Patient Safety, Adverse Events, Oxygen Therapy, and Use of Restraint

Module 6 Overview

  • Title: Patient Safety, Adverse Events, Oxygen Therapy, and Use of Restraint

  • Delivered on the Treaty 4 territory and the homeland of the Métis

  • Instructors: Sarah Todd RPN, BScPN, MN (CNS)

  • Adaptation: Adapted from Nori Manson-Brick, RN BScN, MN

Learning Objectives

  • Respiratory Function and Oxygenation

  • Oxygen Therapy

  • Promoting Airway Clearance and Bronchial Hygiene

  • Patient Safety

    • Assessing Patient Safety

    • CNA Code of Ethics and Safety

    • Cultural Safety

  • Safe Use of Restraints

    • Least Restraint Approach

Oxygen Therapy Refresher

  • Purpose:

    • Used to prevent or treat hypoxemia

  • Definition:

    • Hypoxemia: Low levels of oxygen in the blood.

Oxygen Therapy: Signs and Symptoms of Hypoxia

  • Symptoms:

    • Decreased Level of Consciousness (LOC)

    • Confusion

    • Drowsiness

    • Altered Concentration

    • Dizziness

    • Increased Pulse

    • Increased Rate and Depth of Respiration or Irregular Patterns

    • Increased Blood Pressure evolving to Decreased Blood Pressure

    • O2 Saturation < 90%

    • Decreased Lung Sounds with Adventitious Sounds

    • Dyspnea

    • Pallor

    • Cyanosis

    • Accessory Muscle Use

    • Cardiac Arrhythmias

    • Increased Fatigue

Treatment and Administration of Oxygen

  • Oxygen as a Medication:

    • Administer according to the 10 Rights of Medication

  • Selection of Oxygen Devices Based On:

    • Level of Oxygen Required

    • Severity of Hypoxia

    • Disease Process

    • Additional Factors:

    • age and developmental level

    • health status

    • level of orientation

    • presence of artificial airway

    • setting (acute vs. community)

    • support available

Oxygen Delivery Methods

  • Nasal Cannula:

    • Flow Rate: 1-6 L/Min

    • O2 Concentration: 24%-44%

    • Humidity: Higher levels should be given with humidity

    • Advantages:

    • Safe, simple, easily tolerated, allows eating/drinking

    • Disadvantages:

    • Contraindicated with nasal obstruction, drying to mucous membranes, can be dislodged, skin breakdown, and breathing pattern affects FiO2

  • Simple Mask:

    • Flow Rate: 5-10 L/Min

    • Usage: Used for short periods

    • Contraindications:

    • Not for CO2 retainers, increased risk of aspiration

    • WARNING: If < 5 L/min, can cause hypoxia

  • Partial and Non-Rebreather Mask:

    • Flow Rate: 10-15 L/Min

    • O2 Concentration: Delivers 60-80% O2

    • Benefits: Easily humidifies and does not dry mucous membranes

  • Venturi Mask:

    • O2 Concentration: 24-50%

    • Functionality: Provides a specific amount of O2 based on the adapter

Oxygen Safety

  • General Guidelines:

    • Oxygen is a medication and levels should not be adjusted without consulting a healthcare provider

    • An “OXYGEN IN USE” sign should be posted at the client's residence

    • Oxygen delivery systems should be at least 3 meters (10 ft) from heat sources

    • Oxygen is combustible but does not explode

    • Oxygen cylinders must be secured upright

    • No smoking allowed in areas where oxygen is in use

    • Ensure electrical equipment is functioning and properly grounded

    • Avoid anything that might create a spark, e.g., electric razor

    • Check oxygen levels of portable tanks before client transport

Nursing Role in Oxygen Delivery

Roles involve:

  • Assessing the patient’s respiratory status

  • Administer oxygen as per prescribed protocols

Promoting Airway Clearance

  • Purpose: To promote bronchial hygiene and clear airway while maximizing gas exchange

  • Interventions Include:

    • Client Positioning

    • Deep Breathing and Coughing

    • Using an Incentive Spirometer

    • Pursed Lip Breathing

Client Positioning

  • Effective Positions:

    • Semi-Fowler’s

    • High Fowler’s

    • Tripoding or Orthopneic position promotes chest expansion

Deep Breathing and Coughing

  • Benefits:

    • Facilitates opening of alveoli, mobilizing, and clearing secretions

    • Indicated for patients with chronic lung diseases, post-surgical conditions, and pneumonia

Incentive Spirometry

  • Function: Encourages practice of deep breathing

  • Feedback: Provides visual feedback to encourage long, slow breaths

  • Impact: Helps decrease risk of pulmonary postoperative complications when used alongside other techniques

Pursed Lip Breathing

  • Purpose: Helps patients control breath pace

  • Benefits: Promotes prolonged oxygen exchange and prevents airway collapse

Nursing Diagnoses

  • Common Diagnoses:

    • Impaired gas exchange (actual or risk for)

    • Impaired ventilation

    • Inability to fulfill roles related to respiratory compromise

    • Anxiety related to dyspnea

    • Insomnia related to orthopnea

    • Activity intolerance

Developing a Patient Care Plan

  • Overall Goals:

    • Improve comfort and ease of breathing

    • Maintain or improve pulmonary ventilation and oxygenation

    • Improve tissue perfusion

    • Enhance ability to participate in physical activities

    • Encourage health-promoting behaviors

Implementing Oxygenation Promotion

  • Nursing Interventions Include:

    • Change positions frequently

    • Encourage ambulation

    • Provide comfort measures

    • Administer fluids and humidification

    • Teach deep breathing and coughing methods

    • Use of pursed lip breathing and incentive spirometry

Patient and Nurse Safety

  • Importance of Safety:

    • Patient safety and nurse safety are interconnected

    • Nurses have professional and ethical duties to address safety concerns

    • Unsafe care usually reflects systemic failures rather than individual mistakes

Safety Terminology

  • Near Miss: An event caught before reaching the patient (also called good catch)

  • Adverse Event: An incident resulting in patient harm unrelated to their medical condition

  • Critical Incident: An adverse event leading to significant physical impairment or death

Patient Safety Statistics

  • Adverse Events:

    • 7.5% of all patients experience adverse events

    • 35% of those events are considered preventable

Safety Systems Approach

  • Swiss Cheese Model:

    • Safeguards consist of slices with holes representing weaknesses

    • Weaknesses aligning can lead to harmful events

  • Domino Effect:

    • Visualizes events cascading through system layers leading to patient harm

  • Iceberg Model:

    • Identifies visible and underlying contributing factors to patient safety issues

  • System-Wide Approach:

    • Learning from events to improve systems, emphasizing teamwork and communication

Nurse Safety and Violence Prevention

  • Incidents: All incidents of violence should be reported

  • Awareness: Be aware of surroundings to prevent and minimize risks

Culture of Safety

  • Reporting Culture: Trust in the reporting process without fear of punishment

  • Informed & Flexible Culture: Continuous awareness of issues and adapting systems for safety improvements

Risk Management in Safety Culture

  • Components: Quality improvement, investigation, root cause analysis, psychological safety

Falls Prevention

  • Statistics:

    • >1/3 of seniors experience falls

    • Associated with significant health risks and costs of ~$2 billion annually

Universal Fall Precautions

  • SAFE Approach:

    • Safe Environment: Ensure environments are free of hazards

    • Assist with Mobility: Support patient movement to prevent falls

    • Fall Risk Reduction: Engage patients and families in safety measures

Restraints in Healthcare

  • Definition: Restrictions preventing injury or managing behavior that threatens safety

  • Best Practice: Use restraints as a last resort, following policies and obtaining physician orders

Physical Restraint Guidelines

  • Procedure:

    • Attempt alternative methods first, obtain history and physical exam, explain restraints to patients

    • Document rationale and adhere to all applicable regulations

Alternatives to Restraints

  • Examples:

    • Therapeutic management, alarms, mattress adjustments, assistive devices

Bed Rails Considerations

  • Common Myths:

    • Belief that bed rails are entirely safe or useful for fall prevention

  • Risks: Injuries, agitation, isolation, and accidental deaths related to improper use

Best Practices for Bed Rails

  • When to Use:

    • Assistance with mobility, requested by capable patient, short-term use with assessment

  • When to Avoid: Confusion, risk for climbing or falls, reduced strength

Codes in Emergency Situations

  • Code Blue: Cardiac arrest/medical emergency

  • Code Red: Fire

  • Code White: Violent patient

  • Code Yellow: Missing patient

  • Code Green: Evacuation

  • Code Orange: Environmental disaster

  • Code Brown: Chemical spill

  • Code Black: Bomb threat

  • Code Purple: Hostage taking

References

  • Various sources cited for course material, including the Canadian Nurses Association, Truth and Reconciliation Commission of Canada, and other books related to nursing education and patient safety.