Nursing Safety: Assessments & Devices

Emphasizes the $60\text{-second}$ assessment as triage-like in nursing; quick check of patient and environment for safety risks and immediate needs.
Quick visual checks of the ABCs: $\text{airway, breathing, circulation}$ , patient position, and the room hazards (e.g., trash, sharps, glove stock, bed height).
Performed at shift start, after report, after entering a patient's room, and multiple times per shift.
Purpose: helps nurses prioritize which patients need attention first based on initial findings; not intended for detailed vitals or head-to-toe assessment.
Quick assessments become second nature with practice and are integral during simulations and real-life scenarios.

Common patient room hazards include trash, improperly stored sharps, absence of gloves, elevated bed, and lack of dignity such as improper dress.
Responsibility for supplies: all staff are responsible for ensuring gloves, etc., are stocked; it’s not just a tech/PCT’s job.

Wristbands serve multiple roles: general ID, DNR, fall risk, limb alerts, etc.; meanings and color codes vary by facility.
Yellow is often used for fall risk, but bracelet colors differ between institutions; always verify facility codes.
Wristband must always be on the patient—not attached to the bed; unattached wristbands are not used by students.
Identity confirmation must involve multiple identifiers (name, birthdate, and, for confused patients, possibly a picture or family member) and not rely solely on the chart or wristband.
Mistakes in patient identification can lead to critical errors; prevention is the nurse’s responsibility.
Registration staff are part of the care team; accurate wristband details are essential for safety and billing.

SCDs (sequential compression devices) and TED hose are used to prevent DVTs in surgical, immobilized, or high-risk patients.
SCDs work by rhythmically squeezing the legs to promote blood flow and reduce clot risk; TED hose provide constant compression.
SCDs must be properly connected and sized; TED hose are difficult to apply; best put on before the patient gets out of bed to prevent swelling.
Interference: devices must be wrinkle-free to avoid pressure ulcers.
Ambulatory patients may not need SCDs/TEDs; follow orders/protocols.
Proper sizing and monitoring are crucial to avoid impeding circulation and causing skin issues.
Documentation and communication with providers are required if appropriate sizes are not available.

Restraints include more than physical ties; bed alarms, mitts, socks on hands, and four raised bedrails are all considered restraints.
Use of restraints is policy-driven; acute care often justifies them as safety measures, but restraint usage still requires adherence to policy.
The most common restraint in critical care is the soft restraint to prevent self-harm (e.g., pulling tubes).
Application and documentation of restraints are critical; includes frequent checks and procedures for circulation.
Hard restraints/leathers are now often made from cleanable hard plastics for infection control.
Restraints should always be tied to the bed frame (not bed rails or walls) for safety.
Improper use or lack of monitoring/assessment related to restraints or compression devices can lead to harm and is the nurse’s responsibility.

Practice performing comprehensive 60-second assessments in simulated and clinical settings.
Consistently check and restock room supplies (gloves, linens, equipment).
Ensure every patient’s wristband is in place and confirm identity with multiple methods before administering care or meds.
Familiarize with facility-specific wristband codes and restraint policies.
Measure patients and monitor for correct application of SCDs and TED hose; document issues and communicate with providers as needed.
Review clinical policies regarding restraint use, including documentation, assessment, and safety checks.
Real-world relevance: This content aligns with patient safety goals and quality improvement practices in clinical settings and simulations.