kozier and erb chapter 32

Kozier & Erb's Fundamentals of Nursing, 8eBerman, Snyder, Kozier, ErbCopyright 2008 by Pearson Education, Inc.

Chapter 32

Safety

Copyright 2008 by Pearson Education, Inc.

Question 1

Because a hospitalized elderly female client, who ambulates with a walker, is receiving diuretics which results in frequent trips to the bathroom at night, the nurse should perform which of the following?

1. Leave the bathroom light on.2. Withhold the client’s diuretic medication.3. Provide a bedside commode.4. Keep the side rails up.


Rationales 1

1. Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of falling when rushing to the bathroom.

2. The nurse cannot withhold a client’s medication without consultation with the physician.

3. Correct. A bedside commode decreases the number of steps required to reach the goal.

4. Rails up would increase the risks of falls as well as falling from a greater distance.


Question 2

Which NANDA nursing diagnosis is most applicable for toddlers?

1. Risk for Suffocation2. Risk for Injury3. Risk for Poisoning4. Risk for Disuse Syndrome


Rationales 2

1. The risk for suffocation could happen but is more likely with a newborn or infant, which is the reason parents are taught not to prop the bottle, to cut food in small pieces, and to use toys with no small detachable pieces.

2. Option 2 is too vague to address risks associated with a specific group of clients.

3. Correct. Remember that toddlers are active, like to explore, and are unable to use discretion about what they place in their mouths and as a result are at risk for poisoning (e.g., lead poisoning, toxic substances under the sink or in a drawer).

4. Option 4 is more applicable to the elder who is on total bed rest.


Question 3

A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), is unable to ambulate without help. What is the most appropriate safety measure?

1. Restrain the client in bed.2. Ask a family member to stay with the

client.3. Check the client every 15 minutes.4. Use a bed exit safety monitoring device.


Rationales 3

1. Option 1 can increase agitation and confusion and removes the client’s independence.

2. Option 2 would help but transfers the responsibility to the family member.

3. Option 3: Client could fall during the unobserved interval and is also not a realistic answer for a nurse.

4. Correct. Answer 4 is an intervention that can allow the client to feel independent and also alert the nurse and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety.


Question 4

Which of the following nursing interventions is the highest in priority for a client at risk for falls in a hospital setting?

1. Keep all of the side rails up.2. Review prescribed medications.3. Complete the “get up and go” test.4. Place the bed in the lowest position.


Rationales 41. Option 1 can cause a fall with injury because the

client may fall from a higher distance when trying to get over the rail.

2. Option 2 is important to do as certain meds can increase a risk of a fall (e.g., tranquilizers, analgesics).

3. Option 3 would help the nurse assess if a client is at risk for a fall.

4. Correct. Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting up if the bed is at an appropriate height. The nurse would discuss this with the primary care provider. While it may be a priority, placing the bed in the lowest position would be a higher priority in the hospital setting.


Question 5

When planning to teach health care topics to a group of male adolescents, the nurse should consider which of the following topics a priority?

1. Sports contribute to an adolescent’s self-esteem.

2. Sunbathing and tanning beds can be dangerous.

3. Guns are the most frequently used weapon for adolescent suicide.

4. A driver’s education course is mandatory for safety.


Rationales 5

1. Option 1 is true; however, it is not be as high a priority as preventing suicide.


3. Correct. Suicide and homicide are two leading causes of death among teenagers, and adolescent males commit suicide at a higher rate than adolescent females.

4. Option 4 is not true. A driver’s education course is certainly encouraged; however, completing a course does not ensure safe practice.


Factors Affecting Ability to Protect Self from Injury

• Age and development• Lifestyle• Mobility and health status• Sensory-perceptual alterations• Cognitive awareness• Emotional state• Ability to communicate• Safety awareness• Environmental factors


Assessing Clients at Risk for Injury

• Nursing history and physical examination

• Risk assessment tools • Assessment of client’s home

environment


National Patient Safety Goals (NPSGs)

1. Improve the accuracy of patient identification.

2. Improve the effectiveness of communication among caregivers.

3. Improve the safety of using medications.4. Reduce the risk of health care–associated

infections.5. Accurately and completely reconcile

medications across the continuum of care.6. Reduce the risk of patient harm resulting

from falls.

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/



7. Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.

8. Reduce the risk of surgical fires.9. Implement applicable National Patient Safety

Goals and associated requirements by components and practitioner sites.

10. Encourage the active involvement of patients and their families in the patient’s care as a patient safety strategy.

11. Prevent health care–associated pressure ulcers (decubitus ulcers).


Common Potential Hazards: Developing Fetus

• Exposure to maternal smoking, alcohol consumption, addictive drugs

• X-rays (first trimester)• Certain pesticides


Common Potential Hazards: Newborns and Infants

• Falling• Suffocation in cribs• Choking from aspirated milk or ingested

objects• Burns from hot water or other spilled hot

liquids• Motor vehicle crashes• Cribs or playpen injuries• Electric shock• Poisoning


Common Potential Hazards: Toddlers

• Physical trauma from falling, banging into objects, or getting cut by sharp objects

• Motor vehicle crashes

• Burns• Poisoning• Drowning• Electric shock


Lead Poisoning Animation

Click here to view an animation on lead poisoning.

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Common Potential Hazards:Preschoolers

• Injury from traffic, playground equipment, and other objects

• Choking, suffocation, and obstruction of airway or ear canal by foreign objects; poisoning

• Drowning• Fire and burns• Harm from other people or animals


Common Potential Hazards: Adolescents

• Motor vehicle or bicycle crashes• Recreational injuries• Firearms• Substance abuse


Common Potential Hazards:Older Adults

• Falling• Burns• Motor vehicle crashes and pedestrian

injuries


Nursing Diagnoses for Clients at Risk for Injury

• Risk for Injury – Risk for Poisoning– Risk for Suffocation– Risk for Trauma– Latex Allergy Response– Risk for Aspiration– Risk for Disuse Syndrome

• Deficient Knowledge (Injury Prevention)


Desired Outcomes for Clients with Safety Risks

• Prevent injury• Often need to change health

behavior • Modify their environment • Desired outcomes depend on

individual client


Nursing Interventions for Clients

at Risk for Injury• Helping the client and family 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


Preventing Thermal Injuries

• Pot handles should not protrude over edge of stove

• Electrical appliances should be out of reach of crawling infants and young children

• Bath water should not be excessively hot• Monitor clients with impaired skin

sensitivity• Use care when using therapeutic

applications of heat


Preventing Agency Fires

• Be aware of fire safety regulations and fire prevention practices of the agency

• If fire occurs:– Protect and evacuate clients who are in

immediate danger– Report the fire– Contain the fire– Extinguish the fire


Preventing Home Fires

• Teach fire safety• Keep emergency numbers near the

telephone, or stored for speed dialing• Be sure smoke alarms are operable and

appropriately located • Teach to change batteries in smoke alarms

annually on a special day• Have a family “fire drill”• Keep fire extinguishers available and in

working order


Preventing Home Fires

• If fire occurs:– Close windows and doors, if possible– Cover mouth and nose with damp cloth– Avoid heavy smoke by assuming bent

position with head close to floor as possible


Preventing Poisoning

• Teaching parents to “childproof” the environment

• Providing information and counseling about insect, snake bites and drugs used for recreational purposes

• Safeguarding the environment and monitoring the underlying problems to prevent accidental ingestion of toxic substances

• Teaching the telephone number of poison control centers

• Educating the public about what to do in the event of poisoning


Preventing Choking and Suffocation

• Teach universal distress signal• Teach Heimlich maneuver


Minimizing Excessive Noise

• Minimize noise in the hospital setting• Encourage clients to protect hearing

as much as possible• Noise can be minimized in several

ways:– Acoustic tile on ceilings, walls, and floors – Drapes and carpeting absorb

– Background music


Reducing Electrical Hazards

• Properly grounded electrical equipment

• Using machines in good repair• Wearing shoes with rubber shoes• Standing on a nonconductive floor

• Using nonconductive gloves


Firearm Safety

• Store all guns in sturdy locked cabinets without glass

• Make sure the keys are inaccessible to children

• Store the bullets in a different location• Tell children never to touch a gun or stay in

a friend’s house where a gun is accessible• Teach children never to point the barrel of a

gun at anyone• Ensure the firearm in unloaded and the

action open when handing to someone else


Firearm Safety

• Don’t handle firearms while affected by alcohol or drugs of any kind, including pharmaceuticals

• When cleaning or dry firing a firearm, remove all ammunition to another room

• Double-check the firearm when entering the room used to clean the firearm

• Have firearms that are regularly used inspected by a qualified gunsmith at least every 2 years


Protecting Against Radiation

• Limit time near source• Provide as much distance as possible

from source• Use shielding devices• Be familiar with agency protocols


Planning for Bioterrorism

• Important health care personnel and facilities plan and prepare for the unknown

• Healthcare organizations expected to address four specific phases of disaster planning– Mitigation– Preparedness– Response – Recovery

• Should participate annually in at least one community-wide practice drill


Measures to Prevent Falls

• Orient clients to surroundings 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 and 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

• 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 clients to wear nonskid footwear



• Keep the environment tidy, especially keeping light cords from underfoot and furniture out of the way

• Use individualized interventions, e.g. electronic devices, rather than side rails for confused client


Potential Environmental Causes of Falls

• Inadequate lighting• Presence of electrical

cords, loose rugs, clutter and slippery floors

• Absent or unsteady railings

• Uneven step height or surfaces

• Unsteady base on furniture

• Lack of armrests on chairs

• Cabinets that are too high or too low

• Inappropriate toilet height

• Slippery floors in the bathroom

• Absence of grab bars


Seizure Precautions

• Pad the bed by securing blankets, linens around the head, foot, and side rails of the bed

• Put oral suction equipment in place and test to ensure that it is functional

• Children who have frequent seizures should wear helmets for protection.


Seizure Precautions

• In the home, safety precautions if seizures are not well-controlled include restriction or direct supervision by others for certain activities:– Tub bathing– Swimming– Cooking– Using electrical equipment or machinery – Driving


Alternatives to Restraints

• Assign nurses in pairs • Place unstable clients in an area that

is constantly or closely supervised• Prepare clients before a move to limit

relocation shock• Stay with a client using a bedside

commode or bathroom if confused, sedated or has a gait disturbance or a high risk score for falling



• Monitor all the client’s medication and if possible lower or eliminate dosages of sedatives or psychotropics

• Position beds in lowest position• Replace full-length side rails with

half- or three-quarter length rails



• Use rocking chairs to help confused clients expend some energy

• Wedge pillows or pads against the sides of wheelchairs

• Place a removable lap tray on a wheelchair



• Try a warm beverage, soft lights, a back rub or a walk

• Use “environmental restraints”• Place a picture or other personal item on

the door to the client’s room• Try to determine the causes of the client’s

sundowner syndrome • Establish ongoing assessment


Use and Legal Implications of Restraints

• Restraints restrict the individual’s freedom

• U.S. Centers for Medicare and Medicaid Services standards– Behavior management standard – Acute medical and surgical care

standard


Behavior Management Standard

• Nurse may apply restraints but the physician or other licensed independent practitioner must see the client within 1 hour for evaluation

• Written restraint order for an adult, following evaluation, valid for only 4 hours.

• Must be continual visual and audio monitoring if client restrained and secluded


Medical Surgical Care Standard

• Up to 12 hours for obtaining the physician’s written order

• Orders renewed daily• Order must state the reason and time period• PRN order prohibited• In all cases, restraints used only after every

possible means of ensuring safety unsuccessful and documented

• Nurses must document need for the restraint made clear both to client and family


Use and Legal Implications of Restraints


Desired Outcomes for Injury Prevention

• Nurse’s role largely educative• Desired outcomes reflect:

– Acquisition of knowledge of hazards– Behaviors that incorporate safety

practices– Skills to perform in the event of certain

emergencies


Examples of Desired Outcomes

• Describe methods to prevent specific hazards

• Report use of home safety measures• Alter home physical environment to

reduce risk of injury


Examples of Desired Outcomes

• 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


Question 1

Because a hospitalized elderly female client, who ambulates with a walker, is receiving diuretics which results in frequent trips to the bathroom at night, the nurse should perform which of the following?

1. Leave the bathroom light on.2. Withhold the client’s diuretic medication.3. Provide a bedside commode.4. Keep the side rails up.