CH27 - Client Safety and Security

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

Factors affecting safety

-Developmental considerations -Lifestyle -Mobility -Sensory perception -Knowledge -Ability to communicate -Physical health state -Psychosocial health state

preventing falls

-do fall assessment on every patient -keep bed low wheels locked and bed rails up -call button near bed -non skid footwear -instruct client properly

Restraints should not

-interfere w/physiological function -limit physical activity to the point of immobilization -interfere with respiratory function

reason for falls

-loss of balance and need to use the toilet -standing up and feeling dizziness -not having necessary items within reach

Risk factors for falls

-lower body weakness -poor vision -gait or balance weakness -problems with feet and/or shoes -use of psychoactive medications -postural dizziness -hazards in home/community

Side rails

-only 2 up at a time -4 is considered a restraint -small people at greater risk for asphyxiation -must be able to raise and lower

Morse Fall Risk Scale

-quick assessment of 6 questions and lets you know if the patient is at a high risk for a fall

Focus of safety assessment

-the person -the environment -specific risk factors

general documentation for a restraint

-type of restraint -when was it applied -alternatives attempted -patient, family, and physician notification -frequency of assessments -regular intervals of released -nursing interventions

8 risk factors for Hendrich II Fall Risk Model

1. confusion/disorientation 2. systematic depression 3. altered elimination 4. dizziness/vertigo 5. male sex 6. administration of antiepileptic meds 7. administration of benzodiazepine meds 8. performance of the up and go test

morse fall risk scale questions

1. history of falling 2. secondary diagnosis 3. ambulatory aid 4. IV/Heparine lock 5. Gait/Transferring, weak/impaired 6. Mental status, oriented to own ability

Event report

A document that includes information about the victim of the accident and the victim's description of the accident as well as statements from any witnesses.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Drowsiness Headache Vomiting

Hendrich II Fall Risk Model

Eight-factor assessment model, well established and used widely in acute care settings to assess the fall risk of patients

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

RACE

Rescue and remove all patients from danger Activate alarm Confine the fire by closing the doors, turn off oxygen and equipment Extinguish the fire w the appropriate extinguisher

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 the baby in a car seat.

What generalization can be made about safety in client care?

Safety is a paramount concern underlying all nursing care.

A nurse is caring for an 18-month-old client after a tracheostomy. The is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate?

a rocking horse

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents.

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

4 P's

pain potty position presence

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom