Foundations Ch 27 Safety, Security and emergency

Preschooler Falls Cuts Burns Drowning Inhalation or ingestion Guns and weapons

- Teach child to wear proper safety equipment when riding bicycles or scooters. • Ensure that playing areas are safe. • Begin to teach safety measures to child. • Do not leave child alone in the bathtub or near water. • Practice emergency evacuation measures. • Teach about fire safety.

Preventing Procedure-Related Accidents

- The nurse must always be cautious and alert to prevent procedure-related accidents. Errors are possible when administering medications or intravenous solutions, transferring a patient, changing a dressing, or applying external heat to a patient's extremity. Therefore, nurses must follow correct procedures when administering care (see the Research in Nursing box that describes the development of a process to improve patient safety). Safeguards to prevent errors include making sure that the patient is identified correctly

Child physical abuse

- Unexplained or repeated injuries resulting from physical force. - Manifestations include bruises, fractures (arms, legs, facial, ribs), burns, bite marks, head injuries, and any other indications of force.

Falls can be categorized as either

- accidental (clutter or a spill cause a person to trip), -anticipated physiologic fall (a direct consequence of gait imbalances, effects of medication, or dementia), -unanticipated physiologic falls (caused by unknown or unexpected medical issues such as a stroke or seizure), - intentional falls (occur when patients act out behaviorally with intent to fall)

Several categories of chemicals can be used as weapons of mass destruction (CDC, 2016b):

- biotoxins - blister agents/vesicants -blood agents -caustics (acids) -chocking/lung/pulmonary agents -incapacitating agents -long acting -anticoagulants -metals -nerve agents -organic solvents -riot control agents/ tear gas -toxic alcohols -vomiting agents

extrinsic fall risk factors

- lack of stair handrails - poor stair design - lack of bathroom grab bars - dim lighting or glare - obstacles and tripping hazards - slippery or uneven surfaces - psychoactive medications improper use of assistive devices

NURSING HISTORY

-Be alert to any history of falls or accidents, because a person with a history of falling is twice as likely to fall again - Note any assistive devices that the patient uses (e.g., a cane or walker). - Be alert to any history of drug or alcohol abuse. - Knowledge of family support systems and the home environment is crucial for the nurse to plan protective health measures.

FALLS

-Many falls at home go unreported because they do not cause injuries requiring medical attention. However, injuries from falls may also go unreported because older adults fear activity restrictions, loss of independence, or placement in a long-term care facility. - The fear of falling can also cause anxiety and panic, which may make an older adult more vulnerable to a fall. - Falls are actually the most common cause of traumatic brain injuries.

Intrinsic fall risk factors

-advanced age -previous falls -muscle weakness -gait and balance problems -poor vision -postural hypertension chronic conditions -fear of falling

Assessment of risk for falling

-includes the use of nursing history and physical examination - include inquiring about and inspecting for factors that contribute to falls, and an understanding of the types of and reasons for falls. -

Orienting the Person to Surroundings

A person who is familiar with one's surroundings is less likely to experience an accidental injury. As part of the hospital admission routine, orient the patient to the safety features and equipment in the room. An explanation and demonstration of the adjustable bed and side rails, call system, telephone, television, and bathroom help the patient adjust to the new environment. The patient identification bracelet and a discussion of facility routine further ensure safety and assist the patient to adapt to the unfamiliar setting. Similarly, teach the importance of orienting an older adult to new surroundings when the older adult moves in with a family member or other caregiver.

Alterations in sensory perception can have a devastating effect on safety.

Any impairment in sight, hearing, smell, taste, or touch can reduce a person's sensitivity to the environment.

Falls are the leading cause of nonfatal injuries for all children of ages 0 to 19.

Approximately 8,000 children are treated in emergency rooms in the United States for fall-related injuries every day. This means that close to 2.8 million children are injured from falling every year (CDC, 2016a). Climbing equipment on public playgrounds and swings on home playgrounds are responsible for the majority of pediatric fall injuries. Specific interventions to diminish this fall risk for children are discussed later in this chapter.

Drowning is a form of suffocation.

Approximately one in five people who die from drowning are children aged 14 or younger. Drowning is the fifth leading cause of unintentional death from injury in the United States. Most drowning deaths in young children occur because of inadequate adult supervision of a child in or near a bathtub or pool, even a small wading pool. Older children are more likely to drown while swimming or boating.

Preventing Suffocation

As a result of suffocation, unconsciousness, respiratory failure, and cardiac arrest can occur. Emergency measures must start without delay, beginning with the removal of any obstruction and administration of cardiopulmonary resuscitation (CPR). When teaching parents, the nurse should emphasize careful supervision of children and should outline specific situations that place children at risk for suffocation. Health education is a valuable preventive force

PHYSICAL EXAMINATION

Assess the patient's mobility status, ability to communicate, level of awareness or orientation, and sensory perception in the physical examination. Early identification of any potential safety hazards is essential. Recognize any manifestations that suggest domestic violence or neglect.

Nurses are responsible for identifying patients who are at high risk for falls, documenting pertinent assessments on the chart, and planning appropriate interventions to ensure their safety.

A nurse whose behavior is reasonable, prudent, and similar to the behavior that would be expected of another nurse in similar circumstances is unlikely to be found liable if a patient falls, even if an injury results.

In the past, side rails were used to provide support and aid equilibrium, but it is now recognized that they can pose serious risks for a confused or agitated patient.

A person of small stature has a greater risk for entrapment or injury. Death from asphyxiation has occurred when patients have become wedged between the mattress and the bed frame or side rail. Although patient entrapment is uncommon, it can be fatal. Most of the victims of side rail fatalities are frail, of advanced age, or confused, and many exhibit uncontrolled body movement. Most incidents of entrapment occur in a long-term care setting.

Promoting safety and preventing injury are dual responsibilities of the nurse.

Being aware of factors that affect safety, such as developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state allows nurses to identify potential hazards and promote wellness.

USING ALTERNATIVES TO RESTRAINTS

Careful nursing assessment is the key to identifying appropriate alternatives to restraint use and finding an individualized solution. Nursing interventions may be used to reduce confusion or agitation and provide a safe environment. Using a restraint on an older adult who tends to wander is unjustified because a variety of alternative options can be used to keep such patients safe.

The ability to communicate is basic to many safety practices. The nurse must assess any factor that influences the patient's ability to receive and send messages.

Fatigue, stress, medication, aphasia, and language barriers are examples of factors that can affect personal communication and prevent the patient from accurately perceiving events. For example, a medication side effect of drowsiness may interfere with a health teaching session between the nurse and the patient taking this drug. A valid assessment by the nurse not only identifies the patient's level of understanding, but also facilitates a positive communication experience.

It is imperative that community nurses are aware of risks or hazards in certain settings that have the potential to result in violence and cause personal injury.

In high-crime areas, a personal escort may be required to ensure a safe nurse visit. Each home care facility must have a policy in place that recognizes violent behavior and has a strategy to deal with it. Facility risk assessment takes into account crime patterns in the area, the willingness and availability of law enforcement to assist with dangerous situations, and staff impressions about previous visits, including the type of environment that was encountered.

A school nurse has many opportunities and a ready audience for health teaching about safety, including screening programs (e.g., vision and hearing), fire prevention sessions, drug and alcohol prevention programs, firearm safety, and classes on various accident prevention techniques.

Managing minor accidents at school often provides an opportunity for additional preventive teaching. In this setting, the school nurse has the opportunity for formal or informal health teaching with children and parents that should include parental encouragement to do the following: - Monitor the child's use of the Internet - Get involved in school activities and ask pertinent questions - Volunteer for safety committees that include staff and parents - Ensure that the school's emergency preparedness plan is current

Safety considerations begin with an awareness of behaviors that may harm the developing fetus.

Newborns of mothers who smoke have a lower birth weight. Excessive alcohol consumption and use of drugs may cause adverse effects that are readily apparent at birth. Reinforce a pregnant woman's knowledge of the risks associated with excess alcohol consumption, smoking, drug use, and exposure to other dangers in the environment

Preventing Injury From Firearms

Nurses are in a unique position to raise awareness and to help reduce high-risk behavior that may lead to firearm injuries and deaths. In homes, schools, and other health care settings, nurses can provide information on how parents can keep guns out of the hands of children. Parents may be unaware of how common gunshot injuries are or the dangers that can occur when a gun is accessible to children and young adults. Healthy People 2020 identified 13 objectives related to violence, several of which involve the use of firearms. This is important because it identifies violence as a public health issue that needs to be addressed at the community level

Vulnerable populations also need support and attention, regardless of the circumstances that made them vulnerable.

Nurses have always been strong patient advocates regarding safety concerns for this population.

Nurses remain at serious risk for musculoskeletal injuries, needlestick and sharp injuries, exposure to hazardous chemicals, radiation exposure, exposure to infectious diseases, and workplace violence

Nurses need to adhere to standards, guidelines, recommendations, and policies to promote safety and minimize preventable injury.

For children, potential hazards multiply as their motor skills develop and their environment expands.

Nurses promote safe sleeping practices for infants when they advise parents to avoid stuffed animals and crib bumpers that increase the risk for suffocation. The risk of falling is noticeably higher for children. Toddlers are increasingly active and need appropriate safeguards to prevent falls in the home. Outdoor play and the associated injuries become an issue in the years between toddlerhood and adolescence. Strategies to reduce the risk and severity of playground injury to children, especially traumatic brain injury (TBI) in children aged 5 to 9, include attentive adult supervision, employing methods to reduce high-risk behavior, designing age-appropriate playground equipment, and creating an environment that is well-designed and maintained

Any limitation in mobility is potentially unsafe.

Supportive devices—such as canes, walkers, and wheelchairs—may facilitate movement, but they require careful patient instruction and preparation for safe use. Recent surgery or a prolonged illness can temporarily affect a patient's mobility and necessitate special precautions to prevent falls or injuries. Nurses must assess a patient's risk for injury with a view toward maintaining independence and fostering self-esteem while providing a safe and predictable environment.

Sports or recreation-related activities (fall or interpersonal contact, roller sports, equestrian and related activities, skiing/snowboarding, water sports) can result in TBI.

TBI usually results from a blow, bump, or jolt to the head that causes disruption in brain function. The direct blow to the head causes the brain to accelerate into the skull and then return and bounce off the opposite side of the skull. The brain can also rotate inside the skull, resulting in further damage.

Living in an area where crime is prevalent can pose a threat to physical security and emotional well-being.

Violence, acts of aggression, and terrorism are components of 21st-century life. Security measures such as locks, security systems, and exterior lighting can promote safety.

Adolescent Motor vehicle accidents Drowning Guns and weapons Inhalation and ingestion

• Teach responsibilities of new freedoms that accompany being a teenager. • Enroll teen in safety courses (driver education, water safety, emergency care measures). • Emphasize gun safety. • Get physical examination before participating in sports. • Make time to listen to and talk with your adolescent (helps with stress reduction). • Follow healthy lifestyle (nutrition, rest, etc.). • Teach about sexuality, sexually transmitted infections, and birth control. • Encourage child to report any sexual harassment or abuse of any kind.

Neonate (first 28 days of life) Infection Falls ASSB

• Wash hands frequently. • Never leave infant unsupervised on a raised surface without side rails. • Use appropriate infant car seat that is secured in the back seat facing the rear of the car. • Handle infant securely while supporting the head. • Place infant on back to sleep.

Infant Falls Injuries from toys Burns Suffocation or drowning Inhalation or ingestion of foreign bodies

- Supervise child closely to prevent injury. • Select toys appropriate for developmental level. • Use appropriate safety equipment in the home (e.g., locks for cabinets, gates, electrical outlet covers). • Never leave child alone in the bathtub. • Childproof the entire house.

Cyberspace is particularly difficult to secure due to many factors including:

(1) the ability of perpetrators to operate from anywhere in the world; (2) the linkages between cyberspace and physical systems, especially those involving critical infrastructure; and (3) and the difficulty of reducing vulnerabilities and minimizing consequences in complex cyber networks

Child emotional abuse

- Behaviors that harm a child's self-worth or emotional well-being. - Manifestations can include extremes in behavior, sleep problems, headaches or stomachaches, avoiding activities.

Nursing Interventions to Prevent Falls in a Health Care Facility

- Complete a risk assessment. - Indicate risk for falling on patient's door and chart. - Keep bed in low position. - Keep wheels on bed and wheelchair locked. - Leave call bell within patient's reach. - Instruct patient regarding use of call bell. - Answer call bells promptly. - Leave a night light on. - Eliminate all physical hazards in the room (clutter, wet areas on the floor). - Provide nonskid footwear. - Leave water, tissues, bedpan/urinal within patient's reach. - Move bedside commode out of sight to discourage attempts at independent transfer (as appropriate). - Document and report any changes in patient's cognitive status to the health care team at the change of shift. - Use alternative strategies when necessary instead of restraints. - As a last resort, use the least restrictive restraint according to facility policy. - If restraint is applied, assess patient at the required intervals.

Child sexual abuse

- Engaging a child in sexual acts including fondling, rape, and exposing a child to other sexual activities. - Can be manifested by vaginal discharge, urinary tract infection, difficulty walking or sitting, sexually transmitted infections, and genital pain.

Toddler Falls Cuts from sharp objects Burns Suffocation or drowning Inhalation or ingestion of foreign bodies/poisons

- Have poison control center phone number in readily accessible location. • Use appropriate car seat for toddler. • Supervise child closely to prevent injury. • Childproof house to ensure that poisonous products, drugs, guns, and small objects are out of toddler's reach. • Never leave child alone and unsupervised outside. • Keep all hot items on stove out of child's reach.

Most health care facilities have fall prevention programs. National initiatives encourage health care providers to ask these three questions at every encounter with older adults:

- Have you fallen in the past year? - Do you feel unsteady when standing or walking? - Do you worry about falling?

Assessing the Environment

- Hazards in the home, community, and health care facility may cause injury. - Nursing assessment includes identifying people at risk and recognizing unsafe situations. - This requires knowledge of the factors that influence safety and predispose people to accidents. - Recognizing these factors helps the nurse develop an individualized plan of care and nursing interventions for protecting the patient. - Assessment includes an awareness of risk factors in both the home and the health care facility, with the focus on the patient's developmental level and health status.

Common manifestation of concussion can be subtle, but parents, teachers, and nurses need to be aware of the following descriptions of symptoms by category that may require a 911 call and immediate ED attention:

- Physical: headache, vomiting, problems with balance, fatigue, dazed or stunned appearance - Cognitive: mentally foggy, difficulty concentrating and remembering, confusion, forgets recent activities - Emotional: irritability, nervousness, very emotional behavior, any change in personality - Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual

Most hospital procedures emphasize the following priorities and recommend that staff members remember the acronym RACE as a guide:

- Rescue anyone in immediate danger - Activate the fire code system and notify the appropriate person - Confine the fire by closing doors and windows - Evacuate patients and other people to a safe area

Applying an Extremity Restraint

1. Determine the need for restraints. Assess the patient's physical condition, behavior, and mental status. 2. Confirm facility policy for the application of restraints. Secure an order from the primary care provider, or validate that the order has been obtained within the required time frame. 3. Perform hand hygiene and put on PPE, if indicated. 4. Identify the patient. 5. Explain the reason for restraint use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure. 6. Include the patient's family and/or significant others in the plan of care. 7. Apply restraint according to the manufacturer's directions: a. Choose the least restrictive type of device that allows the greatest possible degree of mobilit b. Pad bony prominences. c. Wrap the restraint around the extremity with the soft part in contact with the skin.If a hand mitt is being used, pull over the hand with cushion to the palmar aspect of the hand 8. Secure in place with the Velcro straps or other mechanism, depending on specific restraint device. Depending on the characteristics of the specific restraint, it may be necessary to tie a knot in the restraint ties, to ensure the restraint remains secure on the extremity. 9. Ensure that two fingers can be inserted between the restraint and patient's extremity 10 .Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint to the bed frame, not side rail . The restraint may also be attached to a chair frame. The site should not be readily accessible to the patient. 11. Remove PPE, if used. Perform hand hygiene. 12. Assess the patient at least every hour or according to facility policy. Assessment should include the placement of the restraint, neurovascular assessment of the affected extremity, and skin integrity. In addition, assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. Monitor the patient's vital signs. 13. Remove the restraint at least every 2 hours, or according to facility policy and patient need. Perform range-of-motion (ROM) exercises. 14. Evaluate the patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid. 15. Reassure the patient at regular intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep the call bell within the patient's easy reach.

Performing a Situational Assessment

1. Perform hand hygiene and put on PPE, if indicated. 2. Identify the patient. Explain the purpose of the assessment to the patient. 3. Assess for data that suggest a problem with the patient's airway, breathing, or circulation. If a problem is present, identify if it is urgent or nonurgent in nature. 4. Assess the patient's level of consciousness, orientation, and speech. Observe the patient's behavior and affect 5. Assess the patency of an oxygen delivery device, if in use. 6. Survey the patient's environment. Assess the bed position and call bell location. Bed should be in the lowest position and the call bell (based on specific patient care setting) should be within the patient's reach. 7. Assess for clutter and hazards. Remove excess equipment, supplies, furniture, and other objects from rooms and walkways. Pay particular attention to high traffic areas and the route to the bathroom. 8. Note the presence and location of appropriate emergency equipment, based on individual patient situation. 9. Note the presence and location of appropriate assistive devices and mobility aids, based on individual patient situation. Ensure any devices are within the patient's reach. 10. Assess for the presence of an intravenous access and/or infusion. Assess patency of the device and the insertion site. If an infusion is present, assess the solution and rate. 11. Assess for the presence of any tubes, such as gastric tubes, chest tubes, surgical drains, or urinary catheters. Assess patency of device and insertion site. 12. Provide a bedside commode and/or urinal/bedpan, if appropriate. Ensure that it is near the bed at all times. 13. Ensure that the bedside table, telephone, and other personal items are within the patient's reach at all times. 14. Consider what further assessments should be completed and additional interventions that may be indicated. Identify problems that need to be reported and whom to contact.

The possibility of child abduction also needs to be addressed with parents and kids for this age group.

Abduction occurs for a number of reasons and is a tragedy that devastates parents, families, and communities. Strangers, family members, friends, or neighbors may kidnap children. Some children suffer sexual assault or are murdered by their captors. Adults who prey on children often take advantage of the innocent and trusting nature of children to persuade the child to accompany them.

The Joint Commission

Accredits facilities according to established safety and quality standards; revises the emergency management standards for health care facilities

Centers for Disease Control and Prevention (CDC)

Acts as the lead federal facility for disease prevention and control activities; provides backup support to state and local health departments

American Red Cross

Acts as the lead nongovernmental facility that provides safety information and disaster response

Body piercing has become increasingly popular with adolescents and young adults.

Common sites for piercing include the ears, nose, eyebrows, lips, tongue, nipples, navel, and genitals. If not performed in a professional, clean environment, there is a risk for contracting hepatitis B or C, tetanus, or HIV. Even in a sterile environment, some common risks of piercing include chronic infection, skin allergies, abscess formation, inflammation, nerve damage, or prolonged bleeding

Major causes of falls in the home include slippery surfaces, poor lighting, clutter, and improperly fitting clothing or slippers.

Common traffic pathways in the home, the bathroom, and access areas to and from the home are hazardous areas for older adults. Measures as simple as installing hand rails in bathrooms and on stairs, ensuring good lighting, and discarding or repairing broken equipment around the home help prevent accidents

Assessment data and statistical information often provide helpful information for health care personnel who are developing a safety program for patients at risk.

Safety education classes, in addition to situational health teaching, can be worthwhile for hospitalized patients and their family members. Studies have demonstrated that early assessment of vulnerable patients and preventive education programs can decrease the incidence of falls.

Stressful situations tend to narrow a person's attention span and make the person more prone to accidents. Stress may occur over a long period, but the effects tend to be more devastating in the person's later years, when there is typically less adaptive and coping capacity.

Depression may result in confusion and disorientation, accompanied by reduced awareness or concern about environmental hazards. Social isolation or lack of social contact may lead to a reduced level of concentration, errors in judgment, and a diminished awareness of external stimuli.

Adolescents face great dangers when they abuse drugs or alcohol or engage in high-risk sexual activity

Devastating outcomes of these unsafe behaviors include alcohol-related motor vehicle accidents, pregnancy, sexually transmitted infections (STIs), and suicide. Drug and/or alcohol abuse are concerns for young and middle-aged adults employed in stressful work environments. Older adults experiencing altered balance or decline in cognitive abilities are increasingly vulnerable to falls and episodes of confusion. Nurses have first-hand experience with the specific hazards confronting each age group and situation.

Adolescents are particularly at risk for motor vehicle accidents because they spend so much time in automobiles and are prone to distracted driving and driving under the influence of substances.

Distracted driving is a troubling trend for all age groups, but particularly for adolescents who comprise the largest percentage of distracted drivers.

Preventing Equipment-Related Accidents

Electrical equipment can present a safety hazard to both the patient and health care practitioner when safety measures are ignored. Most electrical equipment used in hospitals is equipped with three-prong plugs. The third prong, when inserted into a properly wired wall outlet, provides a ground for the piece of equipment. A ground is a connection from an electricity source to the earth through which electric current leakage can be harmlessly conducted.

Most accidents that involve older adults are preventable.

Falls and motor vehicle accidents are significant hazards for this age group. Visual changes, slowed reaction time, and impaired thinking are realistic concerns that affect the older driver. Some become overly cautious, whereas others are prone to careless behavior. Teach the following interventions to help older adults drive safely: maintain the automobile in optimal driving condition, schedule regular eye examinations, wear corrective lenses when necessary, and keep noise from the radio and other equipment to a minimum. Some states require additional testing for older adults before they can renew their driver's license.

Fires also are a significant hazard for older adults.

Factors such as confusion, forgetfulness, and diminished visual and olfactory senses place them at greater risk for burn injuries. Health teaching should include additional safety precautions if the older adult smokes in the home. Because it may be difficult to distinguish the intensity of temperatures, heating devices often used by older adults need to be carefully monitored and regulated. Smoke detectors indicate the presence of a fire that may not be recognized by an older adult with a diminished sense of smell.

child neglect

Failure to meet a child's basic needs including housing, food, clothing, education, and access to medical care.

Stress may precipitate an unhealthy lifestyle that involves drug or alcohol abuse.

For example, a high school student involved in multiple school activities and intent on maintaining excellent grades may turn to an addictive substance such as methamphetamine as a stimulant. This drug temporarily allows the student to remain alert for more hours each day and complete required class assignments, but has significant negative consequences.

Some people by nature are more inclined to take risks and jeopardize their safety.

For example, failure to wear seat belts or to follow safety precautions is common behavior for some people. Others do not use appropriate protective equipment, such as wearing a helmet when riding a motorcycle. Such behaviors increase the risk for injury.

An awareness of safety and security precautions is crucial for promoting and maintaining wellness throughout the lifespan.

For example, patients need instructions to adhere to a medical regimen or to follow safety precautions when oxygen is in use. They require a certain amount of knowledge to manage new equipment and unfamiliar procedures. Nursing assessment includes identifying and recognizing potentially threatening circumstances caused by a lack of knowledge regarding safety and security precautions. Patient teaching about safety is crucial. Recommendations for specific safety and security precautions are included throughout this chapter.

National Disaster Medical System (NDMS)

Has responsibility for managing and coordinating the federal medical response to major emergencies and federally declared disasters

Fire prevention and emergency response programs in health care facilities are sometimes viewed by staff as time-consuming or unnecessary exercises, but nurses must be prepared at all times to protect patients from injury.

Hospitals are required by law to establish safety boards and to inspect the facility regularly for possible hazards. Equipment must be checked periodically, and escape routes must be kept open. Nurses, as part of their daily care procedures, must be aware of their facility's policies, review equipment and its proper functioning, and assess when and how often drills are performed.

Emergency preparedness has always been a concern for health care workers.

Nurses, as members of emergency response teams, need to be aware of their role when an emergency or disaster occurs. Existing community resources are usually sufficient to respond to an emergency situation, such as a multiple vehicle collision, a fire in an apartment complex involving a significant number of burn injuries, an explosion, or plane crash. Since the September 11, 2001, terrorist attacks in New York, Washington, DC, and Pennsylvania, attention has been focused on national security and strategies for sustaining emergency preparedness levels. These events highlighted the need for communities to step up the level of their involvement in emergency preparedness for any disaster.

A side rail is not considered a restraint if the patient requests that it be raised to aid in getting in or out of bed. Some patients may request that side rails be used at night while they sleep so that they feel more secure

Patients requesting side rails must be able to raise and lower the side rails themselves. If a family member requests the use of side rails for a patient, it is the nurse's responsibility to review benefits and risks associated with their use and periodically evaluate the reason for their use. Side rails are not routinely recommended for all situations. It is the responsibility of health care facilities to evaluate existing bed systems for entrapment risks and investigate corrective actions that may be necessary to provide a safe environment for patients.

Occupation and work environment often affect a person's safety.

People who work in certain occupations may experience exposure to health hazards, such as excessive noise, pollution, toxic chemicals or vapors, or infectious agents. Exposure to excessive noise (e.g., a construction site, extremely loud music) may lead to hearing loss. Nurses working in the operating room are regularly exposed to surgical smoke, a byproduct of laser and electrocautery procedures. Surgical smoke contains chemicals that cause upper respiratory tract irritation and inflammation. Operating room personnel must be empowered to use smoke-evacuation practices

To prevent accidental injury and death in toddlers and preschoolers, parents need to childproof the home environment.

Play areas should allow for exploration, but still provide for safety. Vigilant supervision by parents and guardians should anticipate hazards in the environment and protect the child with precautionary devices. Childproofing products are available that help parents and children recognize dangerous items in the home and prevent injury.

Most exposures to toxic fumes occur in the home.

Poisoning may result from improper mixing of household substances, prolonged use of strong cleaning products, or malfunctioning household appliances (gas, oil, and kerosene heaters) that can release carbon monoxide (CO). CO is a poisonous gas that is also colorless, odorless, and tasteless, which makes it especially dangerous. Exposure can result in mild symptoms or progress to a life-threatening problem or long-term effects. CO toxicity can cause severe organ damage in a very short period of time. More than 150 people in the United States die each year from (non-fire-related) accidental CO poisoning

Department of Homeland Security

Protects the nation against further terrorist attacks and coordinates the response for future emergencies

Tattoo

Risks involved in tattooing include infection (similar to piercings), allergic reactions, granulomas (nodules), keloid formation (scarring), complications with MRIs, dissatisfaction, and problems associated with removal (FDA). Although still regulated at the state (not federal) level, the FDA continues to collect data on pigments used in tattoo inks that are not approved for skin contact. Teens and their parents, who may be required to issue consent, need to be careful with both permanent and temporary tattoos.

The nurse has many opportunities to educate parents about safety and accident prevention for infants. Young infants' lack of mobility limits opportunities for hazardous activity, but safeguards are vital to prevent accidents.

Safe care includes never leaving the infant unattended, using crib rails, and monitoring the setting for objects that the infant could place in the mouth and swallow. As the child becomes more active, parents and caregivers must be alert to hazards that a curious, mobile child may encounter. All items within reach must be carefully inspected and, if dangerous, kept in a safe place, out of the child's reach. Because infants frequently climb or pull up on objects, hot liquids and sharp instruments must be placed out of their reach. Also, remind parents that items that are small enough to fit through a standard toilet paper tube represent a potential choking hazard for young children.

Preventing injuries caused by firearms has become a major concern for health care professionals. Intentional injuries caused by firearms are a leading cause of mortality in children.

Some people believe that keeping a gun in the home provides protection for family and property. However, when a gun is available it is more likely that the owner or a family member, rather than an intruder, will suffer a fatal injury. The presence of a gun in the home is a huge risk factor. If not stored properly, guns can be extremely dangerous. Young children are curious and like to explore their surroundings—when they encounter a loaded gun, the outcome is often tragic. Also, having a gun in the house increases the risk for domestic homicide threefold.

Accidental overdosing on medications is also a safety risk for older adults, possibly related to poor eyesight or confusion.

Special devices such as medication trays can be prefilled to help prevent older adults from taking additional doses.

safety risks exist from conception

Studies have confirmed, for example, that pregnant women who use drugs, consume alcohol, or smoke expose their unborn children to substances that may adversely affect the normal growth and development of the fetus.

Falls in the older adult can be prevented if they can be predicted.

Therefore, continuous surveillance for environmental hazards is crucial in the health care facility and the home environment, especially for patients who are at risk for falls. Family members are an invaluable resource in assessing a patient's risk for a fall. They can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls.

Substance abuse is a significant concern in the adolescent population.

Teenagers abuse legally available drugs such as prescription medications (pain relievers, tranquilizers, stimulants, and sedatives) and over-the-counter (OTC) cough, cold, sleep, and diet medications. They also abuse illegal substances such as marijuana, cocaine, heroin, inhalants, and hallucinogens such as LSD or Ecstasy. Three newer drugs, synthetic marijuana (also known as Spice or K2), bath salts (synthetic stimulants), and N-BOMe (also known as N-bomb or Smiles, a powerful hallucinogen) are emerging public health concerns. These designer drugs, synthetic/chemical derivatives of known illegal drugs, make their way onto the market under the guise of harmless names: bath salts, plant food, herbal incense.

Workplace violence has been identified as a major issue for health care providers

The Joint Commission has issued a new sentinel event alert on workplace violence that specifically addresses the prevention of physical and verbal violence, and promotes reporting of violence in the health care setting

Modifiable fall risk factors

• Lower body weakness • Poor vision • Gait and/or balance issues • Problems with feet and/or shoes • Use of psychoactive medications • Postural dizziness (position changes, hypotension, antihypertensives) • Hazards in the home (and community)

USING RESTRAINTS AS A LAST RESORT

The least restrictive restraint should be the first option. Restraints must never be applied for the convenience of the staff. The patient's family must be consulted and involved in the plan of care before applying restraints in a long-term care setting. They must be informed of the facility's policy regarding applying and removing restraints and may be asked to sign a release form to protect the facility from liability. Facility policy, The Joint Commission, and state and federal guidelines require an order from a provider permitted to provide specific oversight of restraints, such as a physician or nurse practitioner (in some states). The order should include the type of restraint, justification for the restraint, and criteria for removal. The order must never be written for PRN (as needed) use.

Adult Stress Domestic violence Motor vehicle accidents Industrial accidents Drug and alcohol abuse

• Practice stress reduction techniques (e.g., meditation, exercise). • Enroll in a defensive driving course. • Evaluate the workplace for safety hazards and utilize safety equipment as prescribed. • Practice moderation when consuming alcohol. • Avoid use of illegal drugs. • Provide options and referrals to domestic violence victims.

Although school-aged children are increasingly independent, they still need help avoiding activities that are potentially dangerous. Accidents continue to be a leading cause of death.

The nurse should counsel parents of school-aged children about specific interventions for safety at home, at school, and in the neighborhood. All school-aged children need to continue to be secured in safety seats, belt-positioning booster seats, or shoulder lap belts for their size.

In an emergency, the physical restraint can be applied, but an order from a provider must be obtained immediately or within a few minutes according to Joint Commission Standards.

The order must state the intended duration of use. The patient must be monitored and assessed at least every hour or according to facility policy. An inpatient psychiatric patient in restraints requires continual observation, including specific assessments every 15 minutes. Documentation must reflect the date and time the restraint is applied, the type of restraint, alternatives that were attempted (including their results), and notification of the patient's family and health care provider. Include the frequency of assessment, your findings, regular intervals when the restraint is removed, and nursing interventions. Constant reevaluation of the need for the restraint is vital.

Each year, a significant number of children younger than 10 years are injured in bicycle accidents. Many of these injuries involve the head or face.

The protective effect of bicycle helmets among children is well documented. Studies indicate that legislation and injury prevention strategies have had a positive impact on increasing helmet use and decreasing the number and severity of bicycle accidents that result in a head injury in this very vulnerable population. However, their use is far from universal. Because of their multiple experiences with children and parents, nurses—whether in the ED or a well-child setting—have many opportunities for health teaching related to bicycle safety and helmet use.

Polypharmacy

The use of many different drugs concurrently in treating a patient, who often has several health problems.

Ingestion of poisons or medications is a major threat for preschoolers

Their overconfidence, curiosity, and impulsiveness also make them more likely to dart into the street while chasing a ball, climb into a discarded refrigerator, or play with matches.

Anything that affects the patient's health state potentially can affect the safety of the environment.

When a person is chronically ill or in a weakened state, the focus of health care includes preventing accidents as well as promoting wellness and restoring the person to a healthy state. For example, the nurse caring for a patient who is recovering from a stroke (cerebral vascular accident) identifies the patient's neuromuscular impairment, pays particular attention to health teaching concerning the person's ability to maintain a sense of balance, and carefully assists the patient with ambulation to prevent falls. Many patients who fall have a primary or secondary diagnosis of cardiovascular disease. Prevention of complications and return to the optimal level of functioning require attention to safety and become primary concerns in a rehabilitation program. The nurse strives to maximize the patient's potential by considering safety factors in all phases of the illness and recovery experience.

Federal Emergency Management Agency (FEMA)

Works to build and support the national emergency management system

Consider the person's developmental stage when making a safety assessment.

Younger children are more apt to ingest household chemicals, whereas older children may swallow medicines in a suicide attempt. Preschoolers are also at risk for ingestion of lead-containing substances in the home. Adolescents and young adults who experiment with drugs may experience accidental poisoning and death. The ready availability of inhalants on store shelves and in the home may provide the opportunity for children to sniff or huff these dangerous substances. An older adult may inadvertently take an overdose of a medication because of confusion or forgetfulness. Poor vision is also a factor in accidental poisoning in older adults.

Safety—or freedom from danger, harm, or risk—is

a paramount concern that underlies all nursing care.

An infant may suffocate when

a pillow or a piece of plastic inadvertently covers the nose and mouth. Infants are most at risk of suffocation when they are sleeping; accidental suffocation and strangulation in bed (ASSB) is the leading cause of death in infants due to injury . A young child may be strangled accidentally by the shoulder harness of a seat belt or become trapped while playing in a discarded refrigerator and suffocate.

School-Aged Child Burns Drowning Broken bones Concussions (TBI) Inhalation or ingestion Guns and weapons Substance abuse

• Teach accident prevention at school and home. • Teach child to wear safety equipment when playing sports. • Reinforce teaching about symptoms that require immediate medical attention. • Continue immunizations as scheduled. • Provide drug, alcohol, and sexuality education. • Reinforce use of seat belts and pedestrian safety.

Metals

agents that consist of metallic poisons

Organic solvents

agents that damage the tissues by dissolving fats and oils

disaster:

an emergency event of greater magnitude that requires the response of people outside the involved community

sentinel event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

ABC (universal, dry chemical) fire extinguishers

are the most common extinguishers used in health care facilities. In the home setting, cigarettes, grease, and electrical problems are most often responsible for fires. Educating parents about home fire safety includes having a plan of action similar to that used in health care settings.

caustics (acids)

chemicals that burn or corrode the skin, eyes, and mucous membranes on contact

Vomiting agents

chemicals that cause nausea and vomiting

chocking/lung/pulmonary agents

chemicals that cause severe irritation or swelling of the respiratory tract

blister agents/vesicants

chemicals that severely blister the eyes, respiratory tract, and skin on contact

A patient with a reduced ability to distinguish odors may fail to

detect leaking gas or smoke.

restraint

device used to limit movement or immobilize a patient

safety event report

documentation describing any injury or potential for injury suffered by a patient in a health care facility

intimate partner violence (IPV)

domestic violence or battering between two people in a close relationship

Common causes of suffocation are

drowning, choking on a foreign substance inhaled into the trachea, and gas or smoke poisoning.

Incapacitating agents

drugs that affect the ability to think clearly or that cause an altered state of consciousness or even unconsciousness

chemical emergency

event caused by the release of a chemical compound that has the potential for harming people's health

poison control center

facility that handles poison exposure and provides poison prevention teaching to the general population

All 50 states mandate the use of infant carriers and car seats when transporting a child in a motor vehicle.

guidelines recommend that infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) remain in a rear-facing safety seat. This position provides more support for the head, neck, and spine should a crash occur. Children should then progress to a forward-facing seat with a five-point harness until they reach the maximum height and weight limit for that seat. Children should use a belt-positioning booster seat until they are 4 ft, 9 in tall and between 8 and 12 years old (80 to 100 lb). Due to the force of a deployed airbag, sitting in the front seat is not recommended until the child is 13 years old

A patient with a hearing deficit may not be able to

hear safety alarms, automobile horns, or sirens and may not hear health care instructions.

Riot control agents/tear gas

highly irritating agents normally used by law enforcement for crowd control or by individual people for protection

Nerve agents

highly poisonous chemicals that prevent the nervous system from working properly

elder abuse

intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult; includes physical abuse, sexual abuse/contact, emotional/psychological abuse, neglect, and financial abuse/exploitation

nuclear terrorism

intentional dispersal of radioactive materials into the environment for the purpose of causing injury and death

Leaving a relationship:

keep evidence of abuse, plan with your children, contact a local shelter or other community resource, pack and take essential items, communicate your history and needs to new support systems, protect yourself and avoid the perpetrator after leaving, consider your legal options

A concussion is a

milder form of TBI that is usually sports related. Nurses in a variety of settings need to be alert for indications of concussion.

bullying

negative, often repetitive, disruptive behavior; also referred to as horizontal violence, lateral violence, and professional incivility

culture of safety

organizational environment where "core values and behaviors resulting from a collective and sustained commitment by organizational leadership, management, and workers emphasize safety over competing goals"

A patient whose tactile sense is impaired may not

perceive temperature extremes that are a threat to safety.

Toxic alcohols

poisonous alcohols that can damage the heart, kidneys, and nervous system

biotoxins

poisons from plants or animals

blood agents

poisons that are absorbed into the blood

Long-acting anticoagulants

poisons that cause bleeding by preventing blood from clotting properly

Safety planning during pregnancy:

recognize the heightened risk, utilize time with your provider to discuss IPV issues, take a women-only prenatal class

Safety while living with an abusive partner:

remove weapons, keep phone accessible, develop a signal to notify trusted friends and family, teach your children how to get help and how to get out safely, keep the car keys accessible and the car full of gas, do not wear jewelry or scarves that could pose a threat to your safety, keep copies of important documents

Safety planning for pets:

stock extra supplies, copy their medical records

asphyxiation

stoppage of breathing or the lack of air reaching the lungs; synonym for suffocation

Visual changes may cause a person to

stumble, lose one's balance, and fall.

Safety planning with children:

teach them how to call 911, teach them not to intervene, involve them in the plans for physical safety, teach them IPV is not their fault

bioterrorism

the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic

cyber terror

the use of high-tech means to disable or delete critical electronic infrastructure data or information

A patient with a loss of taste may have

unsafe eating habits or may eat tainted food

Fetus Abnormal growth and development

• Abstain from alcohol and caffeine while pregnant. • Stop smoking or reduce the number of cigarettes smoked per day. • Avoid all drugs, including OTC drugs, unless prescribed by a health care provider. • Avoid exposure to pesticides and certain environmental chemicals. • Avoid exposure to radiation.

Older Adult Falls Motor vehicle accidents Elder abuse Sensorimotor changes Fires

• Identify safety hazards in the environment. • Modify the environment as necessary. • Attend defensive driving courses or courses designed for older drivers. • Encourage regular vision and hearing tests. • If prescribed, ensure that eyeglasses and hearing aids are available and functioning. • Wear appropriate footwear. • Have operational smoke detectors in place. • Objectively document and report any signs of neglect and abuse.