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45 Cards in this Set
- Front
- Back
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What are the guidelines for the use of restraints?
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follow agency policy for specific guidelines
have a physician's order for the use of restraints or in an emergency, obtain an order after applying a restraint explain the restraint and the reasons for its use to the client and family apply the restraint to allow freedom of movement and assumption of normal position, without defeating the purpose of the restraint apply restraint securely, but not so tightly that they impede circulation apply restraints to they can be easily reomved in an emergency, but not by the client fasten the ties of a restraint to the part of the bedframe that moves when the head is elevated assess patient and restraint frequently (1/2 - 1 hr) remove limb restraints and exervise the limb and give skin care at least every 2 hrs. note color, temp, motion, pain, numbness, tingling |
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What should you document when using restraints?
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reason for restraint (assessment of the patient's behavior/activity resulting in restraint use)
type and site of restraint alternatives attempted reassessment every 4 hrs needs monitored every 2 hrs removal of restraints every 2 hrs |
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What are restraints?
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any method of physcially restricting a person's freedom of movement, physical activity, or normal acess to his/her body
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What is the purpose of restraints?
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medical treatment restraints are used to prevent patient falls and injuries and to prevent patient from pulling out lines or tubes
behavior management restraints are used to protect patient or others from patient with aggressive or desrtuctive behavior |
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What are the standards for restraint use?
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protect patients from injury in the least restrictive manner possible
try alternatives to restraints re-orienting patient explanation of reasons for lines, tubes, etc. reality links (clock, photos) have someone stay with the patient modify environment lighting diversional therapy (tv, radio) relaxation (back rub, music) assess and correct underlying problems when possible comfort needs consider drug sensitivity offer bathroom use frequently ongoing reassessment regarding continuing need when restraints are used: paitient is respected environment is safe and clean patient is still encouraged to participate in his care modesty/privacy is provided comfortable body temp is maintained physical and emotional well-being of patient is monitored, including toliet needs food and fluid needs privacy/dignity needs prevention of restraint use complications environmental needs |
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What are the types of restraints?
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jacket restraints (vest)
belt/waist restraints wrist/ankle restraints mitt restraints body restraints chemical restraints |
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What are some hazards of using restraints?
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tissue damage under the restraint
injury to other body parts (fractures, burns) immobility related problems (bone loss) nosocomial infections (pneumonia, UTI) worsens confusin, agitation, anxiety fosters depression, dependency, anger death (strangulation, fire) |
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Identify the types of risk to a client's safety within the health care environment.
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falls
procedure related accidents equipment related accidents fire scalds/burns |
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Identify specific safety guidelines and nursing interventions to prevent client falls, accidents or injuries.
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falls:
keep bed in low position leave water, tissues, bedpan/urinal within pt's reach as a last resort, use the lease restrictive restraint according to agency policy procedure related accidents: correctly ID pt know rationale for performing procedure (purpose, expected results, contraindications) know how to perform procedure correctly know implications of improper performance (type of harm that might occur) equipment related accidents: know how to operate equipment report unsafe conditions (frayed/broken cords, odors, sparks, etc) fire: know location of fire alarms, extinguishers, and exits know agency/policy procedure RACE do not go through fire doors do not use elevators evacuate only with order |
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Describe nursing responsibilities for fire safety
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R- rescuse anyone in immediate danger
A- activate the fire code system, notify the appropriate person C-confine the fire by closing the doors and windows E- evacuate patients |
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How can a person's occupation put them at a greater safety risk?
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exposure to excessive noise, pollution, toxic chemicals or vapors, or infectious agents
industrial equipment chemicals |
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How can a person's social behavior put them at a greater safety risk?
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risk takers
failure to wear protective equipment stress drugs or alcohol |
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How can a person's environment put them at a greater safety risk?
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pollutants and other environmental harzards
violence terrorism |
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How is mobility a safety hazard?
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any limitation in mobility is a safety hazard
paralysis or spinal cord injuries, or other neuromuscular disorders recent surgery and prolonged illness |
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How can lack of knowledge be a safety issue?
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if the pt doesn't know how to call for help or doesn't know what we expect from them
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Is inability to communicate a safety issue?
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YES! if pt is unable to communicate their needs to us
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How can a weakened health state be a safety issue?
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more susceptible to infection
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What are the steps to the nursing process?
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assessment
nursing diagnosis planning implementation evaluation |
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What to assess in the individual's history?
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history of:
falls drug or alcohol abuse family support systems home environment age of client health status |
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How to assess a physical examination of the individual?
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mobility status
ability to communicate level of awareness and orientation sensory perception domestic violence or neglect elderly abuse |
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How to perform a specific risk factor assessment (falls)?
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often go unreported
requires constant surveillance fall surveillance programs leading cause of injury fatality in adults older than 65 yr of age hip or other fractur, head trauma, soft tissue injury |
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What are some characteristics of high fall risk?
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> 65 yrs
documented history of falls impaired vision or sense of balance altered gaitor posture certain meds postural hypotension (orthostatic, when standing up BP falls) slowed reaction time confusion or disorientation impaired mobility weakness and physical frailty unfamilar environment |
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How to perform a specific risk factor assessment (fire)?
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how does pt heat their home
fire prevention and home safety should be taught in the healthcare facility know your policy and procedure in your facility |
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How to perform a specific risk factor assessment (poisoning)?
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consider developmental age
teach poison-proofing poison control centers |
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How to perform a specific risk factor assessment (suffocation and choking)?
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keep plastic bags out of child's reach
remove soft pillows or thick blankets from your infant's crib no waterbeds cut food into small pieces know CPR |
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How to perform a specific risk factor assessment (fire arm injuries)?
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keep guns and ammo stored separtely and locked up
install trigger locks on all guns discuss risk for injury with children |
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Nursing diagnosis and outcome id and planning.
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goals for the pt:
identify unsafe situations in his or her environment identify potential hazards in his or her environment demonstrate safety measures to prevent falls and other accidents establish safety priorities with family members or significant others demonstrate familiarity with his or her environment identify resources for safety info remain free of injury during hospitalization |
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What is implementation?
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Acquiring first aid knowledge
the temp. but immediate care rendered to an acutely ill or injured person until competent, professional care arrives. preventing injury, providing acute care for injured persons, and rehab services eliminate risk events |
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What to teach to promote safety?
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monitor internet use
school activities safety committees school emergency prepardness |
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Addressing developmental considerations for the neonate and infant.
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protection of developing fetus
teach parents about safety hazards car seats: rear facing safety seat placed in back seat for infants < 20 lbs and younger than 1 yr |
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Addressing developmental considerations of toddler and preschooler.
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childproofing!
vigilant supervision child abuse- physical, sexual, emotional |
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Addressing developmental considerations of school-aged children.
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accidents still leading cause of deaths
independence is not always good apporpirate care restraint proper protective equipment child abduction |
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Addressing developmental considerations in adolescents.
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away from home more
peer pressure MVA #1 cause of deaths for school-aged, adolescents, and young adults seat belt eduation drinking and driving smoking body piercing guns and violence sex and STDs internet |
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Addressing developmental considerations in adults.
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intimate partner violence
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Addressing developmental considerations in older adults.
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falls, fires, MVAs
slowed reaction time, visual chnages, impaired thinking |
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Orienting the person to surroundings.
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a person who is familiar with his or her own surroundings is less likely to experience an accidental injury
orient new pt to safety features and equipment in room explain and demonstrate adjustable bed and side rails, call system, TV and bathroom ID bands! |
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What is a sentinel event?
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unexpected occurrence involving death or serious psychological or physiological injury that requires an immediate investigation
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How to file an incident report.
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a confidential document that objectively describes the circumstances of an accident
also details the pt's response and the examination and treatment of the patient after the incident completed by the nurse immediately after the incident nurse also documents incident and its effect on the pt in the chart speak openly and honestly to the pt |
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How to maintain emergency preparedness?
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disaster- an event of greater magnitude that requires the response of people outside the community
natural (flooding, tornado) or man mande (toxic spill, war, terrorist act) |
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What is bioterrorism?
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involves the deliberate spread of pathogenic organisms into a community
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What is chemcial terrorism?
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involves the deliberate release of a chemical compound for the purpose of causing mass destruction
probably dispersed in enclosed space include pulmonary agents, cyanide, vesicants, nerve agents, incapacitating agents |
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what is mass trauma terrorism?
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bombs and other explosives used to inflict mass trauma
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How to evaluate?
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final step in nursing process
evaluate the effectivenss of the interventions can the patie: correctly identify unsafe environmental situations? implement safety measures? use available safety resources? remain free of injury? |
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How to apply an extremity restraint.
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dteremine need for restraints
confirm agency policy for application of restraints identify the pt explain reason for use to paitent and family. clarify how care will be given and how needs will be met. explain that restraints are temporary measures. perform hand hygiene apply restraint according to manufacturer's directions choose the least restrictive type of device that allows the greatest possible degree of mobility pad bony prominences wrap the restraint around the extremity with the soft part in contact with the skin. if hand mitt is being used pull over hand with cushion to teh palmar aspect of hand secure in place with the velcro straps or reverse clove hitch ensure that tow fingers can be inserted between the restraint and patients wrist or ankle maintain restrained extremity in normal anatomic position. use a quick release knot to tie the restraint to the bed framde not side rail. the restraint may also be attached to chair frame. the site should not be readily accessible to paitent assess the patient at least every hr or according to facility policy. assessment should include the placement of the restraint, neurovascular assessment of the affected extremity, and skin integrity. assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic and hallucinations remove restraint at least every 2 hrs or according to agency policy and pt need. perform range of motion exercises evaluate pt for continued need of restraint. reapply restraint only if contunued need is evident and order is still valid reasssure pt at regualr intervals. provide continued explanation of rationale for interventions, reorienttaion if necessary, and plan of care. keep call beel within easy reach perform hand hygiene |
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Steps to the get up and go test.
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have the pt sit in a straight-backed chair. observe his posture while seated
instruct the pt to stand. can he stand in one fluid motion, or does he need the use of his hands to push up into a standing position? doe she require multiple attempts to stand? once the pt is standing, ask him or her to keep his or her eyes open and stand as still as possible. then ask him to close his eyes. observe his stability ask him to open his eyes and walk 10 feet. once at that point, he should turn around and walk back to the chair |
