Safety 🦺 Week 2 Module

last chat gpt quiz - 10/14

last ati quiz - 10/12

Week 2 Module – Safety Overview

Musculoskeletal and Nervous Systems

• The musculoskeletal and nervous systems work together to coordinate movement, positioning, and balance.

Proper Body Mechanics

• Employing proper body mechanics like:

  • A stable center of gravity

  • A wide base of support

  • Proper body alignment can help in:

  • Reducing the risk of injury from physical strain.

Ergonomics

• Ergonomics is a field focused on:

  • Designing, adjusting, and arranging items for safer and more efficient use by individuals.

Impacts of Immobility

• Immobility Effects: Widespread negative impacts on:

  • Musculoskeletal System

  • Cardiac System

  • Respiratory System

  • Gastrointestinal System

  • Genitourinary System

  • Integumentary System

  • Mental Health (psyche)

Nursing Practice for Clients with Mobility Deficits

• Nurses must:

  • Plan assessments and interventions to minimize complications from altered mobility.

  • Address age-related changes in older adults that affect mobility:

  • Musculoskeletal and nervous system changes

  • Vision changes

Mobility Assessments

• Prior to ambulating or transferring a client:

  • Conduct a mobility assessment to gauge client abilities and necessary staff support.

• Assistive Devices:

  • Choose devices based on individual client needs and verify proper fit and usage.

Repositioning

• Clients unable to change positions independently should be repositioned every 2 hours, ensuring:

  • Comfort

  • Proper body alignment.

Range of Motion (ROM) Exercises

• Promote mobility and preserve joint flexibility through:

  • Regular range of motion exercises.

Physical Exercise

• Positive impact on:

  • Health outcomes

  • Quality of life

  • Reduction in fall risks

National Patient Safety Goals (NPSGs)

Overview

• The Joint Commission (TJC) establishes NPSGs annually to improve client safety and healthcare effectiveness:

  • Focus on reducing hospital-acquired conditions.

NPSG: Identify Clients Correctly

• Goal: Ensure accurate client identification through:

  • Use of two client identifiers (e.g., name, date of birth).

  • Verify all medications, treatments, procedures, or care intended for the specific client.

  • Verification methods may involve:

  • Asking open-ended questions (e.g., "What is your name?")

  • Cross-checking with ID bracelet or electronic medical records.

• Avoiding using room numbers for identification.

NPSG: Improve Staff Communication

• Goal: Report critical results promptly.

• Critical results are defined as lab or diagnostic results that are significantly outside expected ranges, potentially leading to severe outcomes:

  • Example: Sodium level below 135 mEq/L can lead to seizures.

• Facilities should define and adhere to guidelines for:

  • Timely reporting of critical results.

  • Ensuring results are communicated to the provider directly, never via voicemail for urgent cases.

NPSG: Use Medications Safely

• Goals include:

  • Labeling all medications especially before procedures.

  • Reducing medication errors with anticoagulant medications.

  • Establishing accurate medication lists that providers reconcile against new prescriptions.

NPSG: Alarms Safety

• Reduce risk of harm through clinical alarm systems:

  • Proper implementation and management are essential to prevent alarm fatigue amongst staff, which may lead to overlooked critical alerts.

NPSG: Prevent Hospital-Acquired Infections (HAIs)

• Types of HAIs:

  • Central line-associated bloodstream infection (CLABSI)

  • Catheter-associated urinary tract infection (CAUTI)

  • Surgical-site infection (SSI)

  • Ventilator-associated pneumonia (VAP)

• TJC emphasizes monitoring, analyzing, and developing policies to minimize infection rates related to HAIs, particularly those involving multidrug-resistant organisms (MDROs).

Multidrug-resistant Organisms (MDROs)

• MDROs pose a significant threat in healthcare settings and their management includes:

  • Proper hand hygiene, as evidenced to reduce HAIs significantly.

NPSG: Hand Hygiene

• Imperative for reducing infection spread:

  • Importance of educating healthcare workers on effective hand hygiene practices.

Client Safety Risk Identification

NPSG: Identify Client Safety Risks

• Example::

  • Suicide: The tenth leading cause of death in the U.S. requires:

  • Implementation of suicide prevention measures for at-risk clients with proper screening and ongoing monitoring.

Surgical Safety Protocol

Universal Protocol: Prevention of Adverse Events in Surgery

• Ensure safety through verification steps:

  • Conducting a time-out to confirm client identity, site, and procedure.

• Two identifiers are critical in this process.

Improving Health Care Equity

• Focus on reducing disparities that affect patient safety, including assessing patients' social needs such as:

  • Literacy

  • Housing

  • Transportation

  • Access to nutritious food.

NPSG: Standards of Compliance

• Facilities must maintain compliance with safety standards to retain accreditation, including:

  • Infection control

  • Medication management

Creating a Culture of Safety

Overview

• The Institute of Medicine emphasizes creating a safety-focused culture in healthcare that promotes proactive error reporting and encourages open communication among staff.

Transforming Care at the Bedside

• Initiatives to enhance nursing presence at the bedside, including:

  • Implementing hourly rounding to check on client needs and improving direct care delivery.

Safety Assessments and Hazard Evaluations

General Guidelines

• Regular safety assessments must identify potential hazards to clients and staff alike, including:

  • Environmental hazards

  • Protocols for medication delivery

  • Procedures for emergency situations

Chemical, Electrical, Radiation Safety

Chemical Safety

• Nurses must assess chemical exposure risks and implement safety measures based on OSHA requirements.

Electrical Safety

• Identify risks associated with electrical devices and take necessary precautions to prevent injury.

Radiation Safety

• Proper handling and exposure precautions must be communicated to staff, especially during imaging studies.

Fall Prevention Practices

Assessment Measures

• Conduct fall risk assessments upon admission, utilizing tools like the Morse Fall Scale to guide nursing actions.

Implementation of Safety Measures

• Universal fall precautions encompass measures such as:

  • Using non-skid footwear

  • Keeping beds in the lowest position

  • Educating clients on safety procedures.

Restraint Utilization and Procedures

Restraint Categories

• Physical, mechanical, chemical, barriers, or seclusion are categories defined by their function and application in safety protocols.

Nursing Role in Restraints

• Strict adherence to policies related to the when and how of applying restraints, continuous monitoring, and documentation of their use is essential for client safety and comfort.

Chapter 12: Client Safety

Safety is freedom from injury. Providing for safety and preventing injury are major nursing responsibilities.

Many factors affect clients’ ability to protect themselves. Those factors include the client’s age, with the young and old at greater risk; mobility; cognitive and sensory awareness; emotional state; ability to communicate; and lifestyle and safety awareness.

It is the provider’s responsibility to assess, report, and document clients’ allergies and to provide care that avoids exposure to allergens.

Nursing Actions

• Use risk assessment tools to evaluate clients and their environment for safety.

• Encourage clients to speak up and take an active role in their health care and in preventing errors.

• Create a culture of checks and balances to avoid errors when working in stressful circumstances.

• Communicate risk factors and plans of care to clients, family, and other staff.

• Use protocols for responding to dangerous situations.

• Adopt quality care priorities from the National Quality Forum, including “Never Events.”

• Use current evidence to promote a culture of safety, while using the National Patient Safety Goals as a guide.

• Know the facility’s disaster plan, understand the chain of command and roles, and use common terminology when communicating with the team.

• Identify and document incidents and responses according to the facility’s policy. These reports help identify trends, patterns, and the root cause of adverse events. QS

• Know the location of safety data sheets and hazardous chemicals in the environment.

• Use equipment only after adequate instruction and safety inspection.

Falls

• Older adult clients can be at an increased risk for falls due to decreased strength, impaired mobility and balance, improper use of mobility aids, unsafe clothing, environmental hazards, endurance limitations, and decreased sensory perception. G​​​​​​​

• Other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems (cerebral palsy, injury, multiple sclerosis), and cognitive dysfunction. Adverse effects of medications (orthostatic hypotension, drowsiness) can also increase the risk for falls.

• Clients are at greater risk for falls when they have more than one risk factor.

• Prevention of client falls is a major nursing priority. Nurses must evaluate all clients in health care facilities for risk factors for falls and implement preventative measures accordingly.

• Programs to prevent falls are essential for settings that provide services to older adult clients.

• Health care facilities must actively prevent falls, especially because Medicare and Medicaid no longer reimburse for treating injuries resulting from falls.

Preventing Falls

• Complete a fall-risk assessment for each client at admission and at regular intervals. Individualize the plan for each client according to the results of the fall-risk assessment. For example, instruct a client who has orthostatic hypotension to avoid getting up too quickly, to sit on the side of the bed for a few seconds prior to standing, and to stand at the side of the bed for a few seconds prior to walking.

• Be sure the client knows how to use the call light (by giving a return demonstration), that it is in reach, and to encourage its use.

• Respond to call lights in a timely manner.

• Use fall-risk alerts (color-coded wristbands).

• Provide regular toileting and orientation of clients who have cognitive impairment.

• Provide adequate lighting.

• Orient clients to the setting to make sure they know how to use all assistive devices (grab bars) and can locate necessary items.

• Place clients at risk for falls near the nurses’ station.

• Provide hourly rounding.

• Make sure’ bedside tables, overbed tables, and frequent-use items (telephone, water, facial tissues) are within reach.

• Keep the bed in the low position and lock the brakes.

• For clients who are sedated, unconscious, or otherwise compromised, keep the side rails up.

• Avoid the use of full side rails for clients who get out of bed or attempt to get out of bed without assistance.

• Provide nonskid footwear and nonskid bath mats for use in tubs and showers.

• Use gait belts and additional safety equipment when moving clients.

• Keep the floor clean, dry, and free from clutter with a clear path to the bathroom (no scatter rugs, cords, or furniture).

• Keep assistive devices nearby after validation of safe use (eyeglasses, walkers, transfer devices).

• Educate the client and family about safety risks and the plan of care. Clients and family who are aware of risks are more likely to call for assistance.

• Lock the wheels on beds, wheelchairs, and carts to prevent them from rolling during transfers or stops.

• Use electronic safety monitoring devices (chair or bed sensors) for clients at risk for getting up without assistance to alert staff of independent ambulation.

• Report and document all incidents. This provides valuable information that can help prevent similar incidents.

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Select all that apply.

A

Place a belt restraint on the client when they are sitting on the bedside commode.

B

Keep the bed in its lowest position with all side rails up.

C

Make sure that the client’s call light is within reach.

D

Provide the client with nonskid footwear.

E

Complete a fall-risk assessment.

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?

A

Complete a fall-risk assessment.

B

Educate the client and family about fall risks.

C

Eliminate safety hazards from the client’s environment.

D

Make sure the client uses assistive aids in their possession.

Seizures

A seizure is a sudden surge of electrical activity in the brain. It can occur at any time due to epilepsy, fever, or a variety of medical problems. Partial seizures (also called focal seizures) are due to electrical surges in one hemisphere of the brain, and generalized seizures involve both hemispheres of the brain. Status epilepticus (a prolonged seizure) is a medical emergency.

Seizure Precautions

Seizure precautions (measures to protect clients from injury during a seizure) are imperative for clients who have a history of seizures that involve the entire body and/or result in unconsciousness. QS

• Make sure rescue equipment is at the bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails. Clients at high risk for generalized seizures should have a saline lock in place for immediate IV access.

• Ensure rapid intervention to maintain airway patency.

• Inspect the client’s environment for items that could cause injury during a seizure and remove items that are not necessary for current treatment.

• Assist clients at risk for seizures with ambulation and transferring to reduce the risk of injury.

• Advise all caregivers and family not to put anything in the client’s mouth (except an airway for status epilepticus) during a seizure.

• Advise all caregivers and family not to restrain the client during a seizure but to lower the client to the floor or bed, protect their head, remove nearby furniture, provide privacy, put them on one side with the head flexed slightly forward if possible, and loosen their clothing.

During a Seizure

• Stay with the client, and call for help.

• Maintain airway patency and suction PRN. QS​​​​​​​

• Administer medications.

• Note the duration of the seizure and the sequence and type of movements.

• After a seizure, determine mental status and measure oxygenation saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery.

• Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider.

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

A

“I will place the client on their side."

B

“I will go to the nurses’ station for assistance."

C

“I will note the time that the seizure begins."

D

“I will prepare to insert an airway."

Seclusion and Restraint

• Nurses must know and follow federal, state, and facility policies for the use of restraints.

• Some clients require seclusion rooms and/or restraints.

• In general, use seclusion or restraints for the shortest duration necessary and only if less restrictive measures are not sufficient. They are for the physical protection of the client or the protection of other clients or staff.

• Clients can voluntarily request temporary seclusion if the environment is disturbing or seems too stimulating.

• Restraints can be either physical (devices that restrict movement: vest, belt, mitt, limb) or chemical (sedatives, neuroleptic or psychotropic medications) to calm the client.

• Restraints can cause complications, including pneumonia, incontinence, and pressure injuries.

• It is inappropriate to use seclusion or restraints for:

  • Convenience of the staff

  • Punishment for the client

  • Clients who are extremely physically or mentally unstable

  • Clients who cannot tolerate the decreased stimulation of a seclusion room

• Restraints should:

  • Never interfere with treatment

  • Restrict movement as little as is necessary

  • Fit properly and be as discreet as possible

  • Be easy to remove or change

• When all other less restrictive means have failed to prevent a client from harming themselves or others (orientation to the environment, supervision of a family member or sitter, diversional activities, electronic devices), the following must occur before using seclusion or restraints.

  • The provider must prescribe seclusion or restraints in writing, after a face-to-face assessment of the client.

In an emergency situation when there is immediate risk to the client or others, nurses can place restraints on a client. The nurse must obtain a prescription from the provider as soon as possible according to the facility’s policy.

• The prescription must include the reason for the restraints, the type of restraints, the location of the restraints, how long to use the restraints, and the type of behavior that warrants using the restraints.

• The prescription allows only 4 hr of restraints for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. Providers can renew these prescriptions with a maximum of 24 consecutive hours.

• Providers cannot write PRN prescriptions for restraints.

Nursing Responsibilities for Clients in Restraints

• Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary.

• Ask the client or guardian to sign a consent form.

• Review the manufacturer’s instructions for correct application.

  • Assess skin integrity, and provide skin care according to the facility’s protocol, for example every 2 hr.

  • Offer food and fluid.

  • Provide a means for hygiene and elimination.

  • Monitor vital signs.

  • Offer range-of-motion exercises of extremities.

• Pad bony prominences to prevent skin breakdown.

• Secure/tie restraints to a part of the bed frame that can raise and lower when the bed controls are used.  Do not secure/tie restraints to the side rails of the bed. If restraints with a buckle strap are not available, use a quick-release knot to tie the strap.

• Make sure the restraints are loose enough for range of motion and that there is enough room to fit two fingers between the restraints and the client.

• Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limbs.

• Conduct an ongoing evaluation of the client.

• Regularly determine the need to continue using the restraints. QS​​​​​​​

• Never leave the client alone without the restraints.

• Check facility policy regarding types of restraints. Many facilities no longer use vest restraints due to the risk for strangulation.

Document

• Precipitating events and behavior of the client prior to seclusion or restraints

• Alternative actions to avoid seclusion or restraints

• Time of application and removal of the restraints

• Type of restraints and location

• The client’s behavior while in restraints

• Type and frequency of care (range of motion, neurologic checks, removal, integumentary checks)

• Condition of the body part in restraints

• The client’s response at removal of the restraints

• Medication administration

Fire Safety

Fires in health care facilities are usually due to problems with electrical or anesthetic equipment, or from smoking.

All staff must:

• Know the location of exits, alarms, fire extinguishers, and oxygen shut-off valves.

• Make sure equipment does not block fire doors.

• Know the evacuation plan for the unit and the facility.

Fire response follows the RACE sequence

R: Rescue and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory can walk independently to a safe location.

A: Alarm: Activate the facility’s alarm system and then report the fire’s details and location.

C: Contain/Confine the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag-valve mask.

E: Extinguish the fire if possible using the appropriate fire extinguisher.

Fire Extinguishers

To use a fire extinguisher, use the PASS sequence.

P: Pull the pin.

A: Aim at the base of the fire.

S: Squeeze the handle.

S: Sweep the extinguisher from side to side, covering the area of the fire.

Classes of fire extinguishers:

Class A is for combustibles (paper, wood, upholstery, rags, other types of trash fires).

Class B is for flammable liquids and gas fires.

Class C is for electrical fires.

Class D is for metals/metal shavings.

Class K is for kitchen fires involving fats and oils.

Class A,B,C is a multipurpose fire extinguisher that can be used for fires involving combustibles, flammable liquids, and electrical equipment.

A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority?

A

Extinguish the fire.

B

Activate the fire alarm.

C

Move clients who are nearby.

D

Close all open doors on the unit.

Discrimination

Discrimination and bias can negatively affect a client’s health. Barriers to health care can include factors such as access to care, age, level of education, gender identity, race, ethnicity, language, religion, sexual orientation, economic status, and physical or mental ability. Clients have the right to care that is delivered in an appropriate and timely manner, free from discrimination and bias. Clients are also entitled to courteous and respectful treatment as well as effectives methods of communication, such as an interpreter. TJC has developed standards to guide health care facilities in creating an environment that is free of bias and discrimination. Clients who have experienced discrimination are encouraged to speak up. The Speak Up initiative can be found on TJC website.

Active Learning Scenario

A nurse educator is addressing the safe use of seclusion and restraints with a group of newly licensed nurses. What information should the nurse include? Use the ATI Active Learning Template: Basic Concept to complete this item.

Nursing Interventions: Describe at least six nursing responsibilities when caring for a client in either seclusion or restraints.

Chapter 13: Home Safety

In addition to taking measures to prevent injury of clients in a health care setting, nurses play a pivotal role in promoting safety in the client’s home and community. Nurses often collaborate with the client, family, and members of the interprofessional team (social workers, occupational therapists, and physical therapists) to promote the safety of the client. QTC​​​​​​​

To initiate a plan of care, the nurse must identify risk factors using a risk assessment tool and complete a nursing history, physical examination, and home hazard appraisal.

In the plan of care for safety preparedness, the nurse should include emergency nursing principles (basic first aid and CPR).

Risk Factors for Client Injury

• Age and developmental status

• Mobility and balance

• Knowledge about safety hazards

• Sensory and cognitive awareness

• Communication skills

• Home and work environment

• Community in which the client lives

• Lifestyle choices

Safety Risks Based on Age and Developmental Status

• The age and developmental status of the client create specific safety risks. QPCC

• Infants and toddlers are at risk for injury due to a tendency to put objects in their mouth and from hazards encountered while exploring their environment.

• Preschool- and school-age children often face injury from limited or underdeveloped motor coordination.

• Adolescents’ risks for injury can stem from increased desire to make independent decisions and relying on peers for guidance rather than family.

• Some of the accident prevention measures for specific age groups include the following.

Infants and Toddlers

Aspiration

• Keep all small objects out of reach.

• Check toys and objects for loose or small parts and sharp edges.

• Do not feed the infant hard candy, peanuts, popcorn, or whole or sliced pieces of hot dog.

• Do not place the infant in the supine position while feeding or prop the infant’s bottle.

• A pacifier (if used) should be constructed of one piece and never placed on string or ribbon around the neck.

Suffocation

• Teach “back to sleep” mnemonic and always place infants on their backs to rest. Provide education on the importance of tummy time, which is allowing the infant to lie in the prone position for 3 to 5 minutes, 2 to 3 times each day.

• Keep plastic bags out of reach. 

• Make sure the crib mattress fits snugly and that crib slats are no more than 2 3/8 inches apart.

• Never leave an infant or toddler alone in the bathtub.

• Do not place anything in crib with infant.

• Remove crib toys (mobiles) from over the bed as soon as the infant begins to push up.

• Infants should sleep in a crib or bassinet. Co-sleeping in bed with adults increases the risk for injury.

• Keep latex balloons away from infants and toddlers.

• Fence swimming pools and use a locked gate.

• Begin swimming lessons when the child’s developmental status allows for protective responses (keeping the mouth closed under water).

• Teach caregivers CPR and Heimlich maneuver.

• Keep toilet lids down and bathroom doors closed.

Poisoning

• Keep houseplants and cleaning agents out of reach.

• Inspect and remove sources of lead (paint chips) and provide parents with information about prevention of lead poisoning.

• Have the poison control hotline number available.

• Place poisons, paint, and gasoline in locked cabinet.

• Keep medications, including vitamins, in child-proof containers and locked up.

• Dispose of medication that is expired or no longer taken. A medication take-back program is available, or medication can be mixed in a sealable bag with an undesirable substance like cat litter and disposed of in household trash.

A nurse is providing information about how to reduce the risk of poisoning in infants and toddlers to a group of guardians. What information should the nurse include?

Falls

• Keep crib and playpen rails up. 

• Never leave the infant unattended on a changing table or other high surface.

• Use gates on stairs, and ensure windows have window guards.

• Restrain according to manufacturer’s recommendations and supervise when in highchair, swing, stroller, etc. Discontinue use when the infant or toddler outgrows size or activity limits.

• Place in a low bed when toddler starts to climb.

Motor vehicle injury

• Place infants and toddlers in a rear-facing car seat until 2 years of age or until they exceed the height and weight limit of the car seat. They can then sit in a forward-facing car seat.

• Use a car seat with a five-point harness for infants and children.

• All car seats should be federally approved and be placed in the back seat, which is the safest place in the vehicle. 

• Infants and toddlers remain in a rear-facing car seat until the age of 2 years, or the height recommended by the manufacturer. 

• Toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing car seats, should use a forward-facing car seat until they reach the height and weight requirements for a booster seat.

Burns

• Test the temperature of formula and bath water.

• Place pots on back burner and turn handle away from front of stove.

• Supervise the use of faucets.

• Keep matches and lighters out of reach.

• Cover electrical outlets.

• Apply sunblock of SPF 30 or higher for an infant or toddler to prevent sunburn. Dress the infant or toddler with clothing to protect the skin.

Preschoolers and School-Age Children

Drowning

• Be sure child has learned to swim and knows rules of water safety.

• Have the child wear a life jacket when near water. Implement a buddy system for the school-aged child.

• Place locked fences around home and neighborhood pools.

• Provide supervision near pools or water.

Motor vehicle injury

• Use booster seats for children who are less than 4 feet 9 inches tall and weigh less than 40 lb (usually 4 to 8 years old). The child should be able to sit with their back against the car seat, and both legs should dangle over the seat.

• If the car has a passenger air bag, place children under 12 years in the back seat.

• Use seat belts properly after booster seats are no longer necessary.

• Use protective equipment when participating in sports, riding a bike, or riding as a passenger on a bike.

• Supervise and teach safe use of equipment.

• Teach the child to play in safe areas and never to run after a ball or toy that goes into a road.

• Teach child safety rules of the road.

Begin sex education for school-age child.

Firearms

• Keep firearms unloaded, locked up, and out of reach.

• Teach to never touch a gun or stay at a friend’s house where a gun is accessible.

• Store bullets in a different location from guns.

Play injury

• Teach to not run with candy or objects in mouth.

• Remove doors from refrigerators or other potentially confining structures.

• Ensure that bikes are the appropriate size for child. 

• Teach playground safety.

• Teach to play in safe areas, and avoid heavy machinery, railroad tracks, excavation areas, quarries, trunks, and vacant buildings.

• Teach to never swim alone and to wear a life jacket in boats.

• Wear protective helmets and knee and elbow pads, when needed.

• Teach to avoid strangers and keep parents informed of strangers.

Burns

• Reduce setting on water heater to no higher than 120° F.

• Teach dangers of playing with matches, fireworks, and firearms.

• Teach school-age child how to properly use microwave and other cooking instruments.

• Apply sunscreen of SPF 30 or higher to the child’s skin to prevent sunburn. Dress the child with clothing to protect the skin.

A nurse educator is providing education on infant safety to a group of guardians. Which of the following statements by a guardian indicates an understanding of the teaching?

A

“I should line the crib with bumper pads.”

B

 “I will make sure the crib slats are no more than 3 inches apart.”

C

“I should place the baby on their back when sleeping.”

D

“I should place the baby in a vehicle safety seat facing forward in the back seat of the car.”

Poison

• Teach child about the hazards of alcohol, cigarettes, and prescription, non-prescription, and illicit drugs.

• Keep potentially dangerous substances out of reach.

• Have the poison control hotline number available.

Adolescents

Educate on the hazards of smoking, alcohol, legal and illegal drugs, and unprotected sex.

Motor vehicle and injury

• Ensure the teen has completed a driver’s education course.

• Set rules on the number of people allowed to ride in cars, seat belt use, and to call for a ride home if a driver is impaired.

• Educate on the hazards of driving while distracted (eating or drinking, making phone calls or texting).

• Reinforce teaching on proper use of protective equipment when participating in sports.

• Be alert to manifestations of depression, anxiety, or other behavioral changes.

• Teach about the hazards of firearms and safety precautions with firearms.

• Teach water safety and to check water depth before diving.

Burns

• Teach to use sunscreen of SPF 30 or higher and protective clothing.

• Teach the dangers of sunbathing and tanning beds.

Social media: Discuss, monitor, and limit exposure to social networking and the Internet. Parents should role model appropriate social interactions.

Young and Middle-Age Adults

Motor vehicle crashes are the most common cause of death and injury to adults. Occupational injuries contribute to the injury and death rate of adults. High consumption of alcohol and suicide are also major concerns for adults.

Client Education

• Drive defensively and do not drive after drinking alcohol.

• There are long-term effects related to high alcohol consumption, smoking, second-hand smoke from tobacco use, illicit drug use, and excessive caffeine consumption.

• Ensure home safety with smoke and carbon monoxide detectors, fire alarms, well-lit and uncluttered staircases.

• Be attuned to behaviors that suggest the presence of depression or thoughts of suicide. Consider counseling as appropriate.

• Adhere to diving and water safety.

• Become proactive about safety in the workplace and in the home.

• Remember the dangers of social networking and the Internet.

• Understand the hazards of excessive sun exposure and the need to protect the skin with the use of sun-blocking agents of SPF 30 or higher and protective clothing.

Older Adults

• The rate at which age-related changes occur varies greatly among older adults. 

• Many older adults are able to maintain a lifestyle that promotes independence and the ability to protect themselves from safety hazards.

• Prevention is important because elderly clients can have longer recovery times from injuries and the risk of complications.

• A decrease in tactile sensitivity can place the client at risk for burns and other types of tissue injury.

• When the client demonstrates factors that increases the risk for injury (regardless of age), a home hazard evaluation should be conducted by a nurse, physical therapist, and/or occupational therapist. The client is made aware of the environmental factors that can pose a risk to safety and suggestion modifications to be made.

Risk factors for falls in older adults

• Physical, cognitive, and sensory changes

• Changes in the musculoskeletal and neurologic systems

• Impaired vision or hearing

• Frequent trips to the bathroom at night because of nocturia and incontinence

Modifications to improve home safety

• Remove items that could cause the client to trip (throw rugs and loose carpets).

• Place electrical cords and extension cords against a wall behind furniture.

• Monitor gait and balance, and provide aids as needed.

• Make sure that steps and sidewalks are in good repair.

• Place grab bars near the toilet and in the tub or shower and install a stool riser.

• Use a nonskid mat in the tub or shower.

• Place a shower chair in the shower and provide a bedside commode if needed.

• Ensure that lighting is adequate inside and outside the home and remove clutter.

A home health nurse is educating a new home health aide about home safety for the older adult. Which of the following information should the nurse include?

Fire Safety in the Home

Home fires continue to be a major cause of death and injury for people of all ages. Educate clients about the importance of a home safety plan.

Elements of a Home Safety Plan

• Keep emergency numbers near the phone for prompt use in the event of an emergency of any type.

• Ensure that the number and placement of fire extinguishers and smoke alarms are adequate, that they are functional, and that family members understand how to operate them. Set a time to routinely change batteries in smoke alarms (in the fall when the clocks are set to standard time and spring when set to Daylight Saving Time).

• Have a family exit plan for fires that is reviewed and practiced regularly. Be sure to include closing windows and doors if able and to exit a smoke-filled area by covering the mouth and nose with a damp cloth and getting down as close to the floor as possible.

• Review with clients of all ages that in the event that the client’s clothing or skin is on fire, the mnemonic “stop, drop, and roll” should be used to extinguish the fire. 

• Review oxygen safety measures. Because oxygen can cause materials to combust more easily and burn more rapidly, the client and family must be provided with information on use of the oxygen delivery equipment and the dangers of combustion. Include the following information in the teaching plan:

  • Use and store oxygen equipment according to the manufacturer’s recommendations.

  • Place a “No Smoking” sign in a conspicuous place near the front door of the home. A sign can also be placed on the door to the client’s bedroom.

  • Inform the client and family of the danger of smoking in the presence of oxygen. Family members and visitors who smoke should do so outside the home.

  • Ensure that electrical equipment is in good repair and well grounded.

  • Replace bedding that can generate static electricity (wool, nylon, synthetics) with items made from cotton.

  • Keep flammable materials (heating oil and nail polish remover) away from the client when oxygen is in use.

  • Follow general measures for fire safety in the home (having a fire extinguisher readily available and an established exit route if a fire occurs).

Additional Risks in the Home and Community

Additional risks in the home and community include passive smoking, carbon monoxide poisoning, and food poisoning. Clients should have their homes checked for radon, the second-leading cause of lung cancer. Bioterrorism also has become a concern, making disaster plans a mandatory part of community safety. Nurses should teach clients about the dangers of these additional risks. 

Passive smoking (secondhand smoke)

• Passive smoking is the unintentional inhalation of tobacco smoke.

• Exposure to nicotine and other toxins places people at risk for numerous diseases including cancer, heart disease, and lung infections.

• Low-birth-weight infants, prematurity, stillbirths, and sudden infant death syndrome (SIDS) have been associated with maternal smoking.

• Smoking in the presence of children is associated with the development of bronchitis, pneumonia, and middle ear infections.

• For children who have asthma, exposure to passive smoke can result in an increase in the frequency and the severity of asthma attacks.

Client Education

Be aware and remind family of:

• The hazards of smoking.

• Available resources to stop smoking (smoking cessation programs, medication support, self-help groups).

• The effect that visiting individuals who smoke or riding in the automobile of a smoker has on a nonsmoker.

Carbon monoxide

Carbon monoxide is a very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body.

• Carbon monoxide cannot be seen, smelled, or tasted.

• Manifestations of carbon monoxide poisoning include nausea, vomiting, headache, weakness, and unconsciousness.

• Death can occur with prolonged exposure.

• Measures to prevent carbon monoxide poisoning include ensuring proper ventilation when using fuel-burning devices (lawn mowers, wood-burning and gas fireplaces, charcoal grills).

• Gas-burning furnaces, water heaters, and appliances should be inspected annually.

• Flues and chimneys should be unobstructed.

• Carbon monoxide detectors should be installed and inspected regularly.

• Check carbon monoxide batteries at the same time as smoke detector batteries. Change the batteries annually on a specific date, like on a birthday.

Food poisoning

Food poisoning is a major cause of illness in the United States. Most food poisoning is caused by bacteria (Escherichia coli, Listeria monocytogenes, and Salmonella).

• Healthy individuals usually recover from the illness in a few days.

• Very young, very old, immunocompromised, and pregnant individuals are at risk for complications.

• Clients who are especially at risk are instructed to follow a low-microbial diet.

• Most food poisoning occurs because of unsanitary food practice. Perform hand hygiene before, during, and after food preparation, avoiding cross-contamination of equipment and foods, and cleaning food preparation surfaces well.

• Ensure meat and fish are cooked to the correct temperature, handling raw and fresh food separately to avoid cross contamination, and refrigerating perishable items are measures that can prevent food poisoning.

• Check expiration dates and refrigerate perishable items.

• Avoid any products made from unpasteurized dairy or meat spreads, or uncooked eggs.

• Do not eat raw sprouts, damaged or moldy raw foods, or unwashed produce.

• Heat hot dogs and deli or luncheon meats.

Primary Survey

A primary survey is a rapid assessment of life-threatening conditions. It should take no longer than 60 seconds to perform. QEBP​​​​​​​

• The primary survey should be completed systematically so conditions are not missed.

• Standard precautions (gloves, gowns, eye protection, face masks, and shoe covers) must be worn to prevent contamination with bodily fluids.

ABCDE Principle

The ABCDE principle guides the primary survey and emergency care.

Airway/Cervical Spine: This is the most important step in performing the primary survey. If a patent airway is not established, subsequent steps of the primary survey are futile. Protect the cervical spine if head or neck trauma is suspected.

Breathing: After achieving a patent airway, assess for the presence and effectiveness of breathing.

Circulation: After ensuring adequate ventilation, assess circulation.

Disability: Perform a quick assessment to determine the client’s level of consciousness.

Exposure: Perform a quick physical assessment to determine the client’s exposure to adverse elements (heat or cold).

A nurse is performing a primary survey for a client who has a life-threating condition. In which order should the nurse perform the assessment?

Check the client’s level of consciousness

Check the client’s airway

Check the client’s exposure to adverse elements.

Check the client’s ventilation

Check the client’s circulation

1

2

3

4

5

Basic First Aid

Complete the primary survey before performing first aid.

Bleeding

• Identify any sources of external bleeding and apply direct pressure to the wound site.

• DO NOT remove impaling objects. Instead, stabilize the object.

• Internal bleeding can require intravascular volume replacement with fluids and/or blood products, or surgical intervention.

Fractures and splinting

• Assess the site for swelling, deformity, and skin integrity.

• Assess temperature, distal pulses, and mobility.

• Apply a splint to immobilize the fracture. Cover open areas with a sterile cloth if available.

• Reassess neurovascular status below the injury site after splinting.

Sprains

• Use the acronym RICE to manage sprains:

  • Refrain from weight-bearing.

  • Apply ice to decrease inflammation.

  • Apply a compression dressing to minimize swelling.

  • Elevate the affected limb.

Heat stroke

• The nurse should identify heat stroke (body temperature greater than 40° C [104° F]) quickly and treat it aggressively.

• Manifestations of heat stroke include hot, dry skin; hypotension; tachypnea; tachycardia; anxiety; confusion; unusual behavior; seizures; and coma. The client does not sweat.

• Intervene to provide rapid cooling.

  • Remove the client’s clothing.

  • Place ice packs over the major arteries (axillae, chest, groin, neck).

  • Apply a hypothermia blanket to promote cooling.

  • Irrigate the stomach and large intestine with cooling solution.

  • Wet the client’s body, then fan with rapid movement of air.

  • Do not allow client to shiver. If client shivers, cover with a sheet.

A home health nurse is assessing a client who experienced extreme exposure to heat and has a body temperature of 40°C (104°F). The nurse should anticipate that the client will display which of the following manifestations?

A

Hypotension

B

Bradycardia

C

 Clammy skin

D

Bradypnea

Frostnip and frostbite

• Occurs when the body is exposed to freezing temperatures. 

• Common sites include the earlobes, tip of the nose, fingers, and toes. 

• Frostnip does not lead to tissue injury and can be treated by warming.

• Frostbite presents as white, waxy areas on exposed skin. Tissue injury occurs.

• Frostbite can be full- or partial-thickness.

• Warm the affected area in a warm bath (not hot water).

• Provide pain medication.

• Administer a tetanus vaccination.

Burns

• Burns can result from electrical current, chemicals, radiation, or flames.

• Home hazards include pot handles that protrude over the stove, hot bath water, and electrical appliances.

• Remove the agent (electrical current, radiation source, chemical).

• Smother any flames that are present. Perform a primary survey.

• Cover the client and maintain NPO status.

• Elevate the client’s extremities if not contraindicated (presence of a fracture).

• Perform a head-to-toe assessment and estimate the surface area and thickness of burns.

• Administer fluids and a tetanus toxoid.

Altitude-related illnesses

Clients can become hypoxic in high altitudes. Altitude sickness can progress to cerebral and pulmonary edema and requires immediate treatment.

Expected Findings

• Throbbing headache

• Nausea

• Vomiting

• Dyspnea

• Anorexia

Nursing Interventions

• Administer oxygen.

• Descend to a lower altitude.

• Provide pharmacological therapy (steroids and diuretics) if indicated.

• Promote rest.

CPR

CPR is a combination of basic interventions designed to sustain oxygen and circulation to vital organs until more advanced interventions can be initiated to correct the root cause of the cardiac arrest.

• Efficient CPR improves the client’s chance of survival.

• Trained individuals can deliver basic interventions, but special training and certification is required for the use of advanced interventions with emergency equipment (advanced cardiac life support [ACLS]).

• CPR is directed at artificially providing a client with circulation (chest compressions) and oxygenation (ventilations) in the absence of cardiac output.

• CPR is a component of basic life support (BLS).

• The goal of BLS is to provide oxygen to the vital organs until appropriate advanced resuscitation measures can be initiated or until resuscitative efforts are ordered to be stopped.

• BLS involves the CABs (Chest Compression, Airway, and Breathing) of CPR. QEBP​​​​​​​

  • Assess client for a response and look for breathing. Do not take time to perform a “look, listen, and feel” assessment of breathing. If there is no breathing or no normal breathing (only gasping), call for help.

  • If alone, activate emergency response system and get an automated external defibrillator (AED), if available, and return to the client. If a second person is available, ask the second person to activate the emergency response system and get an AED.

  • Check pulse. Begin CPR compressions alternated with breaths if a pulse is not detected.

• For further detail on CPR, visit the American Heart Association website.

Client Education

• Take basic first aid and CPR courses, along with family members. Consider joining a community agency where basic first aid and CPR are taught.

• Keep emergency numbers (poison control, fire/rescue, providers, nearest hospitals and urgent care facilities) in the home.

Active Learning Scenario

A nurse educator is teaching a module on the basic principles of creating a home safety plan during nursing orientation to a group of newly appointed home health nurses. Use the ATI Active Learning Template: Basic Concept to complete this item.

Nursing Interventions: List four key elements that a home safety plan should include.

Chapter 14: Ergonomic Principles

Ergonomics is a science that focuses on the factors or qualities in an object’s design or use that contribute to comfort, safety, efficiency, and ease of use.

Using good body mechanics when positioning and moving clients promotes safety for the client and the staff.

Before attempting to position or move a client, perform a mobility assessment. Begin with the easiest movements (range of motion) and progress as long as the client tolerates it (balance, gait, exercise).

Client and bed positions are often part of the provider’s prescription, or a nursing intervention that corresponds with the client’s condition and physiological needs.

Ergonomic Principles and Body Mechanics

• Body mechanics is the use of muscles to maintain balance, posture, and body alignment when performing a physical task. Nurses use body mechanics when providing care to clients by lifting, bending, and assisting clients with the activities of daily living.

• Body alignment keeps the center of gravity stable, which promotes comfort and reduces strain on the muscles.

• Good body mechanics reduces the risk of injury. Whenever possible, use mechanical lift devices to lift and transfer clients. Many facilities have “no manual lift” and “no solo lift” policies.

Ergonomic Principles

Center of Gravity

• The center of gravity is the center of a mass.

• Weight is a quantity of matter on which the force of gravity acts.

• To lift an object, it is essential to overcome the weight of the object and to know the center of gravity of the object.

• When the human body is in the upright position, the center of gravity is the pelvis.

• When an individual moves, the center of gravity shifts.

• The closer the line of gravity is to the center of the base of support, the more stable the individual is.

• The vertical line from the center of gravity must fall through a stable base of support in order to maintain balance. To lower the center of gravity, bend the hips and knees.

• Spread your feet apart to lower your center of gravity and broaden your base of support. This results in greater stability and balance.

Lifting

• Situational factors that increase the risk of injury

  • Having to twist while lifting

  • Lifting in a small space

  • Lifting while kneeling or sitting

  • Lifting while arms are extended away from the body

  • Having worked longer than 8 hr

• Client factors that can increase the risk for injury include lifting a client who has a physical condition that affects their ability to be moved (pain, presence of drains) or is combative or uncooperative.

• Use the major muscle groups to prevent back strain, and tighten the abdominal muscles to increase support to the back muscles.

• Distribute your weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and to avoid strain on smaller muscles.

• When lifting an object from the floor, flex your hips, knees, and back. Bring the object to thigh level, bending your knees and keeping your back straight. Stand up while holding the object as close as possible to your body, bringing the load to the center of gravity to increase stability and decrease back strain.

• Use assistive devices whenever possible and seek assistance whenever needed.

• Use an assistive device if lifting more than 15.9 kg (35 lb).

Pushing or Pulling

When pushing or pulling a load:

• Widen your base of support.

• When opportunity allows, pull objects toward the center of gravity rather than pushing them away.

• If pushing, move your front foot forward and, if pulling, move your rear leg back to promote stability.

• Face the direction of movement when moving a client.

• Use your own body as a counterweight when pushing or pulling to make the movement easier.

• Sliding, rolling, and pushing require less energy than lifting and offer less risk for injury.

• Face the direction of movement. Avoid twisting your thoracic spine and bending your back while your hips and knees are straight.

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching?

Select all that apply.

A

“My line of gravity should fall outside my base of support.”

B

“The lower my center of gravity, the more stability I have.”

C

“To broaden my base of support, I should spread my feet apart.”

D

“When I lift an object, I should hold it as close to my body as possible.”

E

“When pulling an object, I should move my front foot forward.”

Transfers and Use of Assistive Devices

• Evaluate each situation and use an algorithm to determine the safest method to transfer or move the client. Answer these questions: Can the client bear weight? Can they assist? Are they cooperative?

• Determine the client’s ability to help with transfers (balance, muscle strength, endurance, use of a trapeze bar).

• Evaluate the need for additional staff or assistive devices (transfer belt, hydraulic lift, sliding board).

• Assess and monitor the use of mobility aids (canes, walkers, crutches).

• Include assistance or mobility aids in the plan of care for safe transfers and ambulation.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse’s priority at this time?

A

Obtain a walker for the client to use to transfer back to bed.

B

Call for additional staff to assist with the transfer.

C

Use a transfer belt and assist the client back into bed.

D

Determine the client’s ability to help with the transfer.

Guidelines for Preventing Injury

• Know your facility’s policies for lifting and safe client handling. 

• Have one or more staff members assist with positioning clients. Moving them up in bed is a significant cause of back pain and injury.

• Plan ahead for activities that require lifting, transfer, and ambulation of a client, and ask others to be available to assist.

• Prepare the environment by removing obstacles prior to the procedure.

• Explain the process to the client and assistants to clarify their roles.

• Be aware that the safest way to lift a client is with assistive equipment.

• Rest between heavy activities to decrease muscle fatigue.

• Maintain good posture and exercise regularly to increase the strength of your arms, legs, back, and abdominal muscles, so these activities will require less energy.

• Keep your head and neck in a straight line with your pelvis to avoid neck flexion and hunched shoulders, which can cause impingement of nerves in your neck.

• Use smooth movements when lifting and moving clients to prevent injury from sudden or jerky muscle movements.

• When standing for long periods of time, flex your hips and knees by using a footrest. When sitting for long periods of time, keep your knees slightly higher than your hips.

• Avoid repetitive movements of the hands, wrists, and shoulders. Take a break every 15 to 20 min to flex and stretch joints and muscles whenever possible.

• Avoid twisting your spine or bending at the waist (flexion) to minimize the risk for injury.

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include?

Select all that apply.

A

Request assistance when repositioning a client.

B

Avoid twisting your spine or bending at the waist.

C

Keep your knees slightly lower than your hips when sitting for long periods of time.

D

Use smooth movements when lifting and moving clients.

E

Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.

Positioning Clients

• Position clients, especially those who are unable to move themselves, so that they maintain good body alignment. Frequent position changes prevent discomfort, contractures, pressure on tissues, and nerve and circulatory damage, and they stimulate postural reflexes and muscle tone.  

• Use pillows, bath blankets, hand rolls, boots, splints, trochanter rolls, ankle support devices, and other aids to maintain proper body alignment.

Bed and Client Positions

Semi-Fowler’s

• The client lies supine with the head of the bed elevated 15° to 45° (typically 30°).

• This position prevents regurgitation of enteral feedings and aspiration by clients who have difficulty swallowing. 

• It also promotes lung expansion for clients who have dyspnea or are receiving mechanical ventilation.

Fowler’s

• The client lies supine with the head of the bed elevated 45° to 60°.

• This position is useful during procedures (nasogastric tube insertion and suctioning). It allows for better chest expansion and ventilation and better dependent drainage after abdominal surgeries.

High-Fowler’s

• The client lies supine with the head of the bed elevated 60° to 90°. 

• This position promotes lung expansion by lowering the diaphragm and thus helps relieve severe dyspnea.

• It also helps prevent aspiration during meals.

Supine or dorsal recumbent

• The client lies on their back with the head and shoulders elevated on a pillow and forearms on pillows or at their sides. A foot support prevents foot drop and maintains proper alignment. Ensure that the vertebrae are in straight alignment without excessive flexion or extension of the head and neck.

Prone

• The client lies flat on their abdomen and chest with the head to one side and back in correct alignment.

• A pillow may be placed under the leg. This promotes relaxation by permitting some knee flexion and dorsiflexion of the ankles.

• This position promotes drainage from the mouth after throat or oral surgery, but inhibits chest expansion. It is for short-term use only.

• This position helps prevent hip flexion contractures following a lower extremity amputation.

Lateral or side-lying

• The client lies on their side with most of the weight on the dependent hip and shoulder and the arms in flexion in front of the body. They should have a pillow under the head and neck, upper arms, and legs and thighs to maintain body alignment. 

• This is a good sleeping position, but the client needs turning regularly to prevent the development of pressure ulcers on the dependent areas. A 30° lateral position is essential for clients at risk for pressure ulcers.

Lateral Semi-prone Recumbent Position

• The client is on their side halfway between lateral and prone positions, with the weight on their anterior ileum, humerus, and clavicle. The lower arm is behind them while the upper arm is in front. Both legs are in flexion, but the upper leg is flexed at a greater angle than the lower leg at the hip as well as at the knee. It differs from the side-lying position in the distribution of the client’s weight.

• This is a comfortable sleeping position for many clients, and it promotes oral drainage.

Orthopneic

• The client sits in the bed or at the bedside with a pillow on the overbed table, which is across the client’s lap. They rest their arms on the overbed table. 

• This position allows for chest expansion and is especially beneficial for clients who have COPD. 

Trendelenburg

• The entire bed is tilted with the head of the bed lower than the foot of the bed. 

• This position facilitates postural drainage and venous return.

Reverse Trendelenburg

• The entire bed is tilted with the foot of the bed lower than the head of the bed.

• This position promotes gastric emptying and prevents esophageal reflux.

Modified Trendelenburg

• The client remains flat with the legs above the level of their heart.

• This position helps prevent and treat hypovolemia and facilitates venous return.

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?

A

Supine

B

Semi-Fowler’s

C

Lateral Semi-prone Recumbent

D

Trendelenburg

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?

A

“Lie on your back with your head and shoulders supported by a pillow.”

B

“Have your head turned to the side while you lie on your stomach.”

C

“Have a table beside your bed so you can sit on the bedside and rest your arms on the table.”

D

“Lie on your side with your top arm resting on the bed and your weight on your hip.”

Active Learning Scenario

A nurse is presenting the basic principles of proper lifting to a group of assistive personnel. Use the ATI Active Learning Template: Basic Concept to complete this item.

Underlying Principles: List four key elements of proper lifting techniques.

Chapter 15: Security and Disaster Plans

A disaster is a mass casualty or intra-facility event that at least temporarily overwhelms or interrupts the normal flow of services of a hospital. Disasters that health care facilities face include internal and external emergencies.

Internal emergencies include loss of electric power or potable water, loss of communication ability, disruption of computer information systems, and severe damage or casualties within the facility related to fire, weather (tornado, hurricane), explosion, or a terrorist act. Internal emergency readiness includes evacuation and relocation plans, procedures to notify extra personnel, safety and hazardous materials protocols, and infection control policies and practices.

External emergencies include hurricanes, floods, volcano eruptions, earthquakes, disease epidemics, industrial accidents, chemical plant explosions, major transportation accidents, building collapse, and terrorist acts (including biological and chemical warfare). External emergency readiness includes a plan for participation in community-wide emergencies and disasters.

The Joint Commission and Emergency Preparedness

The Joint Commission established emergency preparedness management standards for various types of health care facilities. These standards mandate that an institutional emergency preparedness plan is developed by all health care institutions and that these plans include institution-specific procedures for the following. QS​​​​​​​

• Notifying and assigning personnel.

• Notifying external authorities of emergencies.

• Managing space and supplies and providing security.

• Isolating and decontaminating radioactive or chemical agents (measures to contain contamination, decontamination at the scene of exposure).

• Evacuating and setting up an alternative care site when the environment cannot support adequate client care and treatment. Critical processes when an alternative care site is necessary include the following.

  • Client information/care packaging (medications, supplies, admissions, medical records, and tracking)

  • Interfacility communication

  • Transportation of clients, staff, and equipment

  • Cross-privileging of medical staff

• Performing triage of incoming clients.

• Managing clients during emergencies, including scheduling, modification or discontinuation of services, control of client information, and client discharge and transportation.

• Interacting with family members and the media and responding to public reaction.

• Identifying backup resources (electricity, water, fire protection, fuel sources, medical gas, and vacuum) for utilities and communication.

• Orienting and educating personnel participating in implementation of the emergency preparedness plan.

• Providing crisis support for health care workers (access to vaccines, infection control recommendations, mental health counseling).

• Providing performance monitoring and evaluation related to emergency preparedness. 

• Conducting two emergency preparedness drills each year. 

  • Drills should include an influx of clients beyond those being treated by the facility. QS

  • Drills should include either an internal or an external disaster (a situation beyond the normal capacity of the facility).

• Participating in one community-wide practice drill per year.

Nursing Role in Disaster Planning and Emergency Response Plans

Emergency response plans

Each health care institution must have an emergency preparedness plan developed by a planning committee. This committee reviews information regarding the potential for various types of natural and man-made emergencies depending on the characteristics of the community. Resources necessary to meet the potential emergency are determined and a plan is developed that takes into consideration all of the above factors.

• Nurses, as well as a cross-section of other members of the health care team, are involved in the development of a disaster plan for such emergencies. Criteria under which the disaster plan is activated must be clear. Roles for each employee are outlined and administrative control determined. A designated area for the area command center is identified as well as a person to serve as the incident control manager.

• Communication, using common terminology, is important within any emergency management plan. QTC​​​​​​​

• Nurses are expected to set up an emergency action plan for personal family needs.

Triage

Principles of triage are followed in health care facilities involved in a mass casualty event. These differ from the principles of triage that are typically followed during provision of day-to-day services in an emergency or urgent care setting. During mass casualty events, casualties are separated in relation to their potential for survival, and treatment is allocated accordingly.

Categories of triage during mass casualty events

Emergent or Immediate Category (Class I): Highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized.
Urgent or Delayed Category (Class II): Second-highest priority is given to clients who have major injuries that are not yet life-threatening and can usually wait 30 min to 2 hr for treatment.

Nonurgent or Minimal Category (Class III): The next highest priority is given to clients who have minor injuries that are not life-threatening and do not need immediate attention.
Expectant Category (Class IV): The lowest priority is given to clients who are not expected to live and are allowed to die naturally. Comfort measures can be provided, but restorative care is not.

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse’s priority?

A

A client who has partial-thickness and full-thickness burns to the face, neck and chest.

B

A client who received crush injuries to the chest and abdomen and is expected to die

C

A client who has a 4-inch laceration to the head

D

A client who has a fractured fibula and tibia

Discharge/Relocation of Clients

During an emergency (a fire or a mass casualty event), decisions are made regarding discharging clients or relocating them so their beds can be given to clients who have higher-priority needs.

Criteria for identifying when clients can be safely discharged

• Ambulatory clients requiring minimal care are discharged or relocated first.

• Clients requiring assistance are next and arrangements are made for continuation of their care.

• Clients who are unstable and/or require nursing care are not discharged or relocated unless they are in imminent danger.

Fire

• If evacuation of the unit is necessary, horizontal (lateral) evacuation is done first. Vertical evacuation to other floors is done if client safety cannot be maintained.

• If a nurse discovers a fire that threatens the safety of a client, use the RACE (Rescue, Alarm, Contain, and Extinguish) mnemonic to guide the order of actions.

• Turn supplemental oxygen off for clients who can safely tolerate room air.

• Ask ambulatory clients to assist removing clients who are in wheelchairs.

Race Mnemonic

A nurse notes a fire in a trash can in a client’s room. Which of the following actions should the nurse take first?

Pull the fire alarm.

Use the fire extinguisher.

Help the client and others leave the area.

Close doors

1

2

3

4

Severe Thunderstorm/Tornado

• Draw shades and close drapes to protect against shattering glass.

• Lower beds to the lowest position and move away from the windows.

• Place blankets over all clients who are confined to beds.

• Close all doors.

• Relocate as many ambulatory clients as possible into the hallways (away from windows) or other secure location designated by the facility.

• Do not use elevators.

• Monitor for severe weather warnings using television, radio, or Internet.

A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include?

Select all that apply.

A

Open doors to client rooms.

B

Place blankets over clients who are confined to beds.

C

Move beds away from windows.

D

Draw shades and close drapes

E

Instruct ambulatory clients in the hallways to return to their rooms

Biological Pathogens

Bioterrorism is the intentional release of pathogens that can harm people, livestock, or crops. Be alert to indications of a possible bioterrorism attack, as early detection and management is key. Often the manifestations are similar to other illnesses.

• Be alert for the appearance of a disease that does not usually occur at a specific time or place, has atypical manifestations, or occurs in a specific community or people group.

• In most instances, infection from biological agents is not spread from one client to another. Management of the incident includes recognition of the occurrence, directing personnel in the proper use of personal protective equipment, and, in some situations, decontamination and isolation.

• Use recommended isolation measures as indicated.

• Transport or move clients only if needed for treatment and care.

• Take measures to protect self and others.

• Recognize indications of infection/poisoning and recommended treatment. QEBP​​​​​​​

Biological pathogen manifestations, prevention, and treatment

Inhalational anthrax

Manifestations

• Fever

• Cough

• Shortness of breath

• Muscle aches 

• Mild chest pain

• Meningitis 

• Shock

• Sweats (often drenching)

Prevention

• Anthrax vaccine for high-risk 

• Ciprofloxacin & Doxycycline IV/PO

Treatment: includes one or two additional antibiotics (vancomycin, penicillin, and anthrax antitoxin)

Cutaneous anthrax

Manifestations

• Starts as a lesion that can be itchy

• Develops into a vesicular lesion that later becomes necrotic with the formation of black eschar 

• Fever, chills

​​​​​​​Prevention: Anthrax vaccine for high-risk 

Treatment: Ciprofloxacin, Doxycycline 

Botulism

Manifestations

• Difficulty swallowing

• Double vision

• Slurred speech 

• Descending progressive weakness

• Nausea, vomiting, abdominal cramps 

• Difficulty breathing

• Sensation of a thickened tongue (difficulty controlling tongue)

Prevention/Treatment

• Airway management

• Antitoxin

• Elimination of toxin

Viral hemorrhagic fevers (Ebola, yellow fever)

Manifestations

• Fatigue

• Kidney failure

• Elevated temperature

• Nausea, vomiting, diarrhea

• Internal and external bleeding

• Shock

• Jaundice (yellow fever)

Prevention

• Vaccination available for yellow fever, Argentine hemorrhagic fever

• Barrier protection from infected person, isolation precautions specific to disease

• Insect repellent use

Treatment

• No cure, supportive care only

• Minimize invasive procedures

Plague

Manifestations

• Yersinia pestis bacterium is the causative agent

• These forms can occur separately or in combination

  • Pneumonic plague: fever, headache, weakness, pneumonia with shortness of breath, chest pain, cough, and bloody or watery sputum. 

  • Bubonic plague: swollen, tender lymph glands, fever, headache, chills, and weakness.

  • Septicemic plague: fever, chills, prostration, abdominal pain, shock, disseminated intravascular coagulation (DIC), gangrene of nose and digits.

Prevention: Contact precautions until decontaminated or buboes no longer drain (bubonic, septicemic); droplet precautions until 72 hr after antibiotics (pneumonic)

Treatment: Streptomycin/gentamicin or tetracycline/doxycycline.

Smallpox

Manifestations

• High fever

• Fatigue

• Severe headache

• Rash 

• Chills

• Vomiting

• Delirium

Prevention

• Vaccine; can vaccinate within 4 days of exposure 

• Contact and airborne precautions

Treatment

• Supportive care (prevent dehydration, provide skin care, medications for pain and fever)

• Antibiotics for secondary infections

Tularemia

Manifestations

• Sudden fever

• Chills

• Headache

• Diarrhea

• Muscle aches

• Joint pain

• Dry cough

• Progressive weakness

• If airborne, life-threatening pneumonia and systemic infection

Prevention

• Vaccine under review by the Food and Drug Administration

• Insect repellent use

Treatment: streptomycin or gentamicin are the medications of choice; in mass causality, use doxycycline or ciprofloxacin

Chemical Incidents

Chemical incidents can occur as result of an accident or due to a purposeful action (terrorism).

• Take measures to protect self and to avoid contact.

• Assess and intervene to maintain the client’s airway, breathing, and circulation. Administer first aid as needed.

• Remove the offending chemical by undressing the client, removing all identifiable particulate matter. Provide immediate and prolonged irrigations of contaminated areas. Irrigate skin with running water, with the exception of dry chemicals (lye or white phosphorus). In the case of exposure to a dry chemical, brush the agent off of the client’s clothing and skin.

• Gather a specific history of the injury, if possible (name and concentration of the chemical, duration of exposure).

• In the event of a chemical attack, have knowledge of which facilities are open to exposed clients and which are only open to unexposed clients.

• Follow the facility’s emergency response plans (personal protection measures, the handling and disposal of wastes, use of space and equipment, reporting procedures).

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?

A

Irrigate the affected area with running water.

B

Wash the affected area with antibacterial soap.

C

Brush the chemical off the skin and clothing.

D

Leave the clothing in place until emergency personnel arrive.

Hazardous Material Incidents

• Take measures to protect self and to avoid contact.

• Approach the scene with caution.

• Identify the hazardous material with available resources (emergency response guidebook, poison control centers). Know the location of the safety data sheets manual.

• Try to contain the material in one place prior to the arrival of the hazardous materials team. 

• If individuals are contaminated, decontaminate them as much as possible at the scene or as close as possible to the scene.

  • Don gloves, gown, mask, and shoe covers to protect self from contamination.

  • With few exceptions, water is the universal antidote. For biological hazardous materials, wash skin with copious amounts of water and antibacterial soap.

  • Carefully and slowly remove contaminated clothing so that deposited material does not become airborne.

  • Place all contaminated material into large plastic bags and seal them.

Radiologic Incidents

• The amount of exposure is related to the duration of the exposure, distance from source, and amount of shielding.

• The facility where victims are treated activates interventions to prevent contamination of treatment areas (floors and furniture are covered, air vents and ducts are covered, radiation-contaminated waste is disposed of according to procedural guidelines).

• Wear water-resistant gowns, double glove, and fully cover their bodies with caps, shoe covers, masks, and goggles.

• Wear radiation or dosimetry badges to monitor the amount of their radiation exposure.

• Survey clients initially with a radiation meter to determine the amount of contamination.

• Decontamination with soap, water, and disposable towels occurs prior to entering the facility. Water runoff is contaminated and contained.

• After decontamination, resurvey clients for residual contamination. Continue irrigation of the skin until the client is clean of all contamination.

Nuclear Incidents

• Can result in long-term contamination, burn injuries, and puncture wounds.

• Decontamination is necessary.

Explosive Incidents

Can result in burn injuries, wounds from airborne fragments, force due to altered air pressure, and temperature changes.

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge?

Select all that apply.

A

A client who is dehydrated and receiving IV fluid and electrolytes

B

A client who has a nasogastric tube to treat a small bowel obstruction

C

A client who is scheduled for elective surgery

D

A client who has chronic hypertension and blood pressure 135/85 mm Hg

E

A client who has acute appendicitis and is scheduled for an appendectomy

Bomb Threat

When a phone call is received:

• Extend the conversation as long as possible.

• Listen for distinguishing background noises (music, voices, traffic, airplanes).

• Note distinguishing voice characteristics of the caller.

• Ask where and when the bomb is set to explode.

• Note whether the caller is familiar with the physical arrangement of the facility.

• If a bomb-like device is located, do not touch it. Clear the area and isolate the device as much as possible by closing doors, for example.

• Notify the appropriate authorities and personnel (police, administrator, director of nursing).

• Cooperate with police and others. Assist to conduct a search as needed, provide copies of floor plans, have master keys available, and watch for and isolate suspicious objects (packages and boxes).

• Keep elevators available for authorities.

• Remain calm and alert and try not to alarm clients.

A nurse educator is reviewing actions to take in the event of a bomb threat by phone to a group of new nurses. Which of the following statements by a nurse indicates understanding?

A

“I will get the caller off the phone as soon as possible so I can alert the staff.”

B

“I will begin evacuating clients using the elevators.”

C

“I will not ask any questions and just let the caller talk.”

D

“I will listen for background noises.”

Active Shooter Situation

One or more persons attempting to kill people in a confined area.

Run

• Evacuate if there is a clear path of exit.

• Leave belongings behind.

• Instruct others to follow, but do not wait for them.

• Prevent others from entering the area.

Hide

• If unable to evacuate

  • Stay out of shooter's sight.

  • Find a protected area.

  • Block or lock doors.

  • Silence phone and remain quiet.

Fight

• If unable to run or hide and if danger is imminent

  • Throw items and yell at shooter to stop or wound the shooter.

Call 911 if possible, remain calm, do not attempt to move wounded people, and keep hands visible if police enter the area.

Security Plan

All health care facilities have security plans in place that include preventive, protective, and response measures designed for identified security needs.

• Security issues faced by health care facilities include admission of potentially dangerous individuals, vandalism, infant abduction, and information theft.

• The International Association for Healthcare Security & Safety provides recommendations for the development of security plans.

Nursing Role in Security Plan

Nurses should be aware that security measures include:

• An identification system that identifies employees, volunteers, physicians, students, and regularly scheduled contract services staff as authorized personnel of the health care facility.

• Electronic security systems in high-risk areas (maternal newborn to prevent infant abductions, the emergency department to prevent unauthorized entrance). 

  • Key code access into and out of high-risk areas

  • Wristbands that electronically link parents and their infants

  • Alarms integrated with closed-circuit television cameras

Nurses should prepare to take immediate action when breaches in security occur. Time is of the essence in preventing or stopping a breach in security. QS​​​​​​​

Active Learning Scenario

A nurse educator is teaching a module on biological pathogens during orientation to a group of newly hired nurses. What information should the nurse educator include? Use the ATI Active Learning Template: Basic Concept to complete this item.

Related Content: List four manifestations and the recommended treatment for anthrax, botulism, pneumonic plague, and tularemia.