, taste, smell, and vision are highly susceptible to injury.

Front 12

2. Discuss how safety is impacted by Cognitive Awareness

Back 12

include people lacking sleep; unconscious or semiconscious persons; disoriented people; people who perceive stimuli that do not exist, and people whose judgment is altered by disease or medications, such as narcotics, tranquilizers, hypnotics, and sedatives. (morphine drip)

Front 13

2. Discuss how safety is impacted by Emotional state

Back 13

Stressful situations can reduce a person’s level of concentration, cause errors of judgment, and decrease awareness of external stimuli. People with depression may think and react to environmental stimuli more slowly than usual.

Front 14

2. Discuss how safety is impacted by Ability to communicate

Back 14

Individual with diminished ability to receive and convey information are also at risk for injury. (Aphasia… brain injury affects ability to transmit or understand speech)

Front 15

2. Discuss how safety is impacted by Safety Awareness

Back 15

Information is crucial to safety. Clients in unfamiliar environments frequently need specific safety information. Lack of knowledge about unfamiliar equipment, such as oxygen tanks, intravenous tubing, and hot packs is a potential hazard.

Front 16

K.T.

Asphyxiation

Back 16

- A lack of oxygen due to interrupted breathing

Front 17

K.T.

Burn

Back 17

Excessive exposure to thermal, chemical, electrical, or radioactive agents.

Front 18

K.T.

Chemical restraint

Back 18

Medications such as neuroleptics, anxiolytics, sedatives, and psychotropic agents used to control socially disruptive behavior. The purpose of restraints is to prevent the client from injuring self or others.

Front 19

K.T.

Electric Shock

Back 19

- Occurs when a current travels through the body to the ground rather than through electric wiring, or static electricity that builds up on the body.

Front 20

K.T.

Physical restraint

Back 20

Any manual method or physical or mechanical device, material, or equipment attached to the client’s body; they can not be removed easily and they restrict the client’s movement.

Front 21

K.T.

Safety monitoring device

Back 21

Electronic devices that are available to detect when clients are attempting to move or get out of a chair or bed.

Front 22

K.T.

Scald

Back 22

A burn from a hot liquid or vapor, such as steam.

Front 23

2. Discuss factors affecting safety. P. 670 (Kozier)

Back 23

The ability of people to protect themselves from injury is affected by such factors as age and development, lifestyle, mobility and health status, sensory-perceptual alterations, cognitive awareness, psychosocial state, ability to communicate, safety awareness, and environmental factors.

Front 24

2. Discuss how safety is impacted by Lifestyle:

Back 24

unsafe work environments; residence in neighborhoods with high crime rates; access to guns and ammunition; sufficient income to buy safety equipment or make necessary repairs; access to illicit drugs (may also be contaminated by harmful additives) Risk-taking behavior is a factor in some accidents.

Front 25

2. Discuss how safety is impacted by Mobility and health status

Back 25

People who have impaired mobility due to paralysis, muscle weakness, and poor balance or coordination are obviously prone to injury. Stroke, spinal cord

Front 26

2. Discuss how safety is impacted by Sensory-Perceptual Alterations

Back 26

Accurate sensory perception of environmental stimuli is vital to safety. People with impaired touch perception, hearing, taste, smell, and vision are highly susceptible to injury.

Front 27

2. Discuss how safety is impacted by Cognitive Awareness

Back 27

include people lacking sleep; unconscious or semiconscious persons; disoriented people; people who perceive stimuli that do not exist, and people whose judgment is altered by disease or medications, such as narcotics, tranquilizers, hypnotics, and sedatives. (morphine drip)

Front 28

2. Discuss how safety is impacted by Emotional state

Back 28

Stressful situations can reduce a person’s level of concentration, cause errors of judgment, and decrease awareness of external stimuli. People with depression may think and react to environmental stimuli more slowly than usual.

Front 29

2. Discuss how safety is impacted by Ability to communicate

Back 29

Individual with diminished ability to receive and convey information are also at risk for injury. (Aphasia… brain injury affects ability to transmit or understand speech)

Front 30

2. Discuss how safety is impacted by Safety Awareness

Back 30

Information is crucial to safety. Clients in unfamiliar environments frequently need specific safety information. Lack of knowledge about unfamiliar equipment, such as oxygen tanks, intravenous tubing, and hot packs is a potential hazard.

Front 31

2. Discuss how safety is impacted by Environmental Factors

Back 31

home: requires well-maintained flooring and carpets, nonskid bathtub / shower surface, functioning smoke alarms that are strategically placed, knowledge of fire escape routes.
workplace: machinery, industrial belts and pulleys, and chemicals may create danger. Fatigue is also a major factor.
community: Adequate street lighting, safe water and sewage treatment, and regulation of sanitation in food buying and handling; free of excess noise, crime, traffic congestion, dilapidated housing, or unprotected creeks and landfills.

Front 32

3. Describe the classification of fires and devices used for extinguishing various types of fires. (Kozier p. 678)

Back 32

Class A: Paper, wood, upholstery, rags, ordinary rubbish
Class B: Flammable liquids and gases
Class C: Electrical
The right type of extinguisher must be used to fight the fire. Extinguishers have picture symbols showing the type of fire for which they are to be used. Directions for use are also attached.

Front 33

3. List client evacuation techniques:

Back 33

RACE= REMOVE/rescue… alarm… contain…extinguish
• emergency numbers near the telephone, or stored for speed dialing
• smoke alarms are operable and appropriately located
• Teach clients to change the batteries in their smoke alarms annually on a special day such as a birthday or January 1.
• Have a family “Fire Drill” plan. Every member needs to know the plan for the nearest exit from different locations of the home.
• Keep fire extinguishers available and in working order.
• Close windows and doors if possible; cover the mouth and nose with a damp cloth when exiting through a smoke-filled area; and avoid heavy smoke by assuming a bent position with the head as close to the floor as possible.

Front 34

4. Describe safeguards to prevent falls in the home and hospital relative to Poor Vision
(Kozier 679-680)

Back 34

• Ensure eyeglasses are functional.
• Ensure appropriate lighting.
• Mark doorways and edges of steps as needed.
• Keep the environment tidy.

Front 35

4. Describe safeguards to prevent falls in the home and hospital relative to Cognitive dysfunction (confusion, disorientation, impaired memory or judgment)
(Kozier 679-680)

Back 35

• Set safe limits to activities
• Remove unsafe objects.

Front 36

4. Describe safeguards to prevent falls in the home and hospital relative to Impaired gait or balance and difficulty walking because of lower extremity dysfunction (e.g. arthritis)
(Kozier 679-680)

Back 36

• Wear shoes or well-fitted slippers with nonskid soles.
• Use ambulatory devices as necessary (cane, crutches, walker,wheelchair)
• Provide assistance with ambulation as needed
• Monitor gait and balance
• Adapt living arrangements to one floor if necessary
• Encourage exercise and activity as tolerated to maintain muscle strength, joint flexibility, and balance.
• Ensure uncluttered environment with securely fastened rugs.

Front 37

4. Describe safeguards to prevent falls in the home and hospital relative to
Difficulty getting in and out of chair or in and out of bed (Kozier 679-680)

Back 37

• Encourage client to request assistance.
• Keep the bed in the low position
• Install grab bars in bathroom.
• Provide raised toilet seat.

Front 38

4. Describe safeguards to prevent falls in the home and hospital relative to Orthostatic hypotension
(Kozier 679-680)

Back 38

• Instruct client to rise slowly from a lying to sitting to standing position, and to stand in place for several seconds before walking.

Front 39

4. Describe safeguards to prevent falls in the home and hospital relative to Urinary frequency or receiving diuretics
(Kozier 679-680)

Back 39

• Provide a bedside commode.
• Assist with voiding on a frequent and scheduled basis.

Front 40

4. Describe safeguards to prevent falls in the home and hospital relative to Weakness from disease process or therapy
(Kozier 679-680)

Back 40

• Encourage client to summon help
• Monitor activity tolerance

Front 41

4. Describe safeguards to prevent falls in the home and hospital relative to Current Medication regimen that includes sedatives, hypnotics, tranquilizers, narcotic analgesics, diuretics.
(Kozier 679-680)

Back 41

• Attach side rails to the bed.
• Keep the rails in place when the bed is in the lowest positon.
• Monitor orientation and alertness status.
• Discuss how alcohol contributes to fall-related injuries.
• Encourage client not to mix alcohol and medications and to avoid alcohol when necessary
• Encourage annual or more frequent review of all medication prescribed.

Front 42

4. Describe safeguards to prevent falls in the home and hospital relative to Hospital
(Kozier 679-680)

Back 42

• On admission, orient clients to their surrounding and explain the call system.
• Carefully assess the client’s ability to ambulate and transfer. Provide walking aids and assistance as required
• Closely supervise the clients at risk for falls, especially at night.
• Encourage the client to use the call bell to request assistance. Ensure that the bell is within easy reach.
• Place bedside tables and overbed tables near the bed or chair so that clients do not overreach and consequently lose their balance.
• Always keep hospital beds in the low position and wheels locked when not providing care so that clients can move in or out of bed easily.
• Encourage clients to use grab bars mounted in toilet and bathing areas and railings along corridors.
• Make sure nonskid bath mats are available in tubs and showers.
• Encourage the client to wear nonskid footwear.
• Keep the environment tidy; especially keep light cords from underfoot and furniture out of the way.
• Use individualized interventions (e.g. alarm sensitive to client position) rather than side rails for confused clients.

Front 43

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Walkways and stairway (inside and outside):
(p. 144)

Back 43

Note uneven sidewalks or paths, broken or loose steps, absence of handrails or placement on only one side of stairways, insecure handrails, congested hallways or other traffic areas, and adequacy of lighting at night.

Front 44

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Floors:
(p. 144)

Back 44

Note uneven and highly polished or slippery floors and any unanchored rugs or mats.

Front 45

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Furniture:
(p. 144)

Back 45

Note hazardous placement of furniture with sharp corners. Note chairs or stools that are too low to get into and out of or that provide inadequate support.

Front 46

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Bathroom(s):
(p. 144)

Back 46

Note presence of grab bars around tubs and toilets, nonslip surfaces in tubs and shower stalls, handheld showerhead, adequacy of night lighting, need for raised toilet seat or bath chair in tub or shower, ease of access to shelves, and water temp. regulated at a maximum of 49 degrees C(120 Farenheit).

Front 47

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Kitchen:
(p. 144)

Back 47

Note pilot lights (gas stove) in need of repair, inaccessible storage areas, and hazardous furniture.

Front 48

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Bedrooms:
(p. 144)

Back 48

Note adequacy of lighting, particular the availability of night-lights and accessibility of light switches, ease of access to commode, urinal, or bedpan, and need for hospital bed or bed rails.

Front 49

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Electrical:
(p. 144)

Back 49

Note unanchored or frayed electrical cords and outlets that are overloaded or near water.

Front 50

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Fire Protection:
(p. 144)

Back 50

Note presence or absence of smoke detectors, fire extinguisher, and fire escape plan, improper storage of combustibles(e.g. gasoline) or corrosives(rust remover).

Front 51

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Toxic substances:
(p. 144)

Back 51

Note improperly labeled cleaning solutions.

Front 52

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Communication devices:
(p. 144)

Back 52

Note presence of method to call for help, such as a telephone or intercom in the bedroom and elsewhere(e.g. kitchen), and access to emergency telephone numbers.

Front 53

5. List aspects to be considered when conducting an adult home hazard appraisal relative to • Medications:
(p. 144)

Back 53

Note medications kept beyond date of expiration, adequacy of lighting for medication cabinet or storage, and method of disposal of sharp objects such as needles used for injections.

Front 54

6. Identify measures to implement seizure precautions.
(Procedure 30-2 on page 683 kozier)

Back 54

(Procedure 30-2 on page 683 kozier)

Front 55

7. Identify and discuss the major causes of poisoning in children and adults.

Back 55

• The major reasons for poisoning in children are inadequate supervision and improper storage of many household toxic substances.
• Poisoning in elders usually results from accidental ingestion of a toxic substance (e.g. due to failing eyesight) or an overdose of a prescribed medication (e.g. due to impaired memory).
• Adolescent and adult poisonings are usually caused by insect or snake bites and drugs used for recreation or in suicide attempts.

Front 56

7. Identify measures to prevent poisoning. (kozier p. 684)

Back 56

focus on dissemination of information and counseling.
Implementing poison prevention for children is focused on teaching parents to “childproof” the environment, including disposing of unused medication properly by flushing them down a drain. Implementing poison prevention with elders focuses on safeguarding the environment and monitoring the underlying problems.
*** See “Preventing Poisoning” Box on p. 685.***
Poison Control Center will guide U.

Front 57

8. Identify steps to take to reduce electrical hazards. 1 through 6
(kozier p. 686)

Back 57

1. Check cords for fraying or other signs of damage before using an appliance. Do not use if damage is apparent.
2. Avoid overloading outlets and fuse boxes with too many appliances
3. Use only grounded outlets and plugs.
4. Always pull a plug from the wall outlet by firmly grasping the plug and pulling it straight out. Pulling a plug by its cord can damage the cord and plug unit.
5. Never use electric appliances near sinks, bathtubs, showers, or other wet areas, because water readily conducts electricity.
6. Keep electric cords and appliances out of the reach of young children.

Front 58

8. Identify steps to take to reduce electrical hazards. 7 through 12
(kozier p. 686)

Back 58

7. Place protective covers over wall outlets to protect young children
8. Have all noninsulated wiring in the home altered to meet safety standards.
9. Carefully read instructions before operating electric equipment. Clients who do not understand how to operate the equipment should seek advice.
10. Always disconnect appliances before cleaning or repairing them.
11. Unplug any appliance that has given a tingling sensation or shock and have an electrician evaluate it for stray current.
12. Keep electric cords coiled or taped to the ground away from areas of traffic to prevent others from damaging the cords or tripping over them.

Front 59

9. Discuss restraints (general):

Back 59

Restraints are protective devices used to limit the physical activity of the client or a part of the body. They can be classified as physical or chemical. Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to the client’s body; they cannot be removed easily and they restrict the client’s movement. Chemical restraints are medication such as neuroleptics, anxiolytics, sedatives, psychotropic agents used to control socially disruptive behavior. The purpose of restraints is to prevent the client from injuring self or others.

Front 60

9. Discuss restraints (lega):

Back 60

Increasingly, determining the need for safety measures is viewed as an independent nursing function. Because restraints restrict the individual’s freedom, their use has legal implications. Nurses need to know their agency’s policies and the state laws about restraining clients.
The U.S. Centers for Medicare and Medicaid Services published revised standards for use of restraints in the U.S. in 2001. They specify 2 standards for applying restraints.

Front 61

9. Discuss restraints (2 standards for applying):

Back 61

1. The behavior management standard- Client is in danger to self or others.
In the case of the behavior management standard, the nurse may apply restraints but the physician or other licensed independent practitioner must see the client within
1 hour for evaluation. A written restraint order for an adult, following evaluation, is valid for only 4 hours. If the client must be restrained and secluded, there must be continual visual and audio monitoring of the client’s status.
2. The acute medical and surgical care standard- Temporary immobilization of a client related to a procedure. This procedure permits up to 12 hours for obtaining the physician’s written order for the restraints. All orders must be renewed daily.
IN ALL CASES, RESTRAINTS SHOULD BE USED ONLY AFTER EVERY OTHER POSSIBLE MEANS OF ENSURING SAFETY HAVE BEEN TRIED (AND MUST BE DOCUMENTED).

Front 62

9. Discuss restraints (guidelines for selection type):

Back 62

Selecting a restraint- Before selecting a restraint, nurses need to understand its purpose clearly and measure it against the following 5 criteria.

• It restricts the client’s movement as little as possible. If a client needs to have one arm restrained, do not restrain the entire body.
• It does not interfere with the client’s treatments or health problem. If a client has poor blood circulation to the hands, apply a restraint that will not aggravate that circulatory problem.
• It is readily changeable. Restraints need to be changed frequently, especially if they become soiled. Keeping other guidelines in mind, choose a restraint that can be changed with minimal disturbance to the client.
• It is safe for the particular client. Choose a restraint with which the client cannot self-inflict injury. For example, a physically restrained person could incur injury trying to climb out of bed if one wrist is tied to the bed frame. A jacket restraint would restrain the person more safely.
• It is the least obvious to others. Both clients and visitors are often embarrassed by a restraint, even though they understand why it is being used. The less obvious the restraint, the more comfortable people feel.

See pages 689-693 for Guidelines for Applying Restraints.

Front 63

10. What are siderails? (Kozier p. 746)

Back 63

Side rails, or safety sides, are used on both hospital beds and stretchers. They are of various shapes and sizes and are usually made of metal. A bed can have two full-length side rails or four half- or quarter-length side rails (also called split rails). Devices to raise and lower side rails differ. Often one or two knobs are pulled to release the side and permit it to be moved. When side rails are being used, it is important that the nurse never leave the bedside while the rail is lowered. Some side rails have two positions: up and down. Others have three: high, intermediate, and low.

Front 64

10. Discuss the use of siderails. (Kozier p. 746)

Back 64

For decades, the use of side rails has been routine practice with the rationale that the side rails serve as a safe and effective means of preventing clients from falling out of bed. Research, however, has not validated this assumption. In fact, several studies have shown that raised side rails do not deter older clients from getting out of bed unassisted and have led to more serious falls, injuries, and even death.
The health care financing administration now mandates that nurses in both acute care and long-term care decrease the routine use of side rails. Alternatives to side rails do exist and can include low-height bed, mats placed at the side of the bed, motion sensors, and bed alarms.
CLINICAL ALERT Side rail entrapment, injuries, and deaths do occur. When side rails are used, the nurse must assess the client’s physical and mental status and closely monitor high risk (frail, elderly or confused) clients.

Front 65

11. State possible causes of choking/obstructed airway and identify the universal signs and symptoms of choking. (Kozier p. 685)

Back 65

Suffocation occurs when the air source is cut off for any reason. One common reason for choking is that food or a foreign object has become lodged in the throat. The universal sign of distress is the victim’s grasping the anterior neck and being unable to speak or cough. The emergency response is the Heimlich maneuver, or abdominal thrust, which can dislodge the foreign object and reestablish an airway.
Other causes of suffocation are drowning, gas or smoke inhalation, secretions, accidental coverage of the nose and mouth by a piece of plastic, accidental strangulation by the shoulder harness of a seat belt, and being trapped in a confined space (e.g. a discarded refrigerator).

Front 66

12. Apply the nursing process to clients with safety needs. Include the following NANDA diagnostic labels:
Risk for injuries
Deficient knowledge (accident prevention)
Relative to ASSESSMENT

Back 66

Assessing:
Assessing clients at risk for accidents and injury involves:
a) Not pertinent indicators in the nursing history and physical examination
b) Using specifically developed risk assessment
c) Evaluating the client’s home environment

Front 67

12. Apply the nursing process to clients with safety needs. Include the following NANDA diagnostic labels:
Risk for injuries
Deficient knowledge (accident prevention)
Relative to DIAGNOSIS

Back 67

Diagnosing:
A broad diagnostic label related to safety issues:

Risk for Injury: A state in which the individual is at risk for injury as a result of environmental conditions interacting with the individual’s adaptive and defense resources. (This broad label consists of seven subcategories that may be preferred when the nurse wants to describe injury more specifically and or isolate suitable interventions. These seven categories are all listed on page 672)

Another diagnosis the nurse may choose to use is:
Deficient Knowledge (Accident Prevention): Inability to state or explain information or demonstrate a required skill related to safety or self and others.

Front 68

12. Apply the nursing process to clients with safety needs. Include the following NANDA diagnostic labels:
Risk for injuries
Deficient knowledge (accident prevention)
Relative to PLANNING

Back 68

Planning:
When planning care to prevent accidents and injury, the nurse considers all factors affecting the client’s safety, specifies desired outcomes, and selects nursing activities to meet these outcomes. The major goal for clients with safety risks is to prevent accidents and injury. To meet this goal, clients often need to change their health behavior and may need to modify the environment.
Desired outcomes associated with preventing injury depend on the individual client.
Nursing interventions to meet desired outcomes are largely directed toward helping the client and family to accomplish the following:

• Identify environmental hazards in home and community.
• Demonstrate safety practices appropriate to the home health care agency, community, and workplace.
• Experience a decrease in the frequency or severity of injury.
• Demonstrate safe childrearing practices or lifestyle practices.

Front 69

12. Apply the nursing process to clients with safety needs. Include the following NANDA diagnostic labels:
Risk for injuries
Deficient knowledge (accident prevention)
Relative to IMPLEMENTATION

Back 69

Hazards to safety occur at all ages and vary according to the age and development level of the individual.
Measures to ensure the safety of people of all ages focus on:
a) Observation or prediction of potentially harmful situations so that harm can be avoided.
b) Client education that empowers clients to safeguard themselves and their families from injury. (See safety measures throughout the life span on p. 674)

Front 70

12. Apply the nursing process to clients with safety needs. Include the following NANDA diagnostic labels:
Risk for injuries
Deficient knowledge (accident prevention)
Relative to EVALUATION

Back 70

Evaluating:
To prevent injury, the nurse’s rose is largely educative and desired outcomes reflect the client’s acquisition of knowledge of hazards, behaviors that incorporate safety practices, and skills to perform in the event of certain emergencies. The nurse needs to individualize these for clients. Examples of desired outcomes include the client being able to do the following:

• Describe methods to prevent specific hazards (e.g. falls, suffocation, choking, fires, drowning, electric shock).
• Report use of home safety measures (e.g. fire safety measures, smoke detector maintenance, fall prevention strategies, burn prevention measures, poison prevention measures, safe storage of hazardous materials, firearm safety precautions, electrocution prevention, water safety precautions, bicycle safety, motor vehicle safety).
• Alter home physical environment to reduce the risk of injury
• Describe emergency procedures for poisoning and fire.
• Describe age-specific risks or work safety risks or community safety risks.
• Demonstrate correct use of child safety seats
• Demonstrate correct administration of cardiopulmonary resuscitation.

Front 71

Activity 1:

A 78 year old client has a diagnosis of PVD. He is receiving I.V. therapy and has been pulling at the dressing covering the insertion site. The night nurse documented that he tried to get out of bed by climbing over the bed rail just as she was coming in to check on him.

Back 71

Related Questions

1. What actions should the nurse take today to ensure that he does not fall out of bed?

The nurse should exercise the “acute medical and surgical care standard”.
The use of a jacket restraint would be a safer choice as opposed to a single wrist being tied; due to the fact that the client could still get hurt while attempting to climb over the bed rail.

2. What action should be taken to be sure he does not pull out the I.V.

The nurse should use mitt restraints to prevent the client from pulling out the I.V.

Front 72

Activity 2:

The client is an 85 year old woman in a nursing home. Despite efforts to provide for her safety without the use of restraints the night nurse found it necessary to apply wrist restraints around 2:00 a.m. because she was attempting to pull at her feeding tube.

Back 72

1. How often must the nurse assess the restraints on her.

Every 30 minutes. Read box on page 689.

2. How often must the restraints be removed and reapplied?

Release the restraint every 2 hours.

3. List two nursing actions to be carried out while the restraints are off.

• Provide skin care
• Provide range-of –motion exercises

4. Is it safe to leave her restraints off while the nurse is called to the telephone?

No. The nurse must never leave the bedside while the restraints are off. The client could harm herself.

Front 73

Activity 3:

Make a decision on the next 2 questions

Back 73

1. A nurse who discovers a fire should first:

a) Fight the fire with an extinguisher
b) Notify the switchboard of the fire
c) Evacuate clients in immediate danger
d) Activate the fire alarm

Front 74

Activity 3:

Make a decision on the next 2 questions

Back 74

2. An adult home hazard appraisal should assess for all of the following except

a) The number of bedrooms and bathrooms
b) The adequacy of lighting in the bedrooms
c) Medications kept beyond expiration dates
d) Highly polished or slippery floors