Comprehensive Nursing Safety & Mobility Study Notes WEEK 4 FOR FUNDS

Core Principles of Safety in Nursing

• National Patient Safety Goals (NPSGs)
  • Published by The Joint Commission; set standardized best-practice benchmarks.
  • Examples: Correct‐patient ID, medication‐labeling, prevention of hospital-acquired infections.
• Never Events
  • Severe, clearly preventable incidents that must never occur (e.g., wrong-site surgery, falls with injury, retained foreign object).
• QSEN Competencies
  • Safety
  • Patient-Centered Care
  • Evidence-Based Practice
  • Teamwork & Collaboration
  • Quality Improvement
  • Informatics
• Guiding Question: What frameworks guide every safety decision? → NPSGs, QSEN, facility policy, and federal/state regulations.

Factors Influencing a Client’s Safety

• Age-Related
  • Infants/Toddlers → choking, suffocation, drowning, poisoning.
  • Preschool/School-Age → bike crashes, burns, stranger danger.
  • Adolescents → risk-taking, texting & driving, substance use.
  • Adults → motor vehicle accidents (MVA), workplace injuries, stress-related illness.
  • Older Adults → falls, burns, polypharmacy, impaired mobility/sensation.
• Physiologic & Psychosocial
  • Mobility impairments (assistive devices, transfers).
  • Cognitive deficits (dementia, delirium, poor judgment).
  • Sensory loss (vision, hearing) → misinterpreting environment.
  • Medication effects (orthostatic hypotension, sedation).
  • Emotional state (stress, depression) → risk-taking behavior.
  • Communication barriers (language, aphasia, speech disorder).
  • Environmental hazards (clutter, loose rugs, poor lighting, unsafe furniture).

Safety in Facility vs. Home

Facility

• Controlled environment, formal protocols, rapid access to emergency resources.
• Electronic safety alerts (e.g., fall-risk wristbands, EMR banners).

Home/Community

• Client may not recognize hazards; nurse provides education and collaborates with PT/OT/social work.
• Common risks: unsecured rugs, extension cords, absent smoke or CO detectors.

Key Safety Terminology

• Never Event – sentinel event that should never happen.
• QSEN – competency framework for nursing safety & quality.
• Seclusion – involuntary confinement for safety.
• Restraint – physical or chemical method to restrict movement.
• Risk-Assessment Tool – standardized checklist (fall, seizure, home hazard, etc.).
• Incident Report – confidential, non-punitive documentation of errors or near-misses.

Legal & Ethical Responsibilities

• Nurses are legally/ethically accountable to prevent harm.
  • Early recognition of risk, client teaching, advocacy, precise documentation.
• Must follow:
  • Facility policies & protocols.
  • Fire safety (RACE & PASS), emergency & disaster plans.
  • Use only equipment for which they are trained.

Safety Assessment: Why & How

• Continuous process: assess → diagnose → plan → implement → evaluate.
• Components
  • Client factors: mobility, meds, cognition, LOC.
  • Environment: clutter, lighting, equipment safety.
  • Reassess whenever conditions change (post-op opioids, new confusion, etc.).
• Example: Post-op client on opioids → \text{↑ fall risk} → update care plan immediately.

Fall Risk Assessment

• High-Risk Populations
  • Older adults (decreased strength, balance, polypharmacy).
  • Neurologic disorders (Parkinson’s, MS).
  • Vision impairment, previous falls, urinary urgency, orthostatic hypotension, cognitive changes.
• Tools
  • Morse Fall Scale, Hendrich II Fall Risk Model.
• Key Nursing Actions
  • Assess on admission & routinely.
  • Color-coded alerts, bed in low/locked position, place near nurse’s station, nonskid footwear, hourly rounding.

Seizure Risk Assessment & Precautions

• At-Risk Clients: Epilepsy, brain injury, febrile children, ETOH withdrawal, hypo-glycemia/-natremia.
• Assessment
  • Medical history, triggers (sleep deprivation, flashing lights), medication levels (phenytoin).
• Environmental Preparation
  • Suction, oxygen, oral airway, padded rails, saline lock for rescue meds.
• Precautions
  • BEFORE: pad rails, declutter, set up airway equipment.
  • DURING: stay, call for help; ease to floor, side-lying, no objects in mouth, maintain airway, time seizure.
  • AFTER: VS, O2 sat, neuro re-eval, quiet environment, full documentation (aura, duration, postictal state).

Safety Across the Lifespan (Quick Matrix)

• Infants/Toddlers → aspiration, suffocation, drowning, falls, poisoning.
• Preschool/School-Age → bike injuries, burns, stranger danger.
• Adolescents → high-risk behaviors, distractive driving, substance use.
• Adults → workplace hazards, MVA, stress illness.
• Older Adults → falls, burns, polypharmacy, impaired senses.

Home Safety Assessment

• Checklist Items: throw rugs, clutter, lighting, item accessibility, detectors, bathroom setup, emergency numbers.
• Process: client interview + walkthrough; interdisciplinary referral PRN.

Emergency Primary Survey – ABCDE

• A – Airway & Cervical Spine
• B – Breathing (rate, effort)
• C – Circulation (pulse, bleeding, color)
• D – Disability (AVPU, pupils, movement)
• E – Exposure (undress, search for hidden injury)

Environmental Hazard Assessment (Facility & Home)

• Facility: cluttered halls, broken equipment, poor lighting, unsecured chemicals, stressed staff.
• Home: cords on floor, lack of grab bars, unsecured firearms, pets causing tripping.
• Nurse duty: identify, report (incident form), educate, collaborate with maintenance/housekeeping.

Diagnostics – From Data to Judgment

• Vital signs, meds, labs, imaging, functional scores → validate suspected risks & set priorities.
• Example: \text{Hgb/Hct ↓} + weakness → higher fall risk; \text{Na^+ ↓} → seizure prone.

Key Diagnostic Red-Flags for Falls

• Orthostatic drop > 20\,\text{mmHg systolic}.
• Sedating meds, impaired vision/hearing, gait instability.
• Labs: anemia, electrolyte imbalance.

Seizure Diagnostic Highlights

• EEG, MRI/CT, anticonvulsant levels, electrolytes.
• Behavioral: aura, sleep loss, sudden confusion.

Restraints – Diagnostic Justification & Safe Use

• Only if immediate harm risk & less-restrictive measures failed.
• Documentation must include: trigger behavior, type & location, duration, monitoring, neuro/skin checks.
• Safe Use
  • Provider order within 1\,\text{hr} (emergency); renew per policy (usually q24h).
  • Least restrictive device, tie to bed-frame, two-finger space, release q2h for ROM & needs.

Fire Safety – RACE & PASS

• R – Rescue
• A – Alarm
• C – Contain
• E – Extinguish/Evacuate
• PASS: Pull, Aim, Squeeze, Sweep.
• Know extinguisher location, exits, O$_2$ shut-off valves.

Client & Family Education

• Topics: call light, falls, seizures, home O$_2$ safety, med storage, fire plan, detector upkeep.
• Methods: return demo, written pamphlets, visuals, interpreter services.
• Always assess readiness, cognition, health literacy.

Community / Home Health Interventions

• Home hazard check, CPR/first-aid teaching, smoke/CO detectors, food safety, toxin identification.
• Pediatric focus: cord safety, car seats, pool fencing, stair gates.

Emergency Interventions (Heat, Cold, CPR, Altitude)

• Heat stroke → remove clothes, ice groin/axilla, prevent shivering.
• Frostbite → warm bath (tepid), tetanus update, skin assess.
• Burns → stop burn, cover wound, NPO, elevate limbs.
• CPR → CAB sequence, AED ASAP.
• Altitude illness → descend, O$_2$, possible steroids.

Ergonomics & Body Mechanics

• Ergonomics: match equipment to human capability → prevent injury.
• Body Mechanics Basics
  • Center of gravity = pelvis; widen base of support, keep load close, bend hips/knees not waist.
  • No twisting; turn whole body.
  • Ask help if > 35\,\text{lb} or client uncooperative.
• Poor-Mechanic Signs: back pain, twisting, reaching while seated, repetitive strain.
• Assist Devices: gait belts, hydraulic lifts, slide sheets, walkers/canes/crutches.
• Positioning
  • Semi-Fowler 30^{\circ} – aspiration prevention.
  • Fowler 45–60^{\circ} – NG insertion, lung expansion.
  • High-Fowler >60^{\circ} – severe dyspnea, meals.
  • Prone – oral drainage, post- amputation.
  • Lateral – pressure offload.
  • Orthopneic – COPD lung expansion.
  • Trendelenburg – venous return; Reverse Trendelenburg – reflux prevention.

Musculoskeletal & Neurologic Assessment

• Key Terms
  • Gait, ROM, tone, hypertrophy, atrophy.
  • Flexion, extension, supination, pronation, abduction, adduction, dorsiflexion, plantar flexion.
• Neurologic LOC Spectrum: Alert → Lethargic → Obtunded → Stuporous → Comatose.
• Postures: Decorticate (cortex), Decerebrate (brainstem).
• Reflex Grading: 0 none … 2+ expected … 4+ hyperreflexia.
• Cranial Nerves I–XII (smell, vision, eye moves, facial sensation, expression, hearing, taste/swallow, shoulder/tongue).
• Subjective Questions: pain, stiffness, falls, ADL help, exercise habits, nutrition (Ca^{2+}/Vit D).
• Physical Exam
  • Inspect symmetry, posture, spinal curves (kyphosis, lordosis, scoliosis).
  • Palpate for tenderness, warmth, crepitus; test active/passive ROM & strength.
  • Gait: smooth vs. shuffling (Parkinson), hemiplegic (stroke), ataxic (cerebellar).

Diagnostics – Musculoskeletal & Neuro

• Imaging: X-ray (fracture), MRI (soft tissue), CT (bone/joint cross-section), DEXA (bone density).
• Neuro: EEG (brain waves), EMG (muscle vs. nerve), lumbar puncture (CSF), MRI/CT brain.
• Labs: ESR/CRP (inflammation), Ca^{2+}/Vit D (bone), CK (muscle breakdown), uric acid (gout).
• Functional Tools: MMSE, Braden Scale, Timed Up & Go, Morse Fall Risk.

Mobility & Immobility Interventions

• Basic Care
  • Reposition q2h bed / q15min chair.
  • Active/passive ROM, splints, footboards, hand rolls.
  • Early ambulation, assistive equipment.
• Prevent Complications
  • Pressure injury → support surfaces, skin care.
  • DVT → SCDs, ankle pumps, anticoagulants.
  • Respiratory stasis → turn-cough-deep-breathe, incentive spirometer 10\times/\text{hr}.
  • Nutrition → high-protein/calorie, monitor I&O, weight.
  • Psychosocial → orientation aids, routine, family involvement.
• Assistive Device Technique
  • Cane on strong side → cane, weak leg, strong leg sequence.
  • Walker → advance walker 6–8 in, step with weak leg.
  • Crutches → weight on hands, tripod stance; teach 4-, 3-, 2-point gaits.

Heat & Cold Therapy

• Heat: chronic pain, stiffness; increases blood flow.
• Cold: acute injury, swelling; numbs & vasoconstricts.
• Limit application to 15–30\,\text{min}; check skin q10 min; contraindicated in poor circulation/open wounds.

Sensory Perception Fundamentals

• Modalities: vision, hearing, touch, smell, taste, kinesthesia.
• Problems
  • Sensory Deficit → loss of normal sense (e.g., cataracts, neuropathy).
  • Sensory Deprivation → minimal input → boredom, confusion, anxiety.
  • Sensory Overload → excessive input → agitation, restlessness.
• Common Causes
  • Vision: cataract, glaucoma, macular degeneration, diabetic retinopathy.
  • Hearing: wax, infection, ototoxic meds, loud noise, presbycusis.
  • Neuro: stroke, MS, tumors.
  • Taste/Smell: aging, dry mouth, meds.
• Assessment Cues
  • Vision loss → bumping objects, squinting, light sensitivity.
  • Hearing loss → “What?”, head turn, loud speech.
  • Cognitive decline vs. sensory loss – differentiate!
• Diagnostics
  • Vision: Snellen, Rosenbaum, tonometry (IOP), slit-lamp.
  • Hearing: Rinne, Weber, audiometry, tympanometry, otoscopy.
• Interventions
  • Vision: announce presence, stay in field, describe environment, large print, good lighting.
  • Hearing: face client, speak slowly, low pitch, write PRN, check hearing aids.
  • Aphasia: short phrases, allow response time, gesture boards.
  • Deprivation: purposeful stimuli (music, conversation, textures).
  • Overload: quiet room, dim lights, cluster care.
  • Home safety by sense: remove rugs (vision), flashing alarms (hearing), label temps (tactile), etc.
• Interprofessional: audiology, ophthalmology, OT, speech therapy, social work.

Evaluation & Plan Update

• Reassess ROM, gait, skin, vitals, Braden, cognition.
• Monitor for new issues: pressure injuries, falls, delirium, weight loss.
• Document outcomes; revise goals; escalate (PT/OT, dietitian, provider) if goals unmet.
• NGN Strategy: Always cycle through Recognize Cues → Analyze → Prioritize → Generate Solutions → Take Action → Evaluate.

Final Takeaway

• Safety is a mindset; nurses are the primary barrier between risk and harm.
• Use standardized tools, evidence-based protocols, critical thinking, and interprofessional collaboration to maintain client safety across settings and lifespans.