CH 1, 2, 9, 14 EXAM 1

Know which databases contain searchable scientific literature

CINAHL, MEDLINE, EMBASE, PsychINFO, Cochrane, National Guidelines Clearinghouse, & PubMed

To Err is Human- The AHRQ already has made major progress in developing and implementing an action plan. Efforts under way include:

Developing and testing new technologies to reduce medical errors. Conducting large-scale demonstration projects to test safety interventions and error-reporting strategies. Supporting new and established multidisciplinary teams of researchers and health-care facilities and organizations, located in geographically diverse locations, that will further determine the causes of medical errors and develop new knowledge that will aid the work of the demonstration projects. Supporting projects aimed at achieving a better understanding of how the environment in which care is provided affects the ability of providers to improve safety. Funding researchers and organizations to develop, demonstrate, and evaluate new approaches to improving provider education in order to reduce errors.

Patient Safety-Patient outcomes

Besides keeping patients safe, our goal is to help them to optimize their health through Evidence-based practice & core measures. (Evidence-based practice is nursing practice that is based on research.)

IOM report To Err is Human cont..

Building A Safer Health System goal was to reduce in-hospital errors by 50% over next 5 years. 44,000 to 98,000 patients died annually in 2000, 2001, and 2002 due to preventable medical errors (HealthGrades, 2005) 60% of medical errors fell into three areas: infection following surgery, HAIs, failure to diagnose and treat in time. •It ended the period of denial of medical errors •It shifted the focus to system problems rather than individual blame •It brought a number of stakeholders together •It motivated hospitals to make changes in practice [Yet, nursing remains one of the top trusted professions] [Nursing is the nation's largest health care profession, with more than 3.1 million registered nurses nationwide. AACN]

Measures to prevent injury from seizure

-Keep the call light in reach -Have client call for assistance in getting up -Keep bed in low position -Special pads for SRs

What are patient fall risk factors?*

Neurologic Disorders; history of previous fall. Urinary Urgency or Incontinence; use of sedatives, antihypertensive and analgesics; history of unsteady gait; use of assistive devices; history of orthostatic hypotension; memory deficits.

ANA Code of Ethics Provision 3

Promotes, advocates for, and strives to protect the health, safety, and rights of the patient ANA Code of Ethics Provision 3 This means: Participate in review and development of policies Reporting errors and near misses per facility policy (whether you or other made error) Disclosing errors to patients Use the Chain of Command

Review safety equipment

• Validated fall risk assessment tool (TJC, 2014) • Hospital bed with side rails; option: low bed • Wedge cushion • Call-light intercom system • Gait belt for assisting with ambulation • Wheelchair and seat belt (as needed) • Additional safety devices (e.g., bed alarm pad, wedge cushion)

Know how to write a PICO question.

(P=Patient, population or problem) Be succinct. Identify your patients by age, gender, ethnicity, disease, or symptoms. (I=Intervention or issue of interest). Which intervention do you think is worthwhile to use in practice? It can be a treatment; a clinical, educational, or administrative intervention; a process of care; an education strategy; or an assessment approach. (C=Comparison with the intervention). Does a comparison intervention exist? Which standard of care or current intervention do you usually use now in practice? (O=Outcome that is measurable). Which result do you wish to achieve or observe as a result of an intervention (e.g., change in patient's behavior, quality of life, physical finding; change in patient's perception, rate of adverse events, costs)? (T= Time) (An optional component for a clinical question).

The nursing process

(assessment, diagnosis, planning, implementation, and evaluation) is used for admissions, transfers, and discharges to ensure quality care.

Assessment: Identify patient using at least two identifiers

(e.g., name and birthday or name and medical record number) according to agency policy. Ensures correct patient. Complies with The Joint Commission standards and improves patient safety. Perform hand hygiene. Reduces transmission of microorganisms.

Assessment: Assess patient's proprioceptive function (awareness of posture and changes in equilibrium):

-Ability to maintain balance while sitting in bed or on side of bed. Determines stability of patient's balance for transfer. Determines risk for fainting or falling during transfer. -Tendency to sway or position self to one side. Patients with brain dysfunction may have proprioceptive losses. This may cause them to lean to one side or lose balance during transfer.

Fire Extinguishers

-Know where the fire alarms are -Know where the fire extinguishers are -Don't use elevators during fires -Know exit routes -Keep the halls clear -Regularly monitor the environment for safety issues

Measures to prevent seizures

-Make sure patient receives anticonvulsants on time -Determine patient's triggers and avoid them

Restraint application ongoing assessment & evaluation*

-Teach patient & family -Use least restrictive restraint -Attach restraint straps to a part of the bedframe that moves with the patient; never the siderail -Secure restraints on bedframe with quick-release buckle; never a knot -Ensure restraint is not too tight -Assess for circulation, sensation, color of restrained body part. -Assess every 15 minutes for signs of injury -Release restraints at least every 2 hours and assess needs for toileting, food, fluids, mobility

What are the steps of EBP?

1. ASK a clinical question. 2. SEARCH for the most relevant and best evidence that applies to the question 3. Critically APPRAISE the evidence you gather. 4. APPLY or integrate evidence along with your clinical expertise, patient preferences, and values in making a practice decision or change. 5. EVALUATE the practice decision or change. 6. COMMUNICATE your results.

Applying Physical Restraints—4 Side Rails is a Restraint

4-SR elevated was once the standard of care; now it is considered a restraint Research indicated that trying to confine people resulted in harm. EBP. Special Consideration—Applying Physical Restraints Dignity-treat patient with respect.

Which of the following patients should the nurse assist and/or supervise when transferring? (Select all that apply.)

A. A newly admitted patient with a spinal cord injury. B. A patient who is weak from pneumonia and wants to get up to the bedside commode. C. A patient who had a motor vehicle accident and is being transferred for the first time after prolonged bed rest. D. A patient who is 3 days postoperative and progressing well after having a repair of his hip fracture. Answer: A & C The nurse should assist and supervise when moving patients who are unstable and being transferred for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. The nurse should assist and supervise when moving patients who are transferred for the first time because of their risk of injury.

Airborne Precaution

Airborne pathogens are smaller than 5 microns & can travel longer distances than droplets (larger particles). Examples are Chicken Pox & Tuberculosis (TB). Require negative pressure rooms. Require N-95 respirator masks that filter smaller particles.

What is a systematic review? Where can I find a systematic review (which database)?

An author or panel of experts reviews the evidence from randomized controlled trials (RCTs) (and other defined types of research studies) about a specific clinical question and summaries the state of the science. In a meta-analysis there is the addition of a statistical analysis that combines data from all studies. PubMed, CINAHL, Cochrane Database A systematic review explains if the evidence for which you are searching about a specific question exists and whether it supports a change in practice. A systematic review of well-designed research studies provides the best evidence of the effectiveness of different interventions. A meta-analysis involves using statistical techniques to analyze the data from the studies in the systematic review to determine statistically the strength of the evidence.

Assessment Cont...

Assess for history of weakness, dizziness, or postural hypotension (when sitting or standing). Determines risk for fainting or falling during transfer. The move from supine to vertical position redistributes about 500 mL of blood; immobile patients may have decreased autonomic nervous system response to equalize blood supply, resulting in orthostatic hypotension. Assess medical record for patient's level of fatigue and activity tolerance during previous transfers. Assess endurance by noting patient's participation in activities of daily living (ADLs). Estimates ability of patient to participate in transfer. Planned rest periods before transfer may enhance function.

Seizure Precaution Step 2***

Assess for medical and surgical conditions, including history of head trauma, electrolyte disturbances (ex. Hypoglycemia, hyperkalemia)

Seizure Precaution Step 3***

Assess medication history (ex. Antidepressants and antipsychotics). Certain medications lower seizure threshold.

Seizure Precaution Step 5***

Assess patient's individual and cultural perspective about the meaning of seizures and their treatment.

Seizure Precaution Step 1***

Assess patient's seizure history (ex. New diagnosis, frequent seizures, seizure within last year. Ask patient to describe frequency of past seizures, presence and type of aura (ex. Metallic taste, Perception of breeze blowing on face, or noxious odor).

Fall prevention (in health care agencies) cont.....

CMS will not pay for "never events" Refers to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Or traumatic injuries due to in-patient falls. How can we prevent falls? -Assess, assess, assess—patient and environment -Think safety all the time -Follow hospital policy & procedures -Communicate with other health care providers and patients and family about safety.

Contact precautions

Colonization with MDROs (multi-drug-resistant organisms) such as MRSA (methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant Enterococcus), and C-difficle. Private room, gloves, gowns. Leave equipment in room such as disposable stethoscope.

Restraint Usage Alternatives

Common strategies to manage wandering include environmental adaptations, use of signaling tags... -Distraction -Social interaction -Regular exercise -Circular design of a patient care unit -More frequent observation of patients -Involvement of family during visitation -Frequent reorientation Employ strategies to prevent accident removal of medical devices such as IVs or nasogastric tubes. (Provide for patient needs and keep them comfortable) What to do for hourly rounding: (The 5 P's): Pain, potty, possessions, pathway, & pumps.

Seizure Precautions cont...*

Don't put anything in mouth, look for medical alert identification. Time for seizure with a watch, cushion head, remove glasses, loosen tight clothing, don't hold down, turn on side, as seizure ends-offer help.

Droplet Precautions

Droplet precautions (droplets larger than 5 microns; being within 3 feet of patient). Diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants & young children, pertussis, mumps, Mycoplasma pneumonia, menigococcal pneumonia or sepsis, pneumonic plague. Private room or cohort patients; masks or respirator required (depending on condition) (refer to agency policy)

Fall prevention (in health care agencies) cont......

Each year approximately 700,000 to 1,000,000 people in the United States fall in hospitals. A fall may result in fractures, bruises, lacerations, or internal bleeding, leading to increased diagnostic tests and treatments, extended hospital stays, and discharge to rehab or long-term care instead of home. Research shows that approximately one-third of falls can be prevented. Falls are multifactorial. Individual intrinsic factors such as co-morbidities, muscle weakness, and urinary incontinence increase the risk of falling in a hospital and community setting. Transient factors that can change over time such as postural hypotension, polypharmacy, and use of high-risk medications also are fall risks. Extrinsic fall risks such as a health care agency's environment (e.g., poor lighting, slippery flooring, improper use of assist devices also contribute to falls. As a nurse, your role is to assess these factors in each patient and then determine the most suitable preventive interventions that match the patient's risks and behavior. The Centers for Medicare and Medicaid Services (CMS) have identified select serious adverse events as "Never Events" (i.e., adverse events that should never occur in a health care setting). One of these "Never Events" is hospital-acquired injury from external causes (e.g., fractures, head injury, crushing injury), as in the case of falls. The CMS denies hospitals higher payment for any hospital-acquired condition resulting from or complicated by the occurrence of a "Never Event." 1. Accurate patient identification is crucial to safety before any procedures are begun. 2. Safety begins with a patient's immediate environment. The call light/bed control system allows patients to adjust bed position and signal caregivers. Explain to patients and visiting family members how to operate a call system correctly. 3. Always be alert to conditions within a patient's environment that pose risks for patient injury. Dangers in environment: hazards along walking paths, liquid spilled on the floor, poorly functioning equipment. 4. Follow policy and procedure in the institution where you work. Do not use work-arounds when performing skills or procedures. A work-around occurs when a person improvises or works around intended work practices. 5. Communicate clearly to other health care providers the plan of care, including procedures to be performed, procedures completed, and patient response. Communicate all important test results to the right staff person in a timely manner.

Fire safety (RACE) & electrical safety

Electrical & anesthesia-related fires most common in hospitals R - rescue patient from danger A - activate alarm C - contain fire E - evacuate patients, extinguish fire- if you can

Restraint Usage Alternatives (Strategies for Reducing Accidental Removal of Medical Devices Box 14.2)

Endotracheal Tube • Verification of security of system used to anchor tube. • Appropriate sedation and analgesia protocols to reduce agitation Nasogastric Tube • If being used for feeding, consult with nutritionist and speech therapist for swallow evaluation to consider gastrostomy feeding or other appropriate feeding measures. • Anchor tubing by taping technique or commercial holder. Intravenous Lines • Use commercial holder for anchoring. • Provide long-sleeved robes or commercial sleeves for arms to cover IV catheter site. • Consider saline lock and cover with gauze. • Tape or secure IV line under gown. • Keep IV bag out of visual field. Bladder Indwelling Catheter • Consider intermittent catheterization. IV, Intravenous.

IOM reports To Err is Human To achieve a better safety record, the report recommends a four-tiered approach:

Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety. Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems. Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care. Implementing safety systems in health care organizations to ensure safe practices at the delivery level.

Fall prevention's cont..

Fall prevention is not simple. There is no conclusive evidence for any particular set of interventions that will consistently prevent falls. Identified interventions that have shown some success in reducing hospital fall rates: • Developing a culture of safety, including ongoing staff education and feedback on fall incidents. • Using validated fall risk assessments that are predictive of falls in hospitals where used. • Individualizing multi factorial interventions. • Conducting post fall follow-up and quality improvement. • Having a fall risk program integrated with electronic health records (EHR).

Electrical Safety cont.

Health care agencies routinely check and maintain all electrical devices. Every biomedical device (e.g., suction machine, infusion pump) must have a safety inspection sticker with an expiration date applied to it. Electrical equipment in good working order requires a three-prong electrical plug for proper grounding. If a patient brings an electrical device to a hospital, an engineer must inspect the device for safe wiring and function before use. Always discourage patients from bringing nonessential electrical devices (e.g., hair dryers or electric toothbrushes) into a health care agency. Many patients with disabilities use battery chargers for mobility equipment function. These devices need to be inspected by hospital engineers as well.

How to apply & remove protective equipment

How to apply: -Hand Hygiene -Cap if required -Gown-ties in the back; if too small, use two -Mask-tie top tie first, then bottom. Metal piece goes over nose. Use two fingers to gently shape metal strip to nose. Pull down over chin. -Goggles-should fit securely -Gloves-extend gloves over cuffs of gown How to remove: Take off alphabetically -Gloves-remove glove to glove and skin to skin pointing hand down toward the trash can -Goggles -Gown-untie & pull off touching the inside of the gown only & roll it up with outside in -Mask -Hand hygiene

ANA Code of Ethics Provision 5: Duties to Self and Others (Character when no one is looking)

INTEGRITY is an aspect of wholeness of character and is primarily a self-concern of the individual nurse. Nurses have a responsibility to remain consistent with both their personal and professional values.

National Patient Safety Goals (Joint Commission Safety Goals 2019)

Identify patients correctly: use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Make sure the correct patient receives the correct blood when they get a blood transfusion. Improve staff communication: get important test results to the right person on time. Use medicines safely: Label medicines that are not labeled. For example, medicine in syringes cups, and basins. Take extra care with patients who take medicines to thin their blood. Do this in the area where medicines and supplies are set up. Record and pass along correct information about a patient's medicines.

Eletrical Safety

If patient receives an electrical shock, immediately unplug the electrical source and assess for presence of a pulse. Caution: When disengaging electrical source, check for presence of water on floor. Clinical Decision Point: Do not touch a person who is being shocked while he or she is still engaged with the electrical source. If unable to disconnect source, call emergency number for assistance. Once the source of electricity is disconnected, provide appropriate interventions. If patient is pulseless, institute emergency resuscitation. -Notify emergency personnel and patient's health care provider. -If patient has a pulse and remains alert and oriented, obtain vital signs and assess the skin for signs of thermal injury. Prevention: -Make sure electrical equipment is in good working order. -All electrical equipment should have an unexpired hospital biomedical sticker on it. -Patient's personal electrical devices must be inspected by hospital engineers. -All devices should have a 3-prong electrical plug.

Seizure Precaution Step 4***

Inspect patients environment for potential safety hazards (ex. Extra furniture). Keep bed in low position, side-rails up at the head of bed, patient in side-lying position when possible.

Safe & effective transfer

Is a nursing skill assisting dependent patients or patients with restricted mobility attain positions to regain or maintain optimal independence. For example, transferring from a bed to a chair promotes physical activity to maintain and improve joint motion, increase strength, promote circulation, relieve pressure on the skin, and improve urinary and respiratory functions. It also benefits a patient psychologically by increasing social activity and mental stimulation and providing a change in environment. Consider an individual patient's clinical problems during a transfer. For example, a patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred to a chair. To ensure safe patient transfers, always use a gait or transfer belt or an appropriate lift and get help from a colleague

"Never events" & "Core measures"

Never events refer to particularly shocking medical errors (such as wrong-site surgery) that should never occur. The Centers for Medicare and Medicaid Services (CMS) have identified select serious adverse events as "Never Events" (e.g., adverse events that should never occur in a health care setting). One of these "Never Events" is hospital-acquired injury from external causes (e.g., fractures, head injury, crushing injury), as in the case of falls. The CMS denies hospitals higher payment for any hospital-acquired condition resulting from or complicated by the occurrence of a "Never Event." Are national standards of care and treatment processes for common conditions. Are proven to reduce complications and lead to better patient outcomes. One common condition is acute myocardial infarction (AMI) Based on research, treatments have been bundled that are proven to improve outcomes of patients having a heart attack Examples: An aspirin within 24 hours of arrival to the hospital Aspirin, beta blocker, statin at discharge. Core measures are a set of care standards; the percentage of eligible patients that receive care represented by the measure. For example: The percentage of AMI patients that receive aspirin on arrival. Basically describes the basic care that should be provided to the patient in the hospital.

Restraint application. The Joint Commission (TJC), and the National Quality Forum (NQF) all have standards regarding restraints.

Physical or chemical restraints should be the last resort and should be used only when reasonable alternatives fail. Restraints are most commonly used in hospitals to prevent disruption of therapy, such as pulling out intravenous (IV) tubes or removing urinary catheters. The Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and the National Quality Forum (NQF) all have standards regarding restraints. Restraint use is: -Used only to ensure immediate safety -Employed as a temporary measure -Associated with serious complications -Applied according to hospital policy -Discontinued as soon as possible

Fire safety (RACE) & electrical safety

Prevention is the key to fire safety Fires in health care settings are typically electrical or anesthetic related Health care agencies need to routinely check and maintain all electrical devices Safety data sheets (SDSs) are available for each hazardous chemical in the workplace. Other source of fire that poses a risk in a health care setting? Although smoking is not allowed in health care facilities, smoking-related fires still pose a significant risk because of unauthorized smoking in beds or bathrooms. In the home setting, oxygen-related fires are a risk for patients requiring continuous oxygen therapy. Biomedical devices must have a safety inspection sticker with an expiration date, and all electrical equipment should have a three-prong plug for grounding. Hospital engineers should inspect any electrical devices a patient brings to the hospital; discourage patients from bringing nonessential devices. If a fire occurs, health care personnel report the exact location of the fire, contain it, and extinguish it only if it is safe and possible. All personnel are then mobilized to evacuate patients if needed. Most agencies have fire doors that are held open by magnets and close automatically when a fire alarm sounds. Fire doors should never be blocked. Chemicals in many medications, anesthetic gases, cleaning solutions, and disinfectants are potentially toxic. They injure the body after skin or mucous membrane contact, ingestion, or vapor inhalation. A Safety Data Sheet (SDS) form contains information about the properties of the particular chemical and information for handling the substance in a safe manner.

Safety and infection control

Protecting clients and health care personnel from health and environmental hazards. Patient safety initiatives are aimed a reducing harm that comes to patients during the delivery of health care. Health care provided in a safe environment, in which nurses practice safety-related skills, reduces the risk for illness and injury and contains the costs of health care by preventing extended lengths of treatment and/or hospitalization, improving or maintaining a patient's functional status, and increasing the patient's sense of well-being. Nurses must use critical thinking when using the nursing process to assess for hazards and plan/intervene to maintain a safe environment. Assessments are very important.

Quick release tie.

Quick release tie: Tie half bow for restraints, this allows for the knot to quickly become untied by the nurse in case of emergency. Secure restraints on bedframe with quick-release buckle; never a knot.

Restraint application ongoing assessment & evaluation cont...*

Research has shown that patients suffer fewer injuries if left unrestrained. A patient's or family member's informed consent is necessary in the long-term care setting. The Food and Drug Administration (FDA) regulates restraints as medical devices and requires manufacturers to label them "prescription only." Most patient deaths in the past have resulted from strangulation from a vest or jacket restraint. Numerous agencies no longer use vest restraints. For these reasons this text does not describe their use.

Restraint application ongoing assessment & evaluation cont..*

Restraints are a temporary way to keep patients safe -There is no evidence they prevent falls, reduce wandering, or prevent medical devices from being pulled out -Requires a licensed health care provider's order for use, which must be based on face-to-face patient assessment -Serious complications include pressure ulcers, hypostatic pneumonia, constipation, incontinence, and death -Restraints must be reordered every 24 hours based on face-to-face assessment by HCP.

Assessment cont..

Review medical record or directly assess physical capacity of a patient to transfer and help with transfer. Assess the following: -Muscle strength (legs and upper arms) through active range of motion. Immobile patients have decreased muscle strength, tone, and mass. Affects ability to bear weight, raise body, and thus help with transfer. -Joint mobility and contracture formation. Immobility or inflammatory processes (e.g., arthritis) may lead to contracture formation and impaired joint mobility. -Paralysis or paresis (spastic or flaccid). Patient with central nervous system (CNS) damage may have bilateral paralysis (requiring transfer by swivel bar, sliding bar, mechanical lift) or unilateral paralysis, which requires belt transfer to strong side. Weakness (paresis) requires stabilization of knee while transferring. Flaccid arm must be supported with sling during transfer. -Bone continuity (trauma, amputation) or calcium loss from long bones. Patients with trauma to one leg or hip may be non-weight bearing when transferred. Amputees may use sliding board to transfer. Osteoporosis increases risk for injury. Refer to medical record for most recent recorded weight and height for patient. These factors are used to determine if mechanical transfer device or friction-reducing device is needed for transfer.

Seizure Precautions & (generalized vs. partial seizure)** & 3 phases to a seizure & status epilepticus

Seizures are sudden, abnormal, electrical discharges in the brain causing alterations in behavior, sensation, or consciousness. Protect the patient, but avoid restraining & forcing something in the mouth during the seizure. Don't leave the patient alone; call for help. Remember, dignity. (Additional- Observe seizure characteristics and duration -Medicate as indicated) Seizures that appear to begin everywhere in the brain at once are classified as generalized seizures, whereas seizures beginning in one location of the brain are classified as partial seizures. There are three phases to a seizure: • Aura—the start of a partial seizure. If the aura is the only phase a patient experiences, the patient has had a simple partial seizure. If the seizure spreads and affects consciousness, it is a complex partial seizure. If the seizure spreads to the rest of the brain, it becomes a generalized seizure. • Ictus—meaning attack. Ictus is another word for the physical seizure involving a series of muscle contractions, called tonic and clonic contractions. • Postictal—meaning after the attack. Postictal refers to the aftereffects of a seizure (e.g., arm numbness, altered consciousness, partial paralysis). Status epilepticus involves 5 minutes or more of either continuous clinical or electrographic (shown on an electroencephalogram [EEG]) seizure activity or recurrent seizure activity without recovery between seizures. It is a medical emergency. Status epilepticus can be convulsive (rhythmic jerking of the extremities) or nonconvulsive (activity on EEG).

Restraint free goal (physical vs chemical)

Serious, often fatal complications can result from the use of restraints A restraint-free environment is the first goal of care for all patients. Restraints can be physical or chemical. Current federal and state regulations have standards for restraint use. A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to freely move his or her extremities, body, or head. A drug may be considered a chemical restraint when it is given to manage behavior or restrict freedom of movement and is not part of the standard treatment for a patient's condition (i.e., wrist/jacket restraints, medications). Why do you think these can cause complications? -Patients at risk for falls or wandering present special safety challenges in attempts to create a restraint-free environment. -Wandering is the meandering, aimless, or repetitive locomotion that exposes a patient to harm and often conflicts with boundaries, limits, or obstacles. This is a common problem in patients who are confused or disoriented. Interrupting a wandering patient can increase distress.

SBAR

Situation Background Assessment Recommendation

Centers for Disease Control and Prevention Isolation Guidelines Standard Precautions (Tier One) for Use With All Patients Cough etiquette (Box 9.2)

Standard precautions apply to blood, blood products, all body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes. Perform hand hygiene before, after, and between direct contact with patients. (Examples of between-contact activities are cleaning hands after a patient care activity, moving to a non-patient care activity, and cleaning hands again before returning to perform patient contact.) Perform hand hygiene after contact with blood, body fluids, mucous membranes, nonintact skin, secretions, excretions, or wound dressings; after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. When hands are visibly soiled or contaminated with blood or body fluids, wash them with either a nonantimicrobial soap or an antimicrobial soap and water. When hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub to perform hand hygiene. Wash hands with nonantimicrobial soap and water if contact with spores (e.g., Clostridium difficile) is likely to have occurred. Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes. Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items or surfaces is likely. Remove gloves and perform hand hygiene between patient care encounters and when going from a contaminated to a clean body site. Wear personal protective equipment (PPE) when the anticipated patient interaction indicates that contact with blood or body fluids may occur. A private room is unnecessary unless the patient's hygiene is unacceptable (e.g., uncontained secretions, excretions, or wound drainage). Discard all contaminated sharp instruments and needles in a puncture-resistant container. Health care agencies must make available needleless devices. Any needles should be disposed of uncapped, or a mechanical safety device must be activated for recapping. Respiratory hygiene/cough etiquette: Have patients cover the nose/mouth when coughing or sneezing; use tissues to contain respiratory secretions and dispose in nearest waste container; perform hand hygiene after contacting respiratory secretions and contaminated objects/materials; contain respiratory secretions with procedure or surgical mask; sit at least 91.4 cm (3 feet) away from others if coughing.

The nurse assesses any previous falls using the acronym SPLATT:

Symptoms at time of fall Previous fall Location of fall Activity at time of fall Time of fall Trauma after the fall

Fall prevention EBP cont....

The Agency for Healthcare Research and Quality (2013c) cites factors for health care organizations to consider when implementing best practices for fall prevention. Some factors that make fall prevention challenging include: -Fall prevention must be balanced with other priorities for a patient. A patient is usually not in the hospital because of falls, so attention is naturally directed elsewhere. Yet a fall in a sick patient can be disastrous and prolong the recovery process. -Fall prevention must be balanced with the need to mobilize patients. It may be tempting to leave patients in bed to prevent falls, but patients need to transfer and ambulate to maintain their strength and to avoid complications of bed rest. -Fall prevention is one of many activities needed to protect patients from harm during their hospital stay. Health care staff must consider how to prevent falls while maintaining focus on other priorities, such as infection control. -Fall prevention is interdisciplinary. Nurses, physicians, pharmacists, physical therapists, occupational therapists, patients, and families need to cooperate to prevent falls. -Fall prevention needs to be individualized. Each patient has a different set of fall risk factors, so care must thoughtfully address each patient's unique needs.

Restraint application TJC Guidlines for restraint orders. It requires that a restraint be used only under the following circumstances:

The CMS released revisions to the Medicare conditions of participation, outlining standards for the safe use of restraints in hospitals and defining patients' rights and choices regarding restraints. It requires that a restraint be used only under the following circumstances: 1. To ensure the immediate physical safety of the patient, a staff member, or others. 2. When less restrictive interventions have been ineffective. 3. In accordance with a written modification to the patient's plan of care. 4. When it is the least restrictive intervention that will be effective to protect the patient, staff members, or others from harm. 5. In accordance with safe and appropriate restraint techniques as determined by hospital policies. 6. It is discontinued at the earliest possible time.

Box 9.1, Special Tuberculosis Precautions.

The Centers for Disease Control and Prevention (CDC) published guidelines for preventing tuberculosis (TB) transmission in health care agencies in response to a resurgence of TB in the United States associated with the increasing incidence of human immunodeficiency virus (HIV) infection, TB infection transmission in health care settings, and increasing immigration from countries with a high incidence of TB (CDC, 2012). • Current CDC guidelines for preventing and controlling TB focus on early detection of infection, preventing close contact with patients with active TB disease, and applying effective infection control measures in health care settings. Suspect TB in any patient with respiratory symptoms lasting longer than 3 weeks accompanied by other suspicious symptoms such as unexplained weight loss, night sweats, fever, and a productive cough often streaked with blood. • Consider the potential for infectious pulmonary or laryngeal TB from documented positive acid-fast bacilli (AFB) smear or culture, cavitation on chest x-ray film, or history of recent TB exposure. • Isolation for patients with suspected or confirmed TB includes placing the patient on airborne precautions in a single-patient negative-pressure room. • Health care workers who care for patients with suspected or confirmed TB must wear special respirators (e.g., N95 or P100) (CDC, 2010b). These respirators are high-efficiency particulate masks that have the ability to filter particles at a 95% or better efficiency (CDC, 2010b; OSHA, 2011). • The CDC now recommends the use of the QuantiFERON-TB Gold test (QFT-GIT) or the T-SPOT (CDC, 2011), a blood test, in place of the traditional TB skin test. The advantages of the QFT-GIT test are that it does not boost responses measured by subsequent tests and the results are not subject to reader bias.

IOM report To Err is Human

The Quality of Health Care in America Committee of the Institute of Medicine (IOM) concluded that it is not acceptable for patients to be harmed by the health care system that is supposed to offer healing and comfort-a system that promises, "First, do no harm." Helping to remedy this problem is the goal of To Err is Human: Building a Safer Health System, the IOM Committee's first report. In this report, issued in September 1999, the committee lays out a comprehensive strategy by which government, health care providers, industry, and consumers can reduce preventable medical errors. Concluding that the know-how already exists to prevent many of these mistakes, the report sets as a minimum goal a 50 percent reduction in errors over the next five years. In its recommendations for reaching this goal, the committee strikes a balance between regulatory and market-based initiatives, and between the roles of professionals and organizations. One of the report's main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a "bad apple" problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes.

Know how to recognize best evidence when reviewing research

The best evidence comes from well-designed, systematically conducted research studies found in scientific journals. You must also use sources of evidence that include quality improvement and risk management data, infection control data, retrospective or concurrent chart review, and clinicians' expertise.

Chain of Infection

The elements of the chain of infection are: an infectious agent or pathogen (capable of causing disease); a reservoir for pathogen growth (site or origin of microorganism growth); a portal of exit from the reservoir; a mode of transmission; a portal of entry to the host (microorganism enters host); and a susceptible host (patient).

The skill of effective transfer techniques can be delegated to trained nursing assistive personnel (NAP).

The nurse is responsible to initially assess patient's readiness and ability to transfer. The nurse directs the NAP by: Helping and supervising when moving patients who are transferred for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. Explaining the patient's mobility restrictions, changes in blood pressure to monitor for, or sensory alterations that may affect safe transfer. Explaining what to observe for and report back to the nurse such as dizziness or the patient's ability to help.

ANA Code of Ethics Provision 7

The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. The nurse, in all roles and settings, ADVANCES THE PROFESSION through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Table 9.2 (second tier) (screenshot image & info on this slide)

The second tier (Table 9.2) includes precautions designed for care of patients who are known or suspected to be infected, or colonized, with microorganisms transmitted by the contact, droplet, or airborne route or by contact with contaminated surfaces (Screenshot image)

Fire Extinguishers (3 types & how to use)

Three types of extinguishers A-for wood and paper B-for flammable liquids such as anesthetic gas or paint C-for electrical ABC-all of the above Use of fire extinguisher P - pull pin A - aim S - squeeze handle S - sweep

Seizure Precautions (rolling patient on side)** & status epilepticus guidelines cont..

Traditionally patients who have a seizure are immediately placed in the side-lying position to prevent aspiration of oral secretions. This is still a standard of practice. However, the patient should be rolled gently into this position and only if possible without injuring any body part. Refer to your agency policy for positioning guidelines. The current practice guidelines for patients with status epilepticus include the following: • Within first 2 minutes establish and protect the airway when patient loses consciousness. • Provide noninvasive airway protection and gas exchange with head positioning, keeping the airway patent and administering oxygen. • Measure vital signs: oxygen saturation, blood pressure, and heart rate immediately and every 2 minutes. • Establish an intravenous (IV) route for emergency medications. • When seizure begins to subside, intubation (insertion of an artificial airway) should be attempted only if gas exchange is compromised or if patient is believed to have increased intracranial pressure.

Fall prevention's Skill #1 cont...*

Upwards of 1 million people fall in hospitals yearly (AHRQ, 2013). Nursing practice today relating to fall prevention is based on research—Evidence-Based Practice (EBP). Examples: -Screen older patients—they are more likely to fall due to frailty, polypharmacy, multi-morbidity, and vitamin D status. -Single exercise interventions have been shown to reduce falls in older adults. Young neurological patients with impaired gait and balance or medium to severe motor disability are at an increased risk of falling. -Patients who are relatively independent and still involved in challenging activities have an increased exposure to fall risk. -Improperly fitted canes and walkers, wheelchair characteristics, and environmental hazards are significant environmental risk factors. -Long-term care settings, multifactorial interventions (using multiple fall prevention strategies) significantly reduce falls and the number of recurrent fallers. -Older adults should be routinely screened for relevant risk factors for falling. These individuals will most likely benefit from a fall prevention program targeted to their risk factors (e.g., frailty, polypharmacy, multi-morbidity, vitamin D status, and home hazards. -Not all fall prevention strategies are useful for all patients. Single exercise interventions (e.g., Tai Chi) can significantly reduce numbers of falls among older adults with and without cognitive impairment in institutional or noninstitutional settings. -Such programs also reduce the rate of falls that lead to medical care. -Vitamin D and calcium supplementation, home visits, and adjustments within the living environment can reduce the risk of falls among older adults in noninstitutional settings. Including an occupational therapist or physical therapist in a home-hazard assessment may have added benefit. -Exercise programs designed to prevent falls in older adults, including planned group exercise, also seem to prevent injuries caused by falls, including the most severe ones. Such programs also reduce the rate of falls leading to medical care.

National Patient Safety Goals (Joint Commission Safety Goals 2019) cont..

Use alarms safely: make improvements to ensure that alarms on medical equipment are heard and responded to on time. Prevent infection: Use hand cleaning guidelines from the CDC. Use proven guidelines to prevent: Difficult to treat infections, central line bloodstream infections, infections after surgery, & catheter related urinary tract infections. Identify patient safety risks. Identify patients at risk for suicide. Prevent mistakes in surgery: Make sure correct surgery is done on correct patient and at the correct place on the patient's body, mark the place on the body where surgery is to be done, & pause before surgery to make sure a mistake is not being made.

Transmission precautions (contact, droplet, & airborne)

Use for care of patients who are known or suspected to be infected, or colonized, with microorganisms transmitted by the contact, droplet, or airborne route. The three types of transmission-based precautions—airborne, droplet, and contact—may be combined for diseases that have multiple routes of transmission (e.g., chickenpox). When used either singly or in combination, you use them in addition to standard precautions.

Droplet precautions cont... (plus standard precautions)

Visitors- Report to Nurses station before entering room Private room- cohorting possible Masks- wear mask within 3 ft. of patient Essential movement/transport only Mask on patient during transport

Fall prevention (in health care agencies) cont.......

Wheelchair-related falls: -Unlocked brakes -Over reaching -Sliding -Tipping the chair -Unassisted transfers -Nurses must identify all fall risks. -Preventing falls requires diligent ongoing nursing assessment.

Fall prevention (in health care agencies) cont........

Wheelchair-related injuries from falls include fractures, concussions, dislocations, amputations, and serious head and spinal injuries. An example of a wheelchair characteristic that increases risk for falls is having smaller and harder front wheels that cause a chair to tip when striking uneven terrain. -Caregivers are also at risk for injury by not handling patients correctly or not asking for assistance. Injuries can occur while caregivers transfer patients who are agitated, fearful, unsteady, or too weak to transfer. -Tripping over the front foot or leg rest and leaning over the back of the wheelchair to engage or disengage the wheel lock are common sources of injury. -The Joint Commission's Center for Transforming Healthcare aims to prevent inpatient falls with injury. Seven hospitals in the United States worked with the center and successfully reduced total number of falls and falls with injury by creating awareness among staff, empowering patients to take an active role in their own safety, using a validated fall risk assessment tool, engaging patients and their families in the fall safety program, providing hourly rounding that includes proactive toileting, and engaging all hospital staff to ensure no patient walks unaccompanied. -It is important for nurses to identify patients' fall risks and communicate these risks to patients, their visiting family members, and members of the health care team. -Patient-centered care is important, with nurses making patients their partners in recognizing fall risks and taking preventive action. Fall prevention strategies must be targeted to specific patient risks. For example, if a patient has postural hypotension, a nurse might choose a low bed and the practice of dangling the patient for 5 minutes on the side of the bed before trying to ambulate. Or a patient with a history of urinary incontinence might be given a bedside commode to use.

Isolation Precautions

When a patient has a known or suspected source of colonization or infection, health care workers follow specific infection prevention and control practices to reduce the risk of cross-contamination to other patients. Standard precautions require you to wear clean gloves before coming in contact with mucous membranes, nonintact skin, blood, body fluids, or other infectious material. You wear clean gloves routinely when performing a variety of procedures (e.g., nasogastric tube insertion). Masks are worn when there is a risk of splash during a procedure or when certain sterile procedures such as changing a central line dressing are performed. Protective eyewear and masks become important when there is a risk for splash of blood or other body fluids to the eyes or mouth. The Hospital Infection Control Practices Advisory Committee (HICPAC) of the CDC published revised guidelines for isolation precautions (2009). The guidelines contain recommendations for respiratory hygiene/cough etiquette as part of standard precautions.

Standard precautions (Tier 1)

used for all patients, regardless of risk or presumed infection status Apply to blood, blood products, all bodily fluids, secretions, excretions (except sweat), nonintact skin, & mucous membranes

Fall prevention's Components of Evidence-Based Fall Prevention Interventions in Health Care Settings (Box 14.1)

• Correction of environmental hazards • Identification armbands and bed and door signs for high-risk patients • Bed rails and bed height kept at the lowest level • Nurse call bell explained and within reach • Unsafe footwear replaced and/or nonskid footwear provided • Individualized patient and caregiver education and written instructions (preferably prescribed on the basis of risk factors) • Staff assignments in close proximity (assigned to patients in adjacent rooms) • Improving staff communication by including non licensed staff • Improving patient hand-off communication • Advising patients on changing position slowly • Encouraging patients to use eye glasses, hearing aids, footwear, and mobility devices • Nurse toilet and turn or comfort and care safety rounds (conducted hourly) • Supervision and assistance with transfer and toilet use • Toileting before pain medication • Medical referral for abnormal blood pressure • Medication review for sedatives, antidepressants, diuretics, and poly pharmacy • Ophthalmology referral for poor eyesight and optician visit if lost glasses

Be familiar with The Joint Commission (TJC) Patients' Rights Standards

• Right to an appropriate level of care • Right to receive safe care • Respect for cultural values and religious beliefs • Privacy • Consent obtained for recording or filming made for purposes other than the identification, diagnosis, or treatment of patients • Confidentiality of information • Recognition and prevention of potential abuse situation • Notification of unanticipated outcomes • Involvement in care decisions • Information on risks and benefits of investigational studies • End-of-life care • Advance directives • Organ procurement • A right to have advance directives and to have them followed • Freedom from unnecessary restraints • Informed consent for various procedures • The right to refuse care • The right to have their pain believed and relieved • Communication with administration • Education