Unit 4 Physical Safety

Introduction

  • Definition of safety

    • Freedom from risk or occurrence of injury

  • Importance of safety

    • Most accidents are preventable!

      • Safety for both the patient AND the nurse

      • Hospitals pay for the costs of patients who fall during their hospitalization

  • Initiatives to provide for patient safety

    • IOM reports

      • Institutes of medicine - create policies and reports for hospital accidents (which decrease healthcare costs when there are no injuries!)

    • National Patient Safety Goals (2024) (NPSG)

      • Ex; Using 2 identifiers with patients

      • Ex; 1SBAR (the standard for hospitals communication)

      • Ex; 3 checks when giving medication

      • Ex; Decreasing risk of injury from falls

    • Rapid Response Teams

      • Created to improve response to patients’ condition

    • HICS (Hospital Incident Command System)

      • Created to organize a plan during a disaster- Interval and External Disasters

    • NIOSH (Safe Patient Handling Guidelines)

      • Keeps nurses safe

      • Ex; NO lifting patients over 25 pounds » Must use Hoyer lift

Nursing Assessment

Contributing Factors

  • Chemical- Inhaling or skin contact

    • Ex; medications- opioids, sedatives, diuretics, oxygen, anti-hypertensive (orthostatic hypo), anticoagulants, recreational drugs, anesthesia

  • Developmental

    • Very young and very old, individual w/ cognitive issues

  • Physical/Environmental

    • Ex; unsafe equipment (wheelchairs, stretcher), confusing unit floor plan, cluttered room - (Beware of fires)

  • Physiological- Orthostatic hypotension

    • Ex; impaired mobility (paralysis, poor balance, in pain, fatigued, seizure, orthostatic hypo, poor sensory perception)

    • Ex; unable to communicate (aphasia, aspiration)

  • Psycho-socio-cultural

    • Ex; Depression, language barrier, cultural preferences, decreased attention span, anxiety or panic state

Clinical Manifestation

  • Physical Injury

    • Tissue Trauma- identify LAS and look for entry port

    • Bleeding

    • Burns- Diaper rash » urine can cause burns

    • Airway obstruction » position in bed (supervised meal times)

    • Compromised circulation

  • Health setting- Not always the safest (a lot of bacteria)

  • Psychological Response

    • Fear

    • Anxiety

    • Dependency

Analysis

  • Use nursing judgment based on critical thinking and clinical reasoning to identify relevant nursing diagnosis

  • What nursing diagnoses can you identify based on contributing factors?

    • Ex; risk for injury

      • Impaired physical mobility r/t previous fal

      • Deficient knowledge

    • Goal: patient will…

      • Use assistive devices while in my care

      • Be free from injury while in my care

Nursing Inventions

Basic Measures

  • Ongoing risk identification

    • By hourly rounding, using 2 patient identifiers

  • Orient and Educate patient and family

  • Use correct “Body Mechanics”

    • Lift with legs, NOT back

    • No BLT (bending, lifting, twisting)

    • If lifting, life with your core

  • Implement safety measures based on specific contributing factors

    • Implement a safe environment

      • Correct footgear when ambulating (nonskid socks)

      • Wear corrective eyeware (if possible)

      • Hearing aids

      • Use adequate lighting

      • All equipment should have tag/sticker

        • Indicating it has been serviced and is in good working condition

      • Maintain floor free of spills and clutter

      • Call bell within reach

      • Always make sure bed is in lowest position

      • Safe handling of sharps (razors, syringes, etc)

      • 3 side rails on the bed (all 4’s are considered a restraint)

Specific Measures

  • What would the nurse include in a plan of care to maintain safety in a patient with

    • Confusion

      • Continually orient patient (ex; you are in the hospital, here is your call bell, my name is… I am your nurse etc

      • Remove harmful objects

    • Impaired mobility

      • Keep necessary objects within their reach (glasses, dentures, etc)

      • Assess vitals, could have orthostatic hypo

      • Use nonskid socks, walker, assistive devices, Hoyer lift

    • Impaired sensory perception

      • Don’t use too hot or too cold water

      • Limit use of heating pads

      • Make sure glasses and hearing aids are in use (if applicable)

    • Increased risk of bleeding

      • Patients on anticoagulants, aspirin

      • Monitor for ecchymosis (bruising), hematoma (blood clotting, bulging under skin), hematuria (blood in urine), melena (blood in stool), petechial spots (pen pricked size clots on skin)

      • Avoid puncturing the skin (use a soft toothbrush because gums can bleed)

Restraints

General considerations

  • Definition: Protective device to limit physical activity of patient or part of the body

    • Used to prevent falls, keep IV therapy in, prevent scratching, or combative patients

    • Disadvantages: can cause more agitation, skin tears

  • Types

    • Physical

      • Wrists, mitts (depends on hospital), vests (Posey), leathers, waist, etc

    • Chemical

      • Medications (ex; Ativan), narcotics, sedatives

    • Levels: 1 vs 2

      • Level 1 - nondestructive/nonviolent

        • Used to allow for medical treatment

        • Used for safety when patient is unable to follow directions

        • MD order needed every 24 hours

        • Indication, behavioral criteria, start/end time, type of restraint

      • Level 2 - destructive/violent/dangerous

        • 4 point leathers

        • Usually used in psych

        • MD must reorder every 4 hours

    • Alternatives

      • Assessment

      • Put a call bell within reach

      • Ask family to come in and talk to patient (usually therapeutic and calms patient if they are non-compliant)

      • Reorientation of patient to surrounding

Interventions

  • Use minimal restraints necessary

  • Observe every 15-30 minutes

    • Document on flow sheet!

  • Release every 2 hours to assess site, and reposition

    • Assess skin, ROM, and circulation

    • BLS certification required

    • Assess respirations with vest restraints

      • Could affect thorax region and respiratory expansion

    • Attach to bed frame, use a slipknot

    • Educate family and patient

    • Provide nutrition, fluids, and toileting

      • If restrained, they can not readily do these things without help

    • Document according to hospital policy

Fire Safety

  • Prevention

    • Ex; if a patient is on O2 - DON’T use oil based lubricants

    • Ex; NO smoking

    • Ex; cotton blankets only

    • Ex; all outlets in hospital are grounded (no fraying of wires)

    • Ex; all equipment (especially electrical) is functioning properly

  • Institute fire response education

    • Code red

    • Know where the fire extinguisher and fire exits are

  • RACE (Important)

    • Remove patients in immediate danger

    • Activate alarm

    • Contain the fire

    • Extinguish/evacuate

  • Extinguish

    • Class of Extinguishers

      • A - paper, wood, trash

      • B - liquids, and gases

      • C - electrical

    • Operation of Extinguishers

      • PASS

      • Pull, Aim, Squeeze, Sweep

  • Evacuation

    • Stay low to the ground - fire/heat rises

    • Don’t use elevators

Evaluation: Quality Assurance / Improvement

  • Ongoing and systematic process to improve quality of patient care

  • Occurrence Reports

    • Documentation of all occurrences and near misses

    • Document objectively, punitively (cannot put blame on others)

  • Sentinel Event Reporting

    • Unexpected events — serious physical and psychological injury, maybe even death

      • Ex; Joint Commission put into effect a list of DO NOT USE abbreviations because enough medical errors have occurred from mixing up abbreviations

  • Root Cause Analysis

    • Process of identifying deviations in practice

      • System and processes for which the hospital carries out certain protocols and situation

  • MEWS: Modified Early Warning Score

    • Early warning system built into the EMR

    • Views and Ranks patient’s vital signs

    • Picks up or detects subtle changes in patient’s vital signs

    • Allows for every intervention to manage changes in vital signs

    • Prevents a delay in early interventions

    • Prevents unstable vital signs resulting in a rapid response