Safety (27)

Physiologic Hazards Associated with Restraints

-Increased possibility of serious injury due to fall -Skin breakdown -Contractures -Incontinence -Depression -Delirium -Anxiety -Aspiration and respiratory difficulties -Death

Factors that Attribute to Falls

-Lower body weakness -Poor vision -Gait and balance issues -Problems with feet/sores -Use of psychoactive medications -Postural Dizziness -Hazards in home/community

SPICES

-Sleep disorders -Problems with eating or feeding -Incontinence -Confusion -Evidence of falls -Skin breakdown

Restraint Guidelines

-Tie with slip knot -Perform ROM when released -Loosen every 2 hours -Pad bony prominences -Make sure 2 fingers can be inserted between

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

Alternative measures attempted before applying restraints

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant?

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

Nurse details client's response and examination and treatment of client after incident

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform.

-Explain rationale for use to the client and family -Pad bony prominences -Wrap restraint around client's ankle and secure it with hook and loop fastener straps -Ensure that two fingers fit between restraint and client's skin -Position limbs in normal anatomic position -Secure restraints to bed frame with quick release knots

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

Fill out incident report, with goal of preventing similar event in future

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows

Alternatives to Restraints

-Assign sitter -Place patient in area they can be watched -Monitor meds and eliminate psychotropics -Wedge pillows -Furniture/plants to prevent wandering -Ease agitation

Causes of Accidental Injuries in Older Adults

-Changes in vision/hearing -Loss of mass and strength of muscles -Slower reflexes and reaction time -Decreased sensory ability -Combined effects of chronic illness and medications -Economic factors

QSEN Competencies

-Client centered care -Teamwork and collaboration -Quality improvement

RACE

-Rescue -Activate alarm -Confine area -Evacuate

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse?

Ask client "what if" questions to determine level of thought organization

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

Check breathing and heart rate

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush eyes with water for 10 minutes

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

Identifying systemic factors on unit that may have contributed to event

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies?

New systems are introduced to increase communication between nurses and members of other health disciplines

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?

Provide bedside commode and ensure adequate lighting

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first?

Reduce distressing environmental stimuli to maximize client safety

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family?

Reduce temperature on the water heater

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident?

Report this sentinel event to Joint Commission and to relevant state agencies

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain baby in a car seat

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

What should you never attach restraints to?

Side rails

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next?

Submit safety report to appropriate department within facility so that it can be reviewed

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting