CH, 10, 11, 23

Box 23.3 Preventing Inaccuracy in Examination and Test Procedures

-Many factors have the capacity to interfere with examinations and tests and potentially can alter the accuracy of or even nullify their results: • Drug interactions • Insufficient bowel cleansing • Failure to maintain fasting requirements • Inadequate diet preparation • Incompleteness or absence of test requisition • Specimen not delivered on schedule • Inappropriate specimen amount • Contamination of sterile specimen • Absence of required informed consent

CHAPTER 23 SPECIMEN COLLECTION & DIAGNOSTIC TESTING Remembering the meaning of root words, prefixes, and suffixes helps in identifying test names. Knowing the following suffixes is useful:

-ography Procedure in which an image is produced (e.g., mammography) -ogram Actual image or results of a test (e.g., mammogram) -oscopy Procedure in which body structures are visualized (e.g., colonoscopy) -centesis Procedure involving puncture of a body cavity (e.g., thoracentesis)

Interpreter in Hospital

-when using an interpreter they need to use an ID number have to chart that

Box 10.9 Fire Safety Interventions and Safe Evacuation of Patients Action (Rationale)

1. Follow facility fire plan in the event of a fire. (Fire plan outlines procedures to follow.) a. Ascertain patient's age, sensory impairments, level of mobility, ability to comprehend instructions, and overall need for protection. (Protects and assists patient in interpreting environmental stimuli relevant to safety.) b. If indicated, assess patients for type of evacuation assistance needed. (Move individuals at risk for injury to a safer area.) c. Provide clear explanations to patients and visitors in a calm manner. (Anxiety hinders understanding of situation and ability to follow instructions.) d. Assist with evacuations if needed: (1) Usually patients are moved horizontally (e.g., out of rooms, across halls, and through the next set of fire doors). (The fire and its potential for spreading often necessitate movement to a safer area. Some agencies have fire doors that are normally held open by magnets and close automatically when a fire alarm sounds. It is important to keep equipment away from these doors.) (2) If smoke or fire prevents you from moving patients across the hall, proceed vertically down to a lower level. Never use elevators as an exit route. A fire spreads very quickly up through the elevator shaft. (3) If a patient cannot walk or be moved by bed, stretcher, or wheelchair from the fire area, the patient often must be carried. (Use the carrying method that is safe for you and the patient; fire department personnel will help with the evacuation.) (4) Infant and child removal. (a) Place a blanket or sheet on floor. (b) Place two infants in each bassinet, using diapers or small blankets for padding. (c) Place the bassinet in the middle of the blanket. (d) Use the baby vest if available or fold the blanket over one end,fold the corners in, then roll the sides in to form a pocket. (e) Grasp the folded corners of the blanket and pull the infants to safety. Two people (or, if necessary, one person) are able to drag eight babies to the prescribed area. (f) Alternatively, place as many children as possible in one crib and pull the crib to the prescribed area. (5) Universal carry: The universal carry is a method of removing a patient from a bed to the floor. It is a quick and effective method for removing a patient who is in immediate danger. This carry can be used by anyone, regardless of patient size. (a) Spread a blanket, sheet, or bedspread on the floor alongside the bed, placing one-third of it under the bed and leaving about 8 inches to extend beyond the patient's head. (b) Grasp the patient's ankles, and move the patient's legs until they fall at the knee over the edge of the bed. (c) Grasp each shoulder, slowing pulling the patient to a sitting position. (d) From the back, encircle the patient with your arms, place your arms under the patient's armpits, and lock your hands over the patient's chest. (e) Slide the patient slowly to the edge of the bed, and lower the patient to the blanket. If the bed is high, instruct the patient to slide down one of your legs (f) Taking care to protect the patient's head, gently lower the head and upper torso to the blanket and wrap the blanket around the patient. (g) At the patient's head, grip the blanket with both hands, one above each shoulder, holding the patient's head firmly in the 8 inches of blanket. Do not let the patient's head snap back. (h) Lift the patient to a half-sitting position, and pull the blanketed patient to safety. (6) Blanket drag: If vertical or downward evacuation by an interior stairway is necessary, in many cases one person can handle a helpless patient by using the blanket drag. (a) Double a blanket lengthwise, and place it on the floor parallel and next to the bed, leaving 8 inches to extend above the patient's head. (b) Using cradle drop, kneel drop, universal carry, or other suitable means, remove the patient from the bed to the folded blanket on the floor alongside the bed. (c) Grasp the blanket above the patient's head and pull to the stairway; start down the stairs with patient coming headfirst onto the stairway. (d) Position yourself one, two, or three steps lower than the patient, depending on your height and the patient's height. The patient's lower body inclines upward.

ADPIE - Nursing Process

Assessment Diagnosis Planning Implementation Evaluation

CHAPTER 10 INFANTS & CHILDREN AND OLDER ADULTS

*The nurse is responsible for anticipating potential injuries and individualizing patient care and teaching. *Accidents involving children are largely preventable, but parents and caregivers need to be aware of specific dangers at each stage of growth and development. *Examples of dangerous items to children is the swimming pool, stove burner, cleaning products (b/c they have chemicals and poisons), medication containers, falling off bed or crib w/ no side rail and examination table OLDER ADULTS *Unsteady gait, age-related vision changes, and medication side effects (such as vertigo) pose a threat to the older adult's safety. *Ensuring that older adults wear their eyeglasses and hearing aids and use assistive devices for ambulating when necessary are important nursing interventions to promote patient safety *Assisting weak or disoriented older patients when drinking hot liquids such as soups, coffee, or tea can prevent burns. People in this age group are more vulnerable to burns from spilled hot liquids and from heating pads and electric blankets.

Home Care Considerations Specimen Collection and Diagnostic Examination Specimen Urine Postprocedural Considerations After Intravenous Pyelography (IVP) Discharge instructions typically include the following:

• It is best to collect urine specimens for culture and sensitivity in the laboratory setting rather than at home because the chance of bacterial growth is increased by the delay in testing. If a specimen is collected at home, the patient must refrigerate the specimen until time of transport to the laboratory and must keep the specimen on ice during transport. • When obtaining a urine testing kit, the patient needs to know that all supplies except for the specimen container are usually included in the kit. • Urine testing at home typically is performed with reagent strips. Stool • Frequently, patients are instructed to obtain stool specimens at home and then bring the specimen to the laboratory setting or health care provider's office. • If a stool specimen is obtained for occult blood testing, the patient is asked to prepare the slide at home and return the slide to the laboratory or health care provider's office for testing. • Instruct the patient obtaining a stool specimen at home to prevent the specimen from contact with the toilet bowl by using the specimen hat provided by the health care provider. • Many older adults need assistance with the collection of stool specimens. Sputum • Instruct patients obtaining sputum specimens at home on proper specimen collection and the importance of returning the specimen to the laboratory in a timely manner. Wound Drainage • Teach proper technique for obtaining a wound specimen (e.g., hand hygiene) if the specimen is obtained in the patient's home. Venipuncture • In the home setting, a tourniquet is often not available; use a blood pressure cuff before venipuncture. Blood Glucose Testing • Encourage patients to attend meetings of a diabetic support group. • Various glucose meters are available for home use. • Patient teaching should be performed on the specific glucometer model that the patient purchases. Other Specimens and Examinations • Driving is restricted for 24 hours after procedures that necessitate conscious sedation. • Instruct the patient not to make any legal decisions for 24 hours after procedures that necessitate conscious sedation or the use of other medications that may impair judgment. Postprocedural Considerations After Intravenous Pyelography (IVP) Discharge instructions typically include the following: • The kidneys excrete the contrast medium. Instruct the patient to drink at least 24 ounces (720 mL) of water if this is not contraindicated by a current condition. • Delayed allergic reaction from the contrast medium is possible as much as 24 hours after the procedure. -Instruct patients to call the primary health care provider if they have such reactions. -If the reaction is an emergency (facial swelling, especially around the eyes, lips, and mouth; difficulty breathing; difficulty swallowing; wheezing), the patient is to go immediately to the emergency department rather than contacting the primary health care provider. After Paracentesis • Instruct the patient to contact the health care provider if he or she develops a fever or experiences pain, swelling, or discharge from the puncture site. The patient should rest after this procedure because he or she may feel dizzy or lightheaded related to the amount of fluid removed. After Thoracentesis • Give patients written instructions that include signs and symptoms of complications related to perforation of the spleen, liver, or lung. Signs and symptoms to be alert to include fever, leakage of fluid from the puncture site, difficulty breathing, or chest pain. Inform the patient that sometimes these signs and symptoms do not occur until several days after the procedure. After Bronchoscopy • Instruct patients experiencing fever, chest pain or discomfort, or respiratory symptoms such as dyspnea, wheezing, or hemoptysis to contact the health care provider or to seek medical attention immediately. • Inform patients that throat discomfort is common and often is relieved with throat lozenges. After Cardiac Catheterization • Instruct the patient to contact the health care provider or seek immediate medical attention if any of the following occurs: • Excessive bleeding from the puncture site (apply pressure). A small amount of dark blood may be present. Bright red blood indicates active bleeding. • Swelling under the skin at the puncture site. • Increase in bruising at the puncture site or movement of bruising down the extremity that was used for the procedure. • Increased or new sensation of pain at the puncture site or in the extremity used for the procedure. • Paleness, or if the extremity of the puncture site becomes pale or cold. • Redness or warmth at the puncture site.

ELOPMENT (leaving the health care facility without permission or necessary supervision)

*a device referred to as a wander guard may be needed. *This device is worn on the wrist or ankle and sets off an alarm when the person leaves the facility. *These devices are especially beneficial for the confused or disoriented patient or resident who would be at risk for attempting to leave the facility. *By assessing individual patient needs, characteristics of the environment, and organizational change, the licensed practical/vocational nurse (LPN/LVN) often is able to plan interventions that reduce or eliminate the need for SRDs. *Patient safety and the safety of others are the only reasons an SRD is used. *Some facilities require that a health care provider order for SRDs be renewed every 24 hours. Explain to the patient the need for the devices even if the patient does not seem to understand the explanation.

CH.23 Implementation *Implementation includes performing preexamination and postexamination responsibilities that will assist a patient to achieve an optimal state of health (see Table 23.1). * If patient is discharged home, teach home care instructions (see 1856 the Home Care Considerations box on specimen collection and

Evaluation Evaluation involves observing for a patient's response to determine whether goals and outcomes have been met. 1. Ask patient to state purpose and explain steps of the procedure before it is started. 2. Ask whether patient has questions or concerns about the procedure before it begins and later about test results. Assess nonverbal behaviors of anxiety before, during, and after procedure. 3. Ask patient to demonstrate body position required for procedure. Assess patient's body position throughout procedure, and assist to maintain position as necessary. 4. Ask patient to describe level of comfort during and after procedure. 5. Assess patient's respiratory status (rate, rhythm, and depth of respirations; symmetry of chest movement) during and after abdominal paracentesis, thoracentesis, and bronchoscopy. 6. Compare patient's heart rate and blood pressure during and after procedure with preprocedure baseline values. (Check hospital policy; sometimes performed as often as every 15 minutes, typically for a period of 2 hours.) 7. Inspect dressing over puncture site for drainage every hour after the procedure until patient's condition is stable. 8. Assess patient for postprocedure complications. a. Assess patient for a decrease in blood pressure and tachycardia (could signify hemorrhage or allergic reaction to dye [see Box 23.2]). b. Assess patient for flushing, itching, and urticaria c. Assess the patient's respiratory status for sudden, severe shortness of breath (signifies possible laryngospasm and bronchospasm) d. Assess patient for abdominal pain, fever, and bleeding (signify possible perforation of abdominal structures). e. Assess patient for low oxygen saturation; rate and depth of respirations; cyanosis or mottled skin; hypotension; changes in heart rate or rhythm (usually bradycardia); decreased or nonpalpable peripheral pulses; decreased or absent reflexes; and changes in level of consciousness related to conscious sedation. 9. Ask patient to describe postprocedure positioning and activity restriction for lumbar puncture, liver biopsy, and thoracentesis

CH.23 Nursing Process for Specimen Collection and Diagnostic Testing

The role of the LPN/LVN in the nursing process is that the LPN/LVN will • Participate in planning care for patients based on patient needs • Review patient's plan of care and recommend revisions as needed Assessment Do the following in regard to specimen collection and diagnostic testing: • Assess patient's knowledge of procedure to determine level of health teaching required. • Observe verbal and nonverbal behavior to determine patient's anxiety. • Determine patient's ability to understand and follow directions. • Evaluate patient's ability to assume position required for procedure and ability to remain in that position. • Determine whether patient is allergic to antiseptics, anesthetic solutions, or any of the dyes that will possibly be used. • Assess patient's need for preprocedure analgesic administration. Patient Problem With an accurate and thorough assessment, the LPN/LVN will be able to report patient assessment findings to the RN, who can formulate the necessary patient problem statements. Patient problems are likely to include the following: • Anxiousness, related to the manner in which a specimen is obtained or a procedure is performed. Fear of the possible test results is often a factor • Insuficient Knowledge, related to the purpose of the collection or examination and the manner in which the specimen is collected or the test is performed. • Potential for Infection, related to the patient's skin or tissue impairment (broken during a diagnostic procedure). • Recent Onset of Pain, related to invasive diagnostic test (when some type of instrument is inserted into a part of the body). -Patient problems related to optimal oxygenation during diagnostic procedures involving the airway include the following: • Ineficient Oxygenation • Inability to Maintain Adequate Breathing Pattern • Potential for Aspiration Into Airway • Inability to Clear Airway, related to collection of sputum specimen by sneezing and coughing or related to collection of sputum specimen by suctioning

Box 11.5 Discharge Teaching Goals The goals of discharge teaching help to ensure that patients do the following:

• Carefully follow their diet • Comply with their medication therapy • Know about possible complications • Know when to seek follow-up care • Manage their activity level • Recognize their need for rest • Understand their illness • Understand their treatments Be certain that the discharge teaching includes the patient's family or other caregivers to ensure that the patient receives proper care at home

CHAPTER 10: SAFETY IN THE HOSPITAL OR HEALTH CARE ENVIRONMENT

*A safe environement implies freedom from injury and prevention of falls, electrical injuries, fire burns, and poisoning * The nurse must be alert to potential safety problems, including workplace violence, and must know how to report and respond when safety is threatened *Checking to see that the call light or signal system is working and accessible is an example of how the nurse helps maintain a safe environment. *The Joint Commission defines a sentinel event as "any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" * The Joint Commission is required, including a thorough review of the event and the plan for improvements that will prevent the event from occurring again. *Examples of sentinel events include medication errors and errors in procedures and treatments that led to the death of an individual and inappropriate application of safety reminder devices (SRDs; formerly referred to as restraints) FALLS *The very young and older adults are not the only individuals at risk in the health care environment. Individuals who become ill or who are injured are also at risk. *The use of anesthesia, sedatives, or narcotics increases the risk of falling, as does an unstable gait or a problem with balance. A fall risk assessment is necessary on admission to a facility or if a significant change in the patient's condition has occurred. *Facilities require fall precautions if the answer is "yes" to a specified number of questions on a fall risk assessment tool. GAIT BELTS Gait belts are an effective way to help patients ambulate safely. A gait belt is a canvas (or other very strong material) belt that encircles the patient's waist (some belts have handles attached for the staff to grasp) while the patient ambulates. Correct technique in the use of the gait belt is as follows: 1. Apply gait belt securely around the patient's waist. The health care worker should be able to fit two fingers between the gait belt and the patient's waist. 2. Walk to the side of patient, grasping the gait belt toward the patient's back. The other hand may either support the patient's arm or grasp the gait belt toward the patient's side. Unless the patient has a tendency to lean toward one particular side, walk on the patient's weaker side so that you are able to give assistance if the patient starts to fall 3. Have patient support self by leaning on or holding your arm. 4. Walk slightly behind the patient for better support. 5. Walk with your knees and hips flexed. 6. After ambulation, loosen or remove the gait belt. 7. Document procedure.

CHAPTER 10 SAFETY REMINDER DEVICES

*A safety reminder device (SRD) is defined as any of the numerous devices used to immobilize a patient or part of the patient's body, such as arms or hands. *The use of SRDs also tends to result in increased restlessness, disorientation, agitation, anxiety, and a feeling of powerlessness. *It contributes to patient immobility and associated problems with immobility such as dehydration, health care-associated infection, and incontinence. The resulting disuse of body parts has the potential to increase disability and lead to further patient weakness and unsteadiness. Patients often pull against the SRDs, causing skin and circulation problems. *SRDs that restrain the use of a limb (e.g., a wrist restraint) are used primarily in the mental health setting to protect the patient and the staff from harm, pediatric setting to prevent such incidents such as displacement of intravenous lines by the patient, and the intensive care setting to prevent the patient from pulling out medical devices such as an endotracheal tube *Certain patient populations, such as the disoriented patient, are more likely to need SRDs in the forms of bed or chair alarms. A bed or chair alarm alerts the staff if a patient attempts to get out of a bed or chair without assistance. This helps reduce the risk of the patient falling from a bed, chair, or wheelchair

CHAPTER 10 BOX 10.5: LEVELS OF LATEX SENSITIVITY

*CONTACT DERMATITIS: A non-allergic response characterized by skin redness and itching *TYPE IV HYPERSENSITIVITY: Cell-mediated allergic reaction to chemicals used in latex processing. Delayed reaction, including redness, itching, & hives up to 48 hours. Localizing swelling, red, and itchy runny eyes and nose, and coughing. *TYPE I HYPERSENSITIVITY: A true latex allergy is possible life threatening. Reactions are likely based on type of latex protein and degree of individual sensitivity, including local and systemic Symptoms include hives, generalized edema, itching rash, wheezing, broncho spasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia or cardiac arrest

CHAPTER 10 CULTURAL CONSIDERATIONS: SAFETY IN HEALTHCARE SETTINGS

*Cultural heritage affects all dimensions of health; the nurse must consider cultural background when planning for patient safety *The way that culture influences behaviors, values, and attitudes depends on many factors & may not be the same for individual members of the group *Before assessing the cultural background patient, assess the influence of nurses own culture *Adapt the planning and implementation or nursing interventions for safety as much as possible to a patients cultural background *Evaluate attitudes and emotions toward providing nursing interventions for safety to patients from diverse social-cultural backgrounds *Patients from some cultures may seem unfriendly and distant in terms of space. It is often very difficult for them to have an outsider in their home who is suggesting changes w/regard to their personal belongings, even tho the purpose is to reduce physical hazards. *Determination of the patients attitude towards the home is difficult when another language is spoken. Use an interpreter or engage the patients family to interpret if available. *Another culturally issue is the patients sense of environmental control. Be aware of health beliefs and practices that affect the outcome of interventions. For ex, reliance on family and religious organizations

Discharging a Patient Discharge Planning *DISCHARGE PLANNING *DISCHARGE

*Planning for a patient's discharge is just one aspect that aids in providing continuity of care for a patient in a health care facility. DISCHARGE PLANNING is defined as the systematic process of planning for patient care after discharge from a hospital or health care facility. *Although DISCHARGE from a facility usually is considered routine, effective discharge requires careful planning and continued assessment of the patient's needs during the stay in the facility. Ideally, discharge planning begins shortly after admission. Discharge planning has several purposes, including teaching the patient and the family about the patient's illness and its effect on lifestyle; providing instructions for home care; communicating dietary or activity instructions; and explaining the purpose, adverse effects, and scheduling of medication treatment. It also can include arranging for transportation, follow-up care when necessary, and coordination of outpatient or home health care services. *Good discharge planning involves the patient from the beginning, uses the strengths of the patient and caregivers in planning, provides resources to meet the patient's limitations, and is focused on improving the patient's long-term outcomes. *The Joint Commission (Kind and Smith, n.d.) suggests the following instructions be given to patients upon discharge from a health care facility: • Reason for the admission • Safe and effective use of medications and medical equipment • Instruction on nutrition and modified diets • Rehabilitation techniques to support adaptation to or functional independence in the environment • Access to available community resources as needed • When and how to obtain further treatment • The patient's and family's responsibilities in the patient's ongoing health care needs and the knowledge and skills needed to carry out those responsibilities • Maintenance of good standards for personal hygiene and grooming • It is also necessary to identify risk factors for discharge planning, such as the following: • Older adult age group • Multisystem disease process • Major surgical procedure • Chronic or terminal illness Discharge planning is a multidisciplinary process that involves participation by all members of the health care team, the patient, and the patient's family or significant others. Many larger hospitals have discharge planners or coordinators. The social worker is often in charge of discharge planning for the long-term care resident. Considered part of the health care team, these people orchestrate the discharge planning. This is especially important when the patient is considered at risk. Depending on the facility or acuity level of the patient, the staff or the charge nurse may be responsible for discharge planning. With the assistance of social workers or community-based nurses, the staff identifies and anticipates patient needs after discharge from the hospital and formulates a plan for meeting those needs (Box 11.5, Fig. 11.5, and the Home Care Considerations box).

CHAPTER 10 LATEX SENSITIVITY

*Question all patients regarding allergies, and ask specifically about latex allergies. *A latex allergy can precipitate a respiratory arrest, which is a life-threatening event *Do not wear, or permit others to wear, latex gloves when caring for patients with latex allergies. For individuals at high risk of or with suspected sensitivity to latex, use exclusively latex-free products, including gloves, and inspect the contents of all patient care supply kits for items that contain latex (e.g., catheters, tubing). Institutions have latex-free procedure kits available for use

CHAPTER 10 PATIENT TEACHING SAFETY PROMOTION

*Teaching the primary caregiver the dangers associated w/ restraining a patient w/ a history of seizures & how to modify the environment for the patients protection *Instruct the primary caregiver how to position a patient correctly who is nauseated and vomiting if a restraint is in use. *Instruct the primary caregiver how to routinely change the patients position and use passive range of motion *Explain the patient and members of the family why SRDs are necessary *Provide information about the type of SRD to be used and the approximate time frame for use *Inform patient and family that the patient will still receive comfort measures such as repositioning and limb exercise *Inform patients and parents about poison control centers. Call 911, provide number closest to 911 call center *Teach basic interventions to follow in the case of a poisoning *see that safety items such as stickers w/ poison center information are available *Teach parents & caregivers not to try home remedies. When ingestion of a dangerous substance is suspected, appropriate medical intervention must be sought ASAP *Removal of poisonous and toxic substances does not take the place of education as a means to prevent accidental poisoning *Instruct families to a bedside tables and overbed tables close to the patient *Encourage patient to rise from the bed or chair slowly to prevent vertigo (dizziness) that results from postural hypotension *Advise the family to remove clutter from bedside tables, hallways, bathrooms, and grooming areas *Encourage family to mount grab bars around toilets and showers; instruct the patient how to use them *Recommend that rugs and carpets be attached securely to floor and stairs *Recommend that bath straps and non-skid strips be attached to bath tubs and the floor of shoer stalls *Recommend that electrical cords be secured against baseboards so that the patient will not trip easily *Ensure that the call bell is within easy reach of the hospitalized patient, and show patient the location of emergency call bells in bathrooms. (The nurse must response to call lights quickly, especially for the patients who need assistance to the bathroom) *See that wheelchairs remained locked when transporting a patient from bed to wheelchair or back to bed. *Instruct caregivers to check that side-rails are up and safety straps are secured around the patient who is on a gurney. * Use fire drill procedures as an opportunity to talk about fire safety

ACCIDENTAL POISONING "POISON"

*The CDC defines a POISON as "any substance that is harmful to your body when ingested (eaten), inhaled, injected, or absorbed through the skin. Any substance can be poisonous if too much is taken." *Of those calls 6.6 poison exposures/1000 population occurred with 41.3 poison exposures in children younger than 6 years/1000 children *Specific antidotes and treatments are now available for all types of poisons. -Note that syrup of ipecac is no longer recommended for use *Older adults are also at risk *Some older adults share medications with friends or limit their medications because of the expense. *Changes in eyesight sometimes lead to an accidental ingestion. -If elderly patients have any memory impairment, they are likely to forget when they last took either prescribed or over-the-counter medication. *. Changes in eyesight sometimes lead to an accidental ingestion. If elderly patients have any memory impairment, they are likely to forget when they last took either prescribed or over-the-counter medication. *Hospitalized patients and those in other types of health care facilities are at risk for accidental poisoning because of poisonous substances in the environment *Cleaning solutions and disinfectants must be labeled and stored properly. To prevent poisoning, toxic agents are removed from areas where accidental poisoning is possible. *Do not remove toxic or poisonous substances from their original containers because incorrect labeling is one of the likely results, and never use substances from unmarked containers. Drugs are potentially hazardous if prepared or administered inappropriately. Human carelessness causes errors of both types. *Be sure to attend staff in-service programs that present new drugs or provide updated information on frequently used drugs. *Nurses must ensure that the closest poison control center phone number is posted clearly in the patient's home and in the health care facility. -Information received from the center helps in treatment and in referral.

CHAPTER 10 HAZARD COMMUNICATION ACT OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) CENTERS FOR DISEASE CONTROL & PREVENTION (CDC)

*The Hazard Communication Act of the Occupational Safety and Health Administration (OSHA) (a federal organization that provides guidelines to help reduce safety hazards in the workplace) requires health care facilities to inform employees about the presence of or potential for harmful exposures and how to reduce the risk of exposure. *The Centers for Disease Control and Prevention (CDC) (a federal agency that provides facilities and services for the investigation, identification, prevention, and control of disease) also provides guidelines for working with infectious patients (e.g., standard precautions; Referring to this information and following recommended guidelines for reducing exposure to the variety of hazards present in the health care environment are the responsibility of the nurse.

DISASTER PLANNING TERM: DISASTER SITUATION, CODES

*n. A DISASTER SITUATION is an uncontrollable, unexpected, psychologically shocking event that is unique and likely to have a significant impact on a variety of health care facilities. *Examples of natural threats to safety are earthquakes, hurricanes, floods, and tornados. Bombings, arson, riots, shootings, and hostage taking represent acts of violence carried out by people and do not always affect a facility's day-to-day operations. *Factors that affect disaster response include the time of the day; the scope and duration of the triggering event; readiness of the health care facility, personnel, and equipment; preparations for appropriate procedures; and the extent to which the various community agencies and institutions collaborate with one another. Health care facilities are expected to receive victims and survivors and to assist rescuers. *The external disaster originates outside the health care facility and results in an influx of casualties brought to the facility (e.g., an explosion in a chemical plant, a tornado, a train accident). -The emergency department is the main focus of activity. -Typically, no immediate safety threat to staff, patients, or hospital property exists. *The internal disaster represents an extraordinary situation that is brought about by events within the health care facility, such as a fire. -In many cases, the organization's ability to function normally is threatened. -An internal disaster has the ability to threaten the safety of patients, visitors, staff, and facility property *Most state and federal regulators require health care personnel to conduct disaster drills on a routine basis to prepare to meet their responsibilities effectively. *Personnel must be familiar with the location and the contents of the facility's DISASTER MANUAL (sometimes called the Emergency Response Plan or Emergency Management Plan). *This manual specifies chain of command, callback procedures, assignment procedure, departmental responsibilities, patient evacuation procedure and routes, procedures for the receipt and management of casualties, and policies related to the overall management of supplies and equipment. *Various CODES (a system of notification to be transmitted rapidly) are used by health care facilities to alert personnel to the various emergencies affecting the facility. -All personnel in a health care facility must be knowledgeable of the code system and how to act in response to codes.

CHAPTER 10 BOX 10.1: PRECAUTIONS TO PROMOTE SAFETY

- Assist patients when they get out of bed when they have had surgery, received narcotics for analgesia, have an unsteady gait or have been in bed for an extended period of time. -Demonstrate the proper use of emergency call buttons -Encourage the patients to wear non-slippers or shoes when ambulating -encourage the use of handrails in hallways and bathrooms -Follow facility policies regarding the use of side rails -If bed is equipped w/ an alarm, turn on for the restless, disoriented patient -Instruct patient to use call bell for assistance -Keep adjustable beds in the low position -Keep environment free of clutter b/c of items such as books, and shoes where the patient can trip off of on -Lock wheels on bed, wheelchairs, and gurneys -Orient patient to the environment to provide familiarity -Place bedside table & overbed table within reach. Ensure than frequently used items such as cell phone, eye glasses, & other belongings, are easily accessible. -Provide adequate lighting -Some institutions have adopted "fall precaution" policies in which every patient is evaluated on admission to determine the degree of likelihood for a potential fall -Wipe or mop up spilled liquids promptly. Personnel and patients must be to signs warning of wet or slippery floors.

CH.23 Capillary Puncture BLOOD CULTURE

-A less invasive method of collecting a blood specimen is called a CAPILLARY PUNCTURE *It is used commonly to collect blood specimens from newborns and for glucose monitoring in all patients. *The procedure usually is performed by puncturing a vascular area on a finger, toe, or heel with a lancet, although sometimes a sterile needle is used instead. -Even when safety needles are used, never recap needles, and always discard them carefully in puncture-resistant containers close to the patient -Not all needlestick injuries are preventable; however, the use of needles with safety features has decreased substantially the risk of exposure to bloodborne pathogens for health care workers. Blood culture, a specific blood test used to detect the presence of bacteria in the blood (bacteremia), requires a special phlebotomy technique. Specimens for cultures are drawn when the symptoms of fever and chills that often accompany bacteremia are present. It is important to draw at least two culture specimens, one each from a different site. The venipuncture sites are prepared thoroughly according to agency policy before the collection of the blood specimens. The diagnosis of bacteremia is confirmed when both cultures grow an infecting agent. If only one culture produces bacteria, the assumption is that the bacteria were skin contaminants rather than the infecting agent. Because culture specimens obtained through an IV catheter frequently are contaminated, do not perform tests on them unless catheter sepsis is suspected. Blood culture specimens always are drawn before antibiotic therapy is started, because the antibiotic usually interferes with the organism's growth in the laboratory.

FIRE SAFETY RACE PASS

-Housekeeping responsibilities include eliminating all unnecessary combustible material; and maintenance responsibilities include ensuring the proper functioning of fire protection devices, such as alarms, extinguishers, and sprinklers. -It is mandatory to identify, light, and unlock exits. -Cooking and laundry equipment, filters, and air ducts are to be kept free of lint and grease. -It is obligatory to inspect and maintain all mechanical and electrical equipment regularly to keep fire hazards to a minimum. -All employees need to know the telephone number or procedure for reporting a fire and the location of the nearest alarms and firefighting equipment. -Use the appropriate fire extinguisher for each type of fire: • Paper, wood, and cloth fires require a type A fire extinguisher. • Flammable liquid fires, such as those caused by grease and anesthetics, require a type B fire extinguisher. • Electrical fires require a type C fire extinguisher. • Fire extinguishers marked ABC are acceptable for use on any type of fire. -In the event of a fire, patients on life-support systems may need manual respiratory support with an Ambu bag. *By remembering the mnemonic RACE (Rescue patients, sound the Alarm, Confine the fire, and Extinguish or Evacuate), -the LPN/LVN is prepared when safety is threatened by fire. -Then take measures to contain or extinguish the fire if no immediate threat to safety exists. -These measures include closing doors and windows, turning off oxygen and electrical equipment, and using the appropriate fire *The mnemonic PASS (Pull the pin, Aim low, Squeeze handle, Sweep the unit) will help the nurse remember how to operate the fire extinguisher -Notify the maintenance department of any defects in the equipment, and report any shocks felt while using equipment. -The nurse must enforce no smoking policies. -The safety of patients and caregivers depends on the staff's knowledge of fire prevention

CH.23 Expected Outcomes and Planning

-Identify goals and outcomes of care, and set priorities for the plan of care that is likely to result in goal achievement. -Expected outcomes focus on the collection of an uncontaminated specimen by the health care personnel or the patient and the patient's understanding of the purpose of the examination that requires the specimen All Specimens • Patient explains procedure for specimen collection before collection is attempted. • Patient explains purpose of specimen analysis before collection is attempted. • Patient verbalizes lack of fear of specimen collection and test results. 24-Hour Urine Collection • All of patient's urine voided during the specified time is saved. Urine and Stool Specimens • Patient specimen is free of contaminants, including urine or toilet tissue in stool or toilet tissue in urine. Sputum Specimen Obtained by Suction • Patient maintains adequate oxygenation throughout procedure. Wound Drainage Specimen • Specimen is free of contaminants from skin. Contrast Media Studies • Patient explains the purpose and basic steps of the procedure before it begins. • Patient assumes the correct position and remains still during the procedure. • Patient does not experience postprocedure complications, such as flushing, pruritus, and urticaria; respiratory depression or decreased cardiovascular function; diminished or absent peripheral pulses; hypotension and tachycardia; or decreased or absent urinary output. Nuclear Imaging Studies (Scans) • Patient expresses fear and anxieties related to testing and results. • Patient does not experience postprocedure complications such as hematoma, erythema, or edema at injection site.

CHAPTER 10.4 LONG-TERM CARE VARIATIONS FOR SAFETY REMINDER DEVICES

-In 1987 Omnibus Budget Reconciliation Act (OBRA) residents rights are addressed -This act was officially affected in 1990 -The act regulates the use of extremity SRDs, hand mitts, safety vests, & wheelchair safety bars. -SRDs may be used only to ensure the physical safety of the resident or other residents -A written order by the physician must detail the duration & circumstances under which the SRDs are to be used OBRA STATES THE FOLLOWING AS ACCEPTABLE REASONS FOR THE USE OF PHYSICAL RESTRAINTS: *All other interventions have been attempted before the use of restraints *Other disciplines have been consulted for their assistance *Supporting documentation has been completed. ESSENTIALS OF SRD DOCUMENTATION: *Reasons for physical restraint *Explanation given to patient and family *Date and time to the patients response to treatment *Duration *Frequency of observation & patients response *Safety *Release the physical restraint at least every 2 hours *Routine exercise of extremities, including range-of-motion exercises *Assessment for circulation and skin integrity *Assessment for the need for the physical restraint *Patient outcome

CH.23 Collecting a Blood Specimen (Venipuncture) and Blood for Culture TERMS *Venipuncture *Vacutainer

-Nurses are sometimes responsible for collecting blood specimens; however, many facilities have specially trained technicians (phlebotomists) whose sole responsibility is to draw blood. -Be familiar with facility policies and procedures and the state's nurse practice act regarding guidelines for collecting blood samples. -VENIPUNCTURE, the most common method, involves inserting a hollow-bore needle into the lumen of a large vein to obtain a specimen. In some cases, a needle and syringe are used, and in others, a special VACUTAINER tube is used to collect multiple blood samples. *A health care provider's order is required for tests. Before collecting the specimen, review the order to ensure that the specimens and amount for all the tests to be performed are correct, eliminating the need for multiple blood draws. *Older adults have fragile veins that are traumatized easily during venipuncture. -Sometimes an application of a warm compress helps with sample collection. -Using a small-bore catheter is another helpful strategy. In the home care setting, it may be helpful to use a blood pressure cuff, rather than a tourniquet, when performing the venipuncture. *Ask the patient if persistent or recurrent bleeding or expanding hematoma occurs at venipuncture site, and if so, notify the primary health care provider. *Children are often afraid of needles and the loss of blood. *Explain the procedure and tell children that they have a lot of blood and that their bodies constantly make blood. *Provide honest patient teaching for the pediatric patient. Fabrications and mistruths may damage the nurse-patient relationship irrevocably. *Ask a parent or another staff member to hold and comfort the child. *Toys or books may distract the child. Keep the needle out of the child's sight for as long as possible. *Perform the venipuncture and collection of the blood quickly, and an adhesive bandage should be placed over the site. *The bloodborne pathogens standard of the Occupational Safety and Health Administration (OSHA) requires employers to protect workers from any occupational exposure that is related to bloodborne pathogens

Coordinated Care Delegation Assessment and Data Collection

-The Joint Commission (TJC) requires each hospitalized patient to have an admission assessment prepared by a registered nurse (RN) within 24 hours of admission (TJC, n.d.). -The RN then is allowed to delegate aspects of data collection, for example, to the LPN/LVN. -Preadmission assessment and screening for a patient who is hospitalized with a planned admission to a long-term care (LTC) setting usually is performed by the LTC's admissions coordinator, who is typically a registered nurse. -Admission requirements for long-term care facilities are directed by each state's governing agency.

For Safety Reminder

-make sure no clutters on floor, rug and carpet -lighting, make sure patient has enough light to see where they are walking -no fluids on floor, such as beverages liquid, urine, or mop soap -check pulse 3 seconds and DISTAL pulse for circulation -make sure restraints need to be shut

CHPTER 10 10.2: SAMPLE QUESTIONS FOUND ON A FALL ASSESSMENT TOOL

1. Is there any history of a fall(s) in the past year? 2. Does the patient have an unsteady gait or difficulty ambulating? 3. Is the patient on any high-risk medications? 4. Does the patient require equipment to assist ambulating? 5. Does the patient have an altered mental abuse? 6.Is the patient experiencing blood pressure problems, dizziness, or vertigo? 7. Is the patient 70 years or older? 8. Does the patient bowel or bladder incontinence? 9. Does the patient have an Intravenous (IV), or oxygen line, or attachment to any other tubing? 10. Does the patient have any vision or any other sensory problems?

Skill 11.2 Transferring a Patient Nursing Action (Rationale)

1. Perform hand hygiene. (Reduces spread of microorganisms.) 2. Check health care provider's order for transfer. (Verifies if and when a patient is to be transferred.) 3. Inform patient and family of the transfer. (Reduces the fear of the unknown and strengthens the nurse-patient relationship.) 4. Notify the receiving unit of the transfer and when to expect the patient. (Allows preparation time to best welcome the new patient and begin care in a courteous, thoughtful, and unhurried manner.) 5. Gather all the patient's belongings and necessary care items to accompany the patient. (Builds trust and prevents loss of items.) 6. Assist in transferring the patient, usually via stretcher or wheelchair. (Ensures patient safety. The patient's condition determines mode of transportation.) 7. Introduce patient and family to nurses on new unit and to roommate. (Establishes the beginning of new therapeutic nursepatient relationship and gives a sense of belonging.) 8. Provide a brief summary of medical diagnosis, treatment care plan, and medications. Review medical orders with nurse assuming care. Situation, background, assessment, and recommendation (SBAR) is the common format used for reporting this information (see Chapter 3 for information regarding SBAR). If transfer is to another facility, complete an interagency transfer form. (Gives personnel on the receiving unit pertinent information for continuing care. Reviewing records together prevents errors.) 9. Explain equipment, policies, and procedures that are different on the new unit. (Gives the patient some control and reduces anxiety.) 10. Perform hand hygiene. (Reduces spread of microorganisms.) 11. Record condition of patient and means of transfer. The nurse on the new unit also records an assessment of the patient's condition on arrival. (Properly executed, the patient's medical record reflects all care given and the patient's response to that care while in the facility.) 12. For an intra-agency transfer, other departments, such as diagnostic imaging, laboratory, admission department, physical therapy, dietary, and business offices, must be notified of the transfer. (Keeps records current and prevents errors.) 13. An interagency transfer usually is made via air or ground ambulance or via private car. Be sure the patient is dressed or covered appropriately for environmental comfort. If oxygen is necessary, a small transport tank usually is used. A nurse generally accompanies a critically ill patient who is being transferred. (Promotes continuity of care.) 14. Infants generally are transported in an isolette that is later returned to the sending health care facility. Parents usually accompany their child during transfer unless the transfer is via air ambulance. In this case, the parents generally follow in family transportation. (Promotes continuity of care.) 15. Perform patient teaching (see the Patient Teaching box).

Skill 11.1 Admitting a Patient Nursing Action (Rationale)

1. Perform hand hygiene. (Reduces spread of microorganisms.) 2. Prepare the room before the patient arrives: care items in place; bed at proper height and open; light on. (This makes patient feel expected and welcome.) 3. Courteously greet the patient and family. Introduce yourself. Project interest and concern. Introduce roommate. (The patient and family are more at ease when they know the people around them.) 4. Check the ID band and verify its accuracy. (Ensures identification before tests or surgery are performed or medication is given. In long-term care facilities, the residents may not wear ID bands. A picture of the resident is used for identification purposes.) 5. Assess immediate needs. (Establishes trust when needs are recognized and met.) 6. Orient the patient to the unit, the lounge, and the nurses' station. (Promotes safety.) 7. Orient the patient to the room. Explain the use of equipment, call system, bed, telephone, and television. (Allows the patient some control over the environment and promotes safety.) 8. Explain facility routines, such as visiting hours and meal times. (Decreases fear of unknown and gives a feeling of security.) 9. Provide privacy if the patient desires or if abuse is suspected.Family members are sometimes asked to leave the room. (This allows the patient to answer questions openly and honestly without fear of the family member hearing the answers.) Admission of an infant or small child requires emotional support for child and parents. Parents generally are encouraged to stay with their child to prevent separation anxiety. The most reliable source of admission information is the parent. Assist the patient to undress if necessary. (Helps maintain dignity and shows respect for the patient. Helping the patient undress prevents fatigue and falls. Provides opportunity to assess range of motion and the skin.) 10. Follow facility policy for care of valuables, clothing, and medications. (Helps prevent loss of valuables, clothing, or medications, which is disturbing to the patient and family and potentially results in legal problems.) 11. Obtain the patient's health history and perform the initial nursing assessment. (Provides a basis for individualized care.) When a patient is admitted in critical condition, only the most pertinent information must be collected immediately. The remaining information can be obtained later. Young children are very curious about what is happening to them and the environment around them. Encourage the child to use equipment on dolls to help reduce anxieties. Encourage children to express how they feel. Invasive procedures (e.g., obtaining blood specimens, starting intravenous lines) generally are performed best in a treatment room. (Enables children to perceive their room as a safe area.) 12. Provide for safety: bed in low position, side rails up (unless admission is to a long-term care facility), call light within easy reach. (Promotes patient safety.) 13. Begin care as ordered by the health care provider. (The patient and family develop a positive attitude about the institution when care is started immediately.) 14. Invite family back into the room if they left earlier. (Decreases family anxiety when they observe the patient is settled.) 15. Perform hand hygiene. (Reduces spread of microorganisms.) 16. Record the information on the patient's health care record according to agency policy. (Provides information that also can be used by other health professionals. It is the beginning of the permanent record.) 17. Allow patient and family time alone together, if desired. (Admission procedure is often stressful and fatiguing. Allows time for decision making.) 18. Perform patient teaching (see the Patient Teaching box).

Box 10.12 Disaster Planning Interventions Action (Rationale)

1. Planning a. Review facility disaster plan frequently to update knowledge. The development of the disaster preparedness plan is an evolving and ongoing process. The purpose of disaster preparedness planning is to prepare the facility and health care workers for external and internal disasters. (Information helps health care workers anticipate their roles in the event of a disaster.) b. Know your own particular responsibilities in a disaster emergency. (Valuable time is saved and overall performance improved.) c. Participate, when possible, in disaster drills. Learning experiences are provided through disaster drills and formal critiques of the responses. (Drills are helpful in evaluating the overall safety program and are required by accrediting agencies.) Disaster drills may be initiated on a particular nursing unit, facility wide, community wide, or even statewide. d. Participation in a crisis support group is desirable if directly involved in a disaster or a disaster response. Individuals often experience some level of emotional or critical incident stress. (Crisis support teams or groups encourage staf to share thoughts and feelings related to the experience [debriefing].) 2. Follow facility disaster plan in the event of a disaster. (Disaster plan outlines procedures to follow and is most ef ective when personnel respond appropriately.) a. Identify the type of disaster emergency by recognizing the code that is used to announce it. (Unfamiliarity with the codes tends to result in loss of valuable time and injury to patients or personnel.) b. Identify each patient's age, sensory impairments, level of mobility, ability to comprehend instructions, and overall need for protection. (Helps you to protect and assist patients in interpreting environmental stimuli relevant to safety.) c. If indicated, assess patients for possible discharge or transfer. Protection of inpatients, and casualties from a disaster, is a top priority. (Space may be needed for disaster victims.) d. Provide clear explanations to patients and visitors in a calm manner. (The amount of information patients and families have about the situation [drill, disaster event] afFects their ability to cooperate and participate in any planned or unplanned activity.) e. If a disaster occurs when you are off duty, follow your facility protocols for reporting in (i.e., some facilities require you to report for duty at your regularly scheduled times, whereas others require you to contact your manager for instruction). Community agencies and resources are incorporated into the overall plan. (Additional personnel [e.g., student nurses and clinical faculty] in some cases assist with inpatient care to free staf for more critical disaster victims.) f. If an internal disaster occurs, assist with planned evacuations as needed. (Some disasters necessitate moving patients to a safer area.) g. Listen for the "All clear" announcement after a disaster drill. (This indicates that the drill is over.) 3. Evaluation. Compare actual outcomes and performances with disaster preparedness plan (usually a critique session is held). (Evaluation allows facility to examine whether plan accomplished goals and objectives; permits necessary changes to be made.)

Skill 23.7 Determining the Presence of Occult Blood in Stool Nursing Action (Rationale)

1. Refer to the health care provider's order. (Provides basis for care.) 2. Assemble supplies. (Organizes procedure.) • Nonsterile gloves • Additional PPE if indicated • Clean bedpan or specimen device for commode • Hemoccult card • Wooden applicator • Hemoccult developer • Laboratory requisition • Biohazard bag 3. Introduce self. (Decreases patient's anxiety.) 4. Identify patient. (Ensures procedure is performed with correct patient.) 5. Explain procedure. (Promotes cooperation and decreases patient's anxiety. It is advisable to label card before gathering specimen to prevent contamination.) 6. Perform hand hygiene and don nonsterile gloves according to agency policy and guidelines from the CDC and OSHA. (Reduces spread of microorganisms.) 7. Collect stool specimen. (See Skill 23.6, Steps 8 and 9.) (Provides stool for Hemoccult test.) 8. Follow steps on Hemoccult slide test: a. Open flap. (Begins test.) b. Use one end of tongue blade to gather stool, and smear very small amount of stool in box A. (Prepares slide.) c. Use other end of tongue blade to gather from another part of stool, and smear very small amount in box B. (Prepares second slide.) d. Close card and label, if you have not already done so (see Box 23.5). (Ensures accuracy in identification of specimen. e. Enclose specimen in biohazard bag and send to laboratory with requisition slip. (Ensures proper identification.) f. If testing is to be performed on the nursing unit, follow directions on the Hemoccult card. Document findings of occult blood in stool and results of quality control area. 9. Remove gloves, discard them in proper receptacle, and perform hand hygiene. (Reduces spread of microorganisms.) 10. Document procedure and observations (see Skill 23.2, Step 15). (Communicates collection of stool specimen.) 11. Perform patient teaching (see the Patient Teaching box). CDC, Centers for Disease Control and Prevention; OSHA, Occupational Safety and Health Administration; PPE, personal protective equipment. -Instruct the patient on how many stool specimens are ordered by the health care provider and how to collect a stool specimen. -Thenlabel the Hemoccult card appropriately (Box 23.5) and send it to the laboratory. -Some facilities permit nursing staff to perform reagent testing without sending the Hemoccult card to the laboratory.

Skill 23.4 Collecting a 24-Hour Urine Specimen Nursing Action (Rationale)

1. Refer to the health care provider's order. (Provides basis for care.) 2. Assemble supplies and equipment. (Organizes procedure.) • Specimen hat for bedpan, commode, or toilet; or urinal • Specimen container, including preservative of agency's choice, and label • Nonsterile gloves • Additional PPE if indicated • Requisition 3. Introduce self. (Decreases patient's anxiety.) 4. Identify patient. (Ensures procedure is performed with correct patient.) 5. Explain procedure. (Promotes cooperation and decreases anxiety.) a. Stress importance of collecting all urine for a 24-hour period. (Ensures validity of results of a 24-hour kidney function test.) b. Instruct patient not to allow tissue or fecal material to touch specimen or enter container. (Contaminates specimen.) 6. Post signs on bathroom door and near patient's bed to alert staff and patient to save all urine. 7. Perform hand hygiene and don nonsterile gloves according to agency policy and guidelines from the CDC and OSHA each time a specimen is collected and transferred to the large collection container. (Reduces spread of microorganisms.) 8. Have patient void just before the 24-hour specimen collection is to begin; discard this urine. (This urine was formed in urinary system before the study began.) 9. Place labeled container on ice if required. (Some agencies require refrigeration of all specimens. -Others advocate that the urine container be placed on ice. For some collection procedures, refrigeration is not always necessary, or a preservative may be used in 24-hour specimen collection device.) (Keeps the specimen cool, which decreases decomposition and odor.) 10. Save all urine for the 24-hour period; place each voided specimen into the larger container. (It is essential to save all urine; otherwise results will be altered.) 11. Instruct patient to void a few minutes before end of 24 hours; this urine is part of the 24-hour specimen. (This will empty bladder before the end of testing.) 12. Send collection to laboratory promptly; be certain label includes date and time specimen started (see Box 23.5). -If more than one container is necessary, make certain both are labeled and numbered. If patient is menstruating, be certain to note this on the requisition slip. (Ensures proper identification of specimen; ensures accuracy of results; prevents loss and potential delays in obtaining results.) 13. Document procedure and observations (see Skill 23.2, Step 15). (Communicates the patient care administered.) 14. Perform patient teaching (see the Patient Teaching box on specimen collection and diagnostic tests). *CDC, Centers for Disease Control and Prevention; OSHA, Occupational Safety and Health Administration; PPE, personal protective equipment.

Skill 23.6 Collecting a Stool Specimen Nursing Action (Rationale)

1. Refer to the health care provider's order. (Provides basis for care.) 2. Assemble supplies. (Organizes procedure.) • Stool specimen cup or container • Nonsterile gloves • Additional PPE if indicated • Bedpan, specimen device, or commode • Tongue depressor • Specimen container label • Laboratory requisition • Biohazard bag 3. Introduce self. (Decreases patient's anxiety.) 4. Identify patient. (Ensures procedure is performed with correct patient.) 5. Explain procedure to patient; make certain patient understands what is expected. (Promotes cooperation and decreases anxiety.) 6. Perform hand hygiene and don nonsterile gloves according to agency policy and guidelines from the CDC and OSHA.(Prevents transmission of microorganisms.) 7. Assist patient to bathroom when necessary. (Provides patient safety.) 8. Ask patient to defecate into commode, specimen device, or bedpan, preventing urine from entering specimen. (Prevents contamination of specimen.) 9. Transfer stool to specimen cup with use of a tongue blade, and close the lid securely. (Protects specimen.) 10. Remove gloves, discard them in proper receptacle, and perform hand hygiene. (Reduces spread of microorganisms.) 11. Attach requisition slip, enclose in a biohazard bag (see illustration for Skill 23.1, Step 11), label the bag (see Box 23.5), and send specimen to laboratory (it is necessary to take specimens for ova and parasites to the laboratory stat; it is acceptable to keep other stool specimens at room temperature). (Ensures proper identification of specimen; ensures accuracy of results; prevents loss and potential delays in obtaining results.) 12. Assist patient to bed. (Provides for patient safety and comfort.) 13. Document procedure and observations (see Skill 23.2, Step 15). (Communicates care administered.) 14. Perform patient teaching (see the Patient Teaching box). CDC, Centers for Disease Control and Prevention; OSHA, Occupational Safety and Health Administration; PPE, personal protective equipment.

Skill 23.3 Collecting a Sterile Urine Specimen via Catheter Port Nursing Action (Rationale)

1. Refer to the health care provider's order. (Provides basis for care.) 2. Assemble supplies. (Organizes procedure.) • Non-sterile gloves • Sterile specimen container with label • Clamp or rubber band • Sterile syringe and needle • Alcohol preparation • Requisition slip • Biohazard bag • Additional PPE if indicated 3. Introduce self. (Decreases patient's anxiety.) 4. Identify patient. (Ensures procedure is performed with correct patient.) 5. Explain procedure. (Promotes cooperation and decreases patient's anxiety.) 6. Perform hand hygiene and don nonsterile gloves. (Reduces spread of microorganisms.) 7. Catheter port collection: a. Clamp just below catheter port for about 30 minutes. (Allows for urine to collect for removal.) b. Return in 30 minutes; clean port with alcohol preparation. (Prevents needle puncture from causing contamination.) c. Insert needle into port at 30-degree angle and withdraw 5-10 mL of urine for a specimen. (Inserting needle at an angle prevents puncturing opposite side of tubing. Provides for specimen.) d. Place urine in sterile specimen cup. (Keeps specimen sterile.) e. Unclamp catheter. (Allows continuous urine flow to resume.) f. Label specimen and place in biohazard bag for transport to laboratory (see illustration for Skill 23.1, Step 11, and Box 23.5) and send to laboratory with requisition. (Ensures proper identification of specimen; ensures accuracy of results; prevents loss and potential delays in obtaining results.) 8. Remove gloves, discard them in proper receptacle, and perform hand hygiene. (Reduces spread of microorganisms.) 9. Document procedure and observations (see Skill 23.2, Step 15). (Records procedure and patient's response.) PPE, Personal protective equipment.

Skill 23.8 Collecting Gastric Secretions or Emesis Specimen Nursing Action (Rationale)

1. Refer to the health care provider's order. (Provides basis for care.) 2. Assemble supplies. (Organizes procedure.) • Nonsterile gloves • Additional PPE if indicated • Facial tissues • Emesis basin • Wooden applicator • Bulb syringe (60 mL) or catheter-tip syringe • Gastroccult test • Cardboard slide • Gastroccult developing solution • Laboratory requisition • Biohazard bag 3. Introduce self. (Decreases patient's anxiety.) 4. Identify patient. (Ensures procedure is performed with correct patient.) 5. Explain procedure. (Promotes cooperation and decreases patient's anxiety.) 6. It is advisable to label card before obtaining specimen to prevent contamination. 7. Perform hand hygiene and don nonsterile gloves according to agency policy and guidelines from the CDC and OSHA. (Prevents transmission of microorganisms.) 8. To obtain specimen of gastric contents through nasogastric (NG) or nasoenteral tube, position patient in high Fowler's position in bed or chair. (Keeps risk of aspiration of gastric contents to a minimum. Position relieves pressure on abdominal organs. If patient is nauseated, flat position in bed or one in which the patient is not able to sit straight sometimes causes abdominal discomfort.) 9. Verify NG tube placement (see Chapter 15). (Ensures aspiration of gastric contents.) 10. Collect gastric contents via NG or nasoenteral tube (see Chapter 15). (Only a small amount of specimen is needed for pH and occult blood testing.) a. Disconnect tube from suction or gravity drainage b. Attach bulb syringe or catheter-tip syringe. c. Aspirate 5-10 mL. d. Obtain sample of emesis with a 3-mL syringe or wooden applicator. e. Using applicator or syringe, apply 1 drop of gastric sample to test area of Gastroccult test slide. (Sample must cover test paper for test reaction to occur.) f. Follow directions on the Gastroccult card. 11. Close card and label, if you have not already done so (see Box 23.5). (Ensures accuracy in identification of specimen.) 12. Enclose specimen in biohazard bag and send to laboratory with requisition slip (see illustration for Skill 23.1, Step 11). (Ensures proper identification.) 13. Reconnect NG tube to drainage system, suction, or clamp as ordered. (NG tube serves to decompress abdomen by promoting drainage. Clamping sometimes is ordered to determine tolerance to stomach filling.) 14. Dispose of equipment; remove gloves and discard them in proper receptacle; and perform hand hygiene. (Reduces spread of microorganisms.) 15. Document procedure and observations. (Communicates collection of specimen and completion of test.) 16. Perform patient teaching (see the Patient Teaching box). CDC, Centers for Disease Control and Prevention; OSHA, Occupational Safety and Health Administration; PPE, personal protective equipment

Skill 23.5 Measuring Blood Glucose Levels Nursing Action (Rationale)

1. Refer to the health care provider's order. (Provides basis for care.) 2. Assemble supplies. (Organizes procedure.) • Sterile lancet • Automatic lancing device • Alcohol swab or soap and water (see Step 10) • Blood glucose meter • Testing strips for meter • Cotton balls • Nonsterile gloves 3. Introduce self. (Decreases patient's anxiety.) 4. Identify patient. (Ensures procedure is performed with correct patient.) 5. Explain procedure to patient. (Promotes cooperation and decreases patient's anxiety.) 6. Perform hand hygiene and don nonsterile gloves according to agency policy and guidelines from the CDC and OSHA. (Reduces spread of microorganisms.) 7. Remove cap from lancet by using sterile technique. (Maintains sterility of point.) 8. Place lancet into automatic lancing device according to instructions in operating manual. (Allows proper puncture of skin.) 9. Select site on side of any fingertip (for infant, use heel). (The side of the finger is less responsive to pain from puncture than are other sites.) 10. Wipe selected site with alcohol swab and discard swab. (Prepares site. Some manuals now specify washing hands with soap and water—no alcohol because it alters the test strip and dries the skin.) 11. Ask patient to hold arm at side 30 seconds. (Increases blood flow to site and allows site to dry.) 12. Gently squeeze patient's fingertip with thumb of same hand. (Increases blood supply to site.) 13. Hold lancing device. (Provides easy access to device.) 14. Place trigger platform of lancing device on side of finger and press. (Activates lancing mechanism.) 15. Stroke finger with downward motion; using cotton ball, wipe off first drop of blood that appears (if recommended by glucose meter manufacturer) and continue stroking. (Produces enough blood to cover test pad on test strip; producing and wiping first drop removes surface contaminants.) 16. While holding strip level, touch new drop of blood on finger to test pad. Do not allow finger (skin) to touch the test pad. Apply pressure to puncture site using cotton ball. (Causes blood to cover test pad without smearing and prevents alteration of test results.) 17. Begin timing as recommended by glucose meter instructions. Wait for numeric readout. (Ensures test accuracy.) 18. Remove lancet from device and discard. (Prevents accidental needlestick injury.) 19. Remove gloves, discard them in proper receptacle, and perform hand hygiene. (Reduces spread of microorganisms.) 20. Document procedure and observations (see Skill 23.2, Step 15). (Communicates patient care administered.) 21. Perform patient teaching (see the Patient Teaching box on specimen collection and diagnostic tests).

Box 10.11 Accidental Poisoning Interventions Action (Rationale)

1. When a poisoning occurs: a. Obtain an accurate history. (Identifies possible antidote[s] and method of treatment needed.) (1) Identify the route (e.g., injected, ingested, inhaled), type, and amount of poisonous substance(s) received. (2) Determine how long ago the poisoning happened. (3) Obtain a history of allergies, prescribed medications, medical problems, and general state of physical and mental health. b. Assess for changes in mental status and the presence of motor and sensory deficits. (Incomplete data possibly result in incorrect identification of patient's health needs.) c. Notify the poison control center and follow facility protocols (see the Patient Teaching box on nonuse of ipecac). (Treatment guidelines will be furnished.) d. Do not induce vomiting if poisoning is related to the following substances: household cleaners, lye, furniture polish, grease, or petroleum products. (Vomiting increases risk of internal burns.) e. Do not induce vomiting in an unconscious individual. (Vomiting increases danger of aspiration.) 2. Perform hand hygiene. (Reduces spread of microorganisms.) 3. Document procedure. (Note procedure and patient's response.) 4. Follow-up a. Continue to monitor vital signs and response to treatment. (Ongoing assessment is a part of the treatment.) b. Reduce the potential for accidental poisoning by doing the following: (1) Be aware of potentially poisonous substances (e.g., drugs, plants, and cleaning solutions). (2) Inform patients and families about how to handle a poisoning emergency. (3) Ensure that poisonous substances are labeled, locked, and out of the reach of children. (It is possible to greatly reduce the risk of accidental poisoning. Quick and appropriate action often decreases the ef ects of the poisoning.) c. Know where emergency instructions are located. (Procedures and guidelines for handling the emergency are outlined.) d. Know the number of the poison control center (National Poison Control Center: 1-800-222-1222; www.poison.org) or call 911 and be prepared to provide information about the poison. (The poison control center provides information needed to treat the patient, and all dispatchers of er referral assistance.) e. The immediate environment is safe from potential poisoning hazards when poisonous substances are labeled, locked, and properly stored. (Safety practices reduce the risk of accidental poisoning.) Special Concerns • Always follow drug administration policies and procedures. Have your dosage calculations checked, especially if a mixed or prepared drug is to be infused. • Keep informed of new medications and recommended dosages. • Properly label and store cleaning solutions and disinfectants. • Never use substances from unmarked containers.

CHAPTER 10 BOX 10.3: DESIGNING A RESTRAINT-FREE ENVIRONMENT

A weight sensitive alarm can be placed under a patient bed or in chair. When patient tried to get the alarm will go off. A chair alarm may be used to remind the patient or alert the staff when a patient who requires assistance when standing or ambulating tries to get up without assistance. TO DESIGN RESTRAINT-FREE ENVIRONMENT: -orient patient & family to surroundings; explain all procedures and treatments -Encourage family and friends to stay or use sitters for patients who need supervision -Assigned confused or disoriented patients to room near the nurses station. Observe these patients frequently -Provide appropriate visuality and auditory such as (radio, TV, clocks, family picture) -Eliminate bothersome treatments ASAP. FOR EX, discontinue tube feedings and begin oral feedings, as quickly as the patients conditions allows. -Use relaxation technique such as a massage -Institute exercise & ambulation schedule as the patients condition allows -Encourage participation in diversional activities (e.g. long-term care facilities typically have daily activities planned for the residents such as board games, movies, entertainment, -Maintain toileting routines -Consult w/ physical and occupational therapists to enhance patients abilities to carry out daily activities of daily living -Evaluate all medications patients receiving to determine whether the medication is having the desired therapeutic effect - conduct ongoing assessment & evaluation of patients care and patient ongoing response to care

Lifespan Considerations Older Adults

Admission, Transfer, and Discharge • The older adult admitted to the health care facility today is likely to be seriously ill. • In a normally alert and oriented older adult, medical conditions that necessitate admission to a health care facility often result in some level of disorientation. • Older adults, who often have some limitation of vision or hearing, are more likely to become agitated or fearful on admission to a health care facility. Many experience relocation stress. • Transfers, even within the facility, tend to be confusing and upsetting to older adults. • Hospitalized older adults frequently are concerned that they will be unable to return to their homes and will need institutional placement. • Appropriate referrals for home nursing, therapy, homemaking, home nutrition programs, or other services are essential for older adults • Older adult patients need health care professionals to converse with them slowly and clearly because hearing may be less acute and information may take longer to process. Do not rush older patients; wait for patients to answer questions rather than letting family members answer. • The change in environment and daily routine sometimes causes disorientation, loss of appetite, or reversal of sleeping waking patterns. • The stress of being in a health care facility sometimes is serious for the older patient because of a reduction in adaptive capacity. Helplessness, lack of control, and dependency often emerge, although a large degree of personal control possibly can be restored. • When an older adult patient is transferred to a new facility, the relocation is also stressful. Ensure that significant support people are still accessible, the patient is oriented thoroughly to new surroundings, the patient is allowed to take along important memorabilia, and the patient has an opportunity to make decisions about care.

CH.11 Assessment Patient Problem Expected Outcomes and Planning Implementation

Assessment -Assessment of the patient begins at admission. Subjective and objective data are collected during the assessment. Most facilities have a patient database form to assist in organizing these data (see Figs. 11.2 and 11.3). Facility policy mandates the time frame in which the admission assessment must be completed and what the RN and LPN/LVN responsibilities are concerning the admission process. -The nurse determines the patient's understanding of the reason for the transfer and gives explanations as necessary. The patient's condition must be assessed before transfer to determine the necessary method of transfer. The nurse receiving the patient after a transfer also assesses the patient because the patient is now his or her responsibility Patient Problem -Patient problems that the patient had before the transfer may still be current after the transfer. -The nurse's assessment helps in determining whether revisions to the care plan are necessary. -If the patient has been transferred from one facility to another, new patient problem statements are likely to be necessary. - As with admission, the patient commonly has the nursing problem of Anxiousness and Potential for Injury because of the new environment. Expected Outcome Transfer planning involves the development of patient-centered goals based on the nursing diagnosis formed. *Goal 1: Patient will voice an understanding of the reason for and the process involved with the transfer. *Goal 2: Patient will incur no injury during or after transfer Implementation Nursing interventions include the following: • Explain to patient and family the reason for the transfer, when it is to occur, and what procedures are planned. • Encourage questions (see Skill 11.2). • Confirm the patient understands the transfer and procedures through discussion and questions. • Inspect the patient's positioning in or on transport vehicle. • During final assessment, compare present data with previous findings. Evaluation *Goal 1: Patient states the reasons for the transfer. *Goal 2: Patient is secured into wheelchair or gurney and remains injury from

CHAPTER 10 ELECTRICAL HAZARDS RADIATION MERCURY SPILL

ELECTRICAL HAZARDS *Use of properly grounded and functional electrical equipment decreases the risk of electrical injury and fire. *Teaching patients and family how to reduce their risk of electrical injury in the home (e.g., prevention of electrical shock, avoidance of use of electrical appliances near water source, methods of grounding appliances, avoidance of operating unfamiliar equipment) is a responsibility of the home health nurse. RADIATION *Hospitals have strict guidelines on the care of patients who are receiving radiation and on the handling of radioactive materials. *To reduce the amount of exposure to radiation, the nurse must limit time spent near the source, keep as great a distance from the source as possible, and use shielding devices such as lead aprons. *Staff members who work near radiation on a routine basis are required to wear devices that track their cumulative exposure to radiation. After collection and processing of these devices, those staff members whose radiation exposure readings fall above a set limit frequently are assigned to an alternative work area away from radiation exposure. Follow-up medical attention often is mandated for them as well. *The community is put at risk for radiation exposure if radioactive waste products are disposed of or transported incorrectly. *Community health agencies, the Environmental Protection Agency (EPA), the Nuclear Regulatory Commission (NRC), the Department of Energy (DOE), and the Department of Transportation (DOT) have established specific, strict guidelines for the disposal of radioactive waste *If a radioactive leak occurs, these agencies institute measures to prevent exposure of surrounding *neighborhoods, to clean up radioactive leaks as quickly as possible, and to ensure that anyone injured receives prompt medical care. MERCURY SPILL *Exposures in a health care facility include broken thermometers or sphygmomanometers, although these devices are seldom used or allowed in most health care facilities. Mercury enters the body through inhalation and absorption through the skin. *Exposures that occur in a health care facility setting are usually brief but still have the potential to affect the brain or kidney *Although a mercury spill is not likely to occur in the health care setting, it is important to be aware of the facility's policy for proper cleanup of a mercury spill. *Mercury-containing equipment may be used in factory settings, so the occupational health nurse should be aware of mercury spill safety in case an employee comes into contact with mercury while on the job.

CH.23 Electrocardiography

Electrocardiography may be performed by nurses or by technicians specifically trained for this test. *The ELECTROCARDIOGRAM (ECG) is a graphic representation of electrical impulses generated by the heart during a cardiac cycle; it identifies abnormalities that interfere with electrical conduction through cardiac tissue. -This procedure usually is done at the patient's bedside, but sometimes it is done in a specially equipped laboratory. -The patient is assessed for knowledge level of the procedure; ability to understand and follow directions (this procedure requires patient to follow directions closely and assume proper positioning); ability to assume proper position; and vital signs (baseline) for comparison with postprocedure vital signs. -If the patient has large amounts of hair, it is sometimes necessary to clip or shave the hair at the lead placement site. -This promotes adherence of the leads (electrodes) to the chest and on the extremity. Skill 23.14 describes how the ECG is obtained.

CHAPTER 10 NURSING PROCESS FOR PATIENT SAFETY ASSESSMENT PATIENT PROBLEMS EXPECTED OUTCOMES & PLANNING IMPLEMENTATION EVALUATION

The role of the LPN/LVN in the nursing process as stated is that the LPN/LVN will: • Participate in planning care for patients based on patient needs. • Review patient's plan of care and recommend revisions as needed. • Review and follow defined prioritization for patient care. • Use clinical pathways, care maps, or care plans to guide and review patient care. ASSESSMENT : -Using the nursing process, the LPN/LVN can reduce the risk of injury to patients and staff. -Seek to determine which patients are at risk for injury as soon as possible. -Identify actual and potential threats to the patient's safety, the effect of the underlying illness on the patient's safety, and the risks for the patient's developmental stage. PATIENT PROBLEMS Identification of defining characteristics from the data directs the LPN/LVN's efforts to identify appropriate patient problems. -Include specific causes of a patient's safety risk among the patient problems to individualize nursing care. -For example, a patient with an unsteady gait is at risk for falling or injury. Patient problems related to patient safety could include the following: • Compromised Physical Mobility • Potential for Falling • Potential for Harm or Damage to the Body EXPECTED OUTCOMES & PLANNING *Perform planning and goal setting with the patient, the family, and other members of the health care team. *Goals and priorities are based on the risk to patient safety and health promotion. *The overall goal for a patient with a threat to safety is remaining free from injury IMPLEMENTATION Nursing interventions are designed to promote the safety of the patient in the home and the health care setting *These interventions include health promotions, developmental considerations, environmental protection, and education of family members or patient caregivers EVALUATION *Assess patient for signs and symptoms of injury and assess the environment for physical hazards continually throughout hospitalization. *Remove the hazards and modify the environment as necessary *Observe for correct application of SRDs. Observe skin, monitor pulses, assess the restrained body part every 30 minutes, and release the restrained body part every 2 hours. *Continuously monitor for complications of immobility.

Box 10.8 Centers for Disease Control and Prevention Health Care Personnel Vaccination Recommendations

VACCINE: Hepatitis B RECOMMENDATIONS IN BRIEF: If you do not have documented evidence of a complete hepatitis B (HB) vaccine series, or if you do not have an up-todate blood test that shows you are immune to hepatitis B (i.e., no serologic evidence of immunity or prior vaccination) then you should • Get the 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2). • Get anti-HBs serologic tested 1-2 months after dose #3. VACCINE: FLU INFLUENZA; RECOMMENDATIONS IN BRIEF: 1 dose of influenza vaccine annually. VACCINE:MMR (measles, mumps, and rubella) RECCOMENDATIONS IN BRIEF: If you were born in 1957 or later and have not had the MMR vaccine, or if you do not have an up-to-date blood test that shows you are immune to measles or mumps (i.e., no serologic evidence of immunity or prior vaccination), get 2 doses of MMR (1 dose now and the 2nd dose at least 28 days later). -If you were born in 1957 or later and have not had the MMR vaccine, or if you do not have an up-to-date blood test that shows you are immune to rubella, only 1 dose of MMR is recommended. -However, you may end up receiving 2 doses, because the rubella component is in the combination vaccine with measles and mumps. -For health care workers (HCWs) born before 1957, see the MMR Advisory Committee on Immunization Practices (ACIP) vaccine recommendations. VACCINE:Varicella (chickenpox) RECCOMENDATIONS IN BRIEF: -If you have not had chickenpox (varicella), if you have not had varicella vaccine, or if you do not have an up-to-date blood test that shows you are immune to varicella (i.e., no serologic evidence of immunity or prior vaccination) get 2 doses of varicella vaccine, 4 weeks apart. VACCINE: Tdap (tetanus, diphtheria, pertussis) RECCOMENDATION IN BRIEF: Get a one-time dose of Tdap as soon as possible if you have not received Tdap previously (regardless of when previous dose of Td was received). -Get Td boosters every 10 years thereafter. Pregnant HCWs need to get a dose of Tdap during each pregnancy. VACCINE:Meningococcal RECCOMENDATION IN BRIEF: Those who routinely are exposed to isolates of Neisseria meningitidis should get one dose.

CH.11 Home Care Considerations The Discharged Patient

• A patient who needs care at home after discharge from a health care facility often is referred to a home health agency (an organization that provides health care in the home; see Chapter 37). Typical services include skilled nursing care or simply assistance with activities of daily living. A health care provider's order is necessary for these services to be reimbursable from insurance or Medicare and Medicaid. A health history and initial assessment are performed, just as in the hospital. • Discharge from a home health agency involves the same kind of teaching as discharge from the hospital. The nurse is responsible to ascertain whether the patient or family is able to provide any care still needed. • Assess availability and skill of the primary caregiver; assess time availability, ability, willingness, emotional and physical stamina, and knowledge. • Perform the following assessments of immediate family members: attitude; ability to adjust to demands of patient care; impact of care demands on their lives; and impact of potential ongoing nature of the patient's needs. Family members who are not properly prepared for their role as caregivers are more likely to be overwhelmed by the patient's needs, resulting in caregiver role strain or readmission to a health care facility. • Assess additional resources that may be available to help, such as close friends. • Evaluate emergency preparations: for example, signaling device or phone is set up within patient's reach, and appropriate protocol is written out.

Box 11.4 Special Considerations for Transferring Patients

• Arrange transportation via ambulance with social services department, if the patient requires it, for transfer to another facility. Ensure that the necessary equipment is assembled to provide care during transport. • Be especially careful that all documentation is complete when the patient is being transferred to another facility. (A communication breakdown carries high potential to interfere with continuity of the patient's care.) • If the patient is being transferred to a different facility, be sure that all of the appropriate patient care measures have been performed (e.g., suctioning of airway, administration of prescribed medication, changing of soiled dressings, bathing of an incontinent patient, and emptying of collection devices).

Lifespan Considerations Older Adults Specimen Collection and Diagnostic Tests

• Because of the degree of agility necessary to collect a midstream specimen, greater assistance from the nurse or catheterization of the older person is sometimes necessary. It is important to explain the purpose of the procedure and provide privacy during specimen collection. • The use of medications (such as hypnotics and opioids) to reduce pain and anxiety during a procedure may impair respiratory and renal functioning. Monitoring vital signs and intake and output is necessary. • Decreased peripheral circulation sometimes makes it difficult to collect a specimen for blood glucose determination. Wrapping the hand in a warm, moist washcloth or massaging the hand for a few minutes may facilitate the procedure. • Changes in blood vessels make venipuncture more difficult in many older adults. Repeated sticks to obtain blood samples pose the risk of causing emotional and physical trauma to the older adult. Care should be taken to avoid multiple venipunctures. • Collect stool specimens from older adults by using a bedpan or specimen pan in the toilet or commode. • Assessment of certain specimens involves comparing results to a color chart. Older adults may have difficulty reading the color chart. • Many older adults need a written reminder placed on the bathroom mirror to collect all urine samples during a 24-hour specimen collection. • When obtaining a specimen through venipuncture, remember that some older adults do not need a tourniquet for this procedure. • Older adults have fragile veins that are traumatized easily during venipuncture. • If multiple procedures are necessary, schedule adequate rest time between tests. • Restlessness after a procedure in an older adult possibly indicates hypoxia or pain. Assess the patient thoroughly for the cause. • Many older adult patients take multiple medications. Keep in mind that alterations in administration schedules are sometimes necessary because NPO status may be required for certain diagnostic tests. • In older adults, slight variations in vital signs or in behavior often indicate impending problems; therefore skilled observations are critical. • Be aware that NPO status in an older adult patient may result in dehydration. • Many older adults have difficulty assuming various positions needed for specimen collection. Give assistance before and during procedure. • If a patient is confused, it is sometimes useful for an assistant to comfort the patient. • Older adults are at greater risk for skin impairment. Assess skin integrity of a patient after he or she has lain on the examination table. • Older adults often need additional clothing, slippers, and extra blankets to keep them warm in waiting rooms and examination rooms.

Box 23.4 General Guidelines for Specimen Collections

• Consider the patient's needs and his or her ability to participate in specimen collection procedures. • Recognize that collection of a specimen sometimes provokes anxiety, embarrassment, or discomfort. • Provide support for patients who are fearful about the results of a specimen examination. • Recognize that children require a clear explanation of procedures and often benefit from the support of parents or family members. • Obtain specimens in accordance with specific prerequisite conditions (e.g., fasting, nothing-by-mouth [NPO] status) as required. • Wear gloves when collecting specimens of blood or other body fluids, because it is not possible to identify everyone infected with bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B, or other pathogens. • Remove gloves, discard them in proper receptacle, and immediately perform hand hygiene; similarly cleanse other skin surfaces thoroughly if contaminated with blood or body fluids. • Collect specimens in designated containers, at the correct time, in the appropriate amount. • Properly label all specimens with the patient's identification; complete laboratory requisition form as necessary (see Box 23.5). • Most specimens are transported to the laboratory in a separate biohazard bag (see illustration for Skill 23.1, Step 11). • Deliver specimens to the laboratory within the recommended time, or ensure that they are stored properly for later transport. • Use aseptic technique in all collections to prevent contamination, which has the potential to render test results inaccurate. • Transport specimens under special conditions (e.g., iced specimens or special containers with preservatives) as required.

Chapter 10 Key Points

• Discuss safety measures for coping with violence in the workplace. • Prevention of falls, electrical injuries, fires, burns, and accidental poisoning is key to maintaining a safe environment. • Infants, young children, older adults, and the ill or injured patient are at risk for falling. • Proper patient orientation includes information about the use of the call light and bed controls. Place frequently used items within reach of patients. • Question all patients regarding allergies. Ask specifically about food and latex allergies. • Keep adjustable beds in the low position except when care is given. • Gait belts are an added safety feature to use when assisting patients to ambulate. • Consider designing a restraint-free environment before applying an SRD. • Ensure your priority is patient safety or the safety of others when applying an SRD. • SRD use has the potential to result in increased restlessness, disorientation, agitation, anxiety, and feelings of powerlessness • Once SRDs are applied to a patient, document the position of the device, circulation, physical and mental status, and ongoing need for the device. • When extremity SRDs are applied, place gauze or padding around the extremity and secure the ends of the ties to the bed frame, not to the side rails. • Remove SRDs at least every 2 hours and assess the skin. Do not leave the patient unattended during this time. • Know agency policy and procedures regarding SRD use and documentation. • Electrical accidents often are prevented by reporting frayed or broken electrical cords or any shocks felt when using equipment. • Fire-related injuries can be reduced by knowing the location of exits, fire alarm boxes, and fire extinguishers. • By remembering the mnemonic RACE (Rescue patients, sound the Alarm, Confine the fire, and Extinguish or Evacuate), you will be prepared when safety is threatened by a fire. • Participation in fire and disaster drills helps staff become familiar with established protocols. • Poison control centers are valuable sources of information when poisoning is suspected or has occured • Bioterrorism, or the use of biologic agents to create fear and threat, is the most likely form a terrorist attack will take. • Several national organizations, including OSHA, NIOSH, and the CDC, provide guidelines that help reduce safety hazards in the workplace.

Patient Teaching Specimen Collection and Diagnostic Tests

• Explain importance of collecting specimens on time and in the correct amount. • Explain importance of specimen collection (why it is performed). • Explain appropriate hand hygiene, and instruct patient to perform it before and after specimen collection. • Explain proper procedure for obtaining each specimen and preparing for each diagnostic examination. • Some specimen collection is completed outside the health care facility. Make certain patient understands how to complete the collection. - Ask patient to perform return demonstration of obtaining a specimen. Example: Skin puncture for measuring blood glucose level • If dietary restrictions are required, explain importance of adhering to direction. -Example: A meat-free diet often is ordered before a stool specimen for occult blood. • Explain results of test when applicable. Example: Complete blood cell count • Explain normal laboratory values when appropriate. Example: Blood glucose levels desired • Explain when to notify health care provider. Example: Elevated blood glucose level • Advise patient to perform oral hygiene after sputum collection as a comfort measure. • Explain the importance of drinking fluids to decrease thickness of mucus (this is helpful before sputum collection). • Ensure that patient understands the importance of obtaining an uncontaminated specimen. • Allow time for patient questions and provide answers. • Instruct patient to check with the primary health care provider about taking, or readjusting the time schedule for, prescribed medications on the day of the test or examination.

Box 11.1 Patient Room Orientation Orientation should include the following:

• Explanation of policies applicable to the patient • How to adjust the bed and the lights • How to call the nurse from the bed and the bathroom • How to operate the telephone and the radio • How to operate the television • How to use the intercom system if one is present • The location of lounge areas • The location of shower and bathroom facilities • The relationship of the room to the nurses' station

Box 11.2 Managing Emergency Admissions

• For the patient admitted through the emergency department (ED), immediate treatment takes priority over routine admission procedures. -After ED treatment, the patient arrives on the nursing unit with a temporary ID bracelet, a physician's order sheet, and a record of treatment. -Read this record and confer with the nurse who cared for the patient in the ED to gain insight and to ensure continuity of care. • Document any ongoing treatment, such as an intravenous infusion, in the nursing notes. -Obtain and record the patient's vital signs, and follow the health care provider's orders for treatment. -If the patient is conscious and not in great distress, explain any treatment orders. -If family members accompany the patient, ask them to wait in the lounge while assessing the patient and beginning treatment. -Permit them to visit the patient after the patient is settled in the room. -When the patient's condition allows, proceed with routine admission procedures.

Cultural Considerations Diagnostic Testing

• If the patient's language skills are inadequate for communication, assistance from interpreters, word signs, or charts may be necessary. • A patient who is modest and self-conscious about the body will need psychological preparation before some procedures and tests. • Patients may fear medical facilities because of language barriers, unfamiliarity with the facilities, or inadequate understanding of illness and treatment regimen. As a result, they may not comply with medical regimens. • Be aware that diverse age groups and sociocultural groups typically use different words to describe urine and stool. • Avoid cultural conflicts by communicating with the patient and respecting the ethnicity and individuality of each patient. -When patients have questions about diagnostic examinations, consult the agency's procedural manual or the designated department involved. -Maintain confidentiality when disclosing results from testing and diagnostic procedures. -Health care agencies are required to have and to follow policies regarding confidentiality of these records.

Cultural Considerations Admission, Transfer, and Discharge

• It should be noted that any reference to cultural practices among a specific culture are commonalities. Individuals within a culture may or may not possess the same practices, beliefs, or values. • Consider the decision-making process of the family. Some patients may need extra time for decisions regarding care and procedures if the family unit is important in this process. Other patients may refer to whomever is the authority figure for decision making. • Appalachians (found chiefly in the Eastern and some Southern states) often intertwine religion and culture; therefore, in the interests of cultural sensitivity, include the assessment of the patient's religious beliefs on admission to the health care system. Because some Appalachians tend to be fundamental and fatalistic in their religious beliefs, this belief must be considered an influencing variable. • Chinese Americans often value personal relationships over rules and procedures. -Be sure to consider the importance of the patient's loved ones when planning care. • Many Haitians believe that leaves have a special significance in healing. -The nurse may sometimes find leaves in the clothes and on various parts of the body. Leaves are thought to have mystical power related to regaining or keeping health. • Some Haitian American patients are more likely to feel they are receiving effective treatment when a nurse is seen. -In some Haitian cultures, a nurse is given more authority and status than a physician, and the patient may be more cooperative with directions given by a nurse. -When nursing measures are implemented (e.g., taking the patient's blood pressure), tell the patient what you are doing and that it is for the patient's benefit. Nursing actions are seen as caring and helpful. • Some Haitian Americans associate wheelchairs with sickness. Therefore the patient who is allowed to walk out of the hospital at discharge is more likely to feel that care has been effective. • A traditional Japanese belief is that contact with blood, skin disease, and corpses causes illness. Some Japanese also believe improper care of the body, including poor diet and lack of sleep, causes illness. • Orthodox Jewish patients observe sundown Friday to sundown Saturday as the Sabbath, which is a time of rest. -These patients may avoid the use of any electronic equipment during that time, so the nurse should find alternatives to the use of this equipment if possible.

Box 10.10 Fire Prevention Guidelines for Nurses

• Keep the phone number for reporting fires visible on the telephone at all times. • Know the agency's fire drill and evacuation plan. • Know the location of all fire alarms, exits, and fire extinguishers. • Use the mnemonic RACE to set priorities in case of fire: R Rescue and remove all patients in immediate danger. A Activate the alarm. Always do this before attempting to extinguish even a minor fire. C Confine the fire by closing doors and windows and turning off all oxygen and electrical equipment. E Extinguish the fire using an extinguisher. • Memorize the mnemonic PASS to operate the fire extinguisher: P Pull the pin to unlock the handle. A Aim low at the base of the fire. S Squeeze the handle. S Sweep the unit from side to side.

Box 23.1 General Guidelines for Diagnostic Examination (Rationales are provided in parentheses.)

• Know the patient's baseline vital signs. Some diagnostic tests are invasive procedures and have associated complications. (Changes from baseline vital signs provide early physiologic data about potential complications.) • Assess for the presence of tattoos. Older body art may have been prepared with dyes containing metal-based components. This may present issues with CT and MRI such as burning or skin irritation. Report findings to health care provider. • Know the patient's level of education. The nurse is required to teach the patient about diagnostic tests. (Knowing the patient's educational background enables the development of an individualized teaching plan.) • Determine the patient's awareness of actual or potential medical diagnoses. (Provides data about the patient's knowledge and perception of medical diagnoses.) • Perform a thorough nursing assessment, including assessment of the patient's cultural background. (Reveals abnormal findings, which can indicate or contraindicate a diagnostic test.) • Determine the patient's previous experience with diagnostic testing. (Patients who have had smooth, uncomplicated diagnostic tests are usually less anxious about a test. If a patient has had a complication from a diagnostic test, it is possible that the patient will require more pre-procedure education and support.) • Most agencies adhere to standard precautions; know agency policy. (Some facilities have policies that require all specimen containers of body substances to be placed in biohazard bags for transportation to various laboratories. Attach requisitions to specimen container.) • Know normal values of the test being performed and causes of deviations from these normal values. (Be aware that some deviations from normal values occur as a result of medications or dietary intake.) (Allows notification of the prescribing health care provider of end results in a timely manner.) • Refer to the policy manual for the facility's instructions for collection of each specimen during diagnostic examinations (see Table 23.1). • Many factors have the potential to contribute to dysrhythmias in association with diagnostic examinations, including medications such as digitalis and quinidine, hypertrophy of cardiac muscle, alcohol, thyroid dysfunction, coffee, tea, tobacco, electrolyte imbalances, edema, acid-base imbalances, and myocardial ischemia. (Patients with dysrhythmias are at risk for cardiac arrest. Be familiar with crash cart location, and be knowledgeable about emergency equipment, medications, and cardiopulmonary resuscitation [CPR].)

CH.23 Key Points

• Laboratory examinations of specimens of urine, stool, sputum, blood, and wound drainage provide important information about body functioning and contribute to the assessment of health status. • Patients who are given a clear explanation about the purpose of the specimen and how it is obtained will be more cooperative during its collection. • Prepare properly to ensure that the patient is ready for the test and to prevent prolonging the hospital stay because of inadequate test preparations. • Most people prefer that excretions be handled discreetly; therefore it is important to provide the patient with as much comfort and privacy as possible. • Health care professionals are obliged to take into consideration the patient's age and socioeconomic, cultural, and educational background when discussing and collecting laboratory specimens. • Wear gloves when collecting specimens of blood or other body fluids to prevent spread of bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B, and other pathogens. • Collect specimens in proper containers at the correct time and in the appropriate amount. • Label all specimens properly with the patient's identification, and complete laboratory requisition as necessary. • Most invasive diagnostic tests require a signed informed consent. • Wound cultures identify aerobic and anaerobic organisms. • Some diagnostic tests can be performed at the patient's bedside; the nurse's responsibility in this case includes caring for the patient and assisting the health care provider. • After diagnostic testing, provide care and teach the patient what to expect, including the outcomes or side effects of the test.

Box 23.2 Patient Evaluation for Iodine Dye Allergies

• Many types of contrast media are used in radiographic studies: for example, organic iodine and iodized oils. • Possible allergic reactions to iodinated dye vary from mild flushing, itching, and urticaria (hives) to severe, lifethreatening anaphylaxis (an exaggerated life-threatening hypersensitivity reaction to a previous encountered antigen; evidenced by respiratory distress, drop in blood pressure, shock, or a combination of these). In the unusual event of anaphylaxis, treatment consists of administration of drugs such as diphenhydramine (Benadryl), steroids, and epinephrine. Always have oxygen and endotracheal equipment on hand for immediate use. • Always assess the patient for allergies to the iodine dye before its administration. Inform the radiologist if an allergy is suspected. Patients who are allergic to shellfish are likely allergic to iodine-based dyes, because shellfish contain iodine. Non-iodine-based dyes often are used for these patients, or they are pretreated for the likelihood of an allergic reaction. The radiologist is likely to prescribe a diphenhydramine and steroid preparation to be administered before testing. Usually, hypoallergenic contrast media is used during the test. • After the x-ray procedure, evaluate the patient for delayed reaction to dye (dyspnea, rashes, tachycardia, urticaria). This usually occurs within 2 to 6 hours after the test. Treat with antihistamines or steroids, according to the health care provider's order. The American College of Radiology recommends that patients who have a prior documented reaction to contrast material be given a different contrast agent in combination with a premedication regimen if it is not possible to avoid using a contrast medium.

Nursing Process for Patient Admission The role of the LPN/LVN in the nursing process as stated is that the LPN/LVN will:

• Participate in planning care for patients based on patient needs • Review patient's plan of care and recommend revisions as necessary • Review and follow defined prioritization for patient care • Use clinical pathways, care maps, or care plans to guide and review patient care

Box 23.5 Correct Labeling Information

• Patient's full name (last name, first name, and middle name or initial) • Patient's identification number, bed number, room number, and medical record number • Patient's age, sex (male or female) • Health care provider's name • Date and time of specimen collection • Collector's name or initials • Test ordered • Most facilities have an electronic health record (EHR) label containing necessary information.

CH.23 Safety devices and features protect health care workers as follows:

• Provide a barrier between the hands and the needle after use • Allow or require the worker's hands to remain behind the needle at all times • Are simple to operate and necessitate little training to use effectively A less invasive method of collecting a blood specimen is called a capillary puncture. -It is used commonly to collect blood specimens from newborns and for glucose monitoring in all patients. -The procedure usually is performed by puncturing a vascular area on a finger, toe, or heel with a lancet, although sometimes a sterile needle is used instead.

Patient Teaching Patient Admission to the Health Care Facility

• Some teaching occurs during the admission process. -The nurse provides information regarding physical assessment findings, planned diagnostic procedures, and facility routines. -A formal teaching plan does not begin until assessment is completed and a care plan is developed. • In an emergency situation, instruct family members on the rationale for any procedures and routines to expect in the patient's care. • Teaching begins early in a patient's admission to a facility. Introduce instruction when the patient is able to be attentive and learn from the information. This is sometimes difficult in an acute care setting. Keep information specific, and focus on topics such as nature of the patient's illness, medications needed for treatment, and use of equipment in self-care (e.g., dressing, ambulatory devices). • Explain shift times and shift changes to the patient. • Consider how hospitalization influences an adult patient's occupational status. Will the illness seriously delay work that the patient is assigned to complete? Will there be a considerable delay before the patient can return to work? • Confirm the patient's understanding of transfer and procedures through discussion and questions. Explain the reason for the transfer, the time it is to occur, and what procedures are planned. • Be prepared to repeat information and instructions to the patient and significant others during the transfer of a patient because transfers often elicit feelings of anxiety. • Before the patient leaves the facility, provide for return demonstration of any skills taught. • Patients who have short stays in health care facilities often do not receive teaching until the day of discharge. • Anticipation of some prescriptions is not always possible. The day of discharge is sometimes the only opportunity to teach patient about medications. Some facilities have standardized information material that provides specific information about individual medications (see Fig. 11.4). • Obtain the help of social services or discharge planners to ensure the transfer of a patient to a long-term care facility or home care agency is appropriate in meeting the patient's physical and mental needs.

Coordinated Care Collaboration Specimen Collection

• The collection of urine specimens may be performed by unlicensed assistive personnel (UAP) who are familiar with aseptic and sterile technique and if allowed by the facility policy. UAP should be informed of when to collect a specimen and proper transport of the specimen. UAP are directed to immediately notify the nurse if appearance of urine a specimen is abnormal (e.g., presence of blood, cloudiness, or excess sediments). • The collection of stool and emesis for testing may be performed by UAP. -However, assessing the significance of test results requires skills of critical thinking and knowledge application that are unique to a nurse. Delegation of the analysis of test results to UAP is inappropriate. UAP are directed to notify the nurse immediately if results are positive so that testing can be repeated by the nurse. • The skills used to obtain and test gastric secretions from an NG or nasoenteral tube require the critical thinking and knowledge application unique to a nurse. Delegation of these procedures to UAP is inappropriate. • Obtaining and testing the blood glucose level after skin puncture can be performed by UAP who are certified to perform the procedure. It is necessary to assess the patient to determine whether his or her need for glucose monitoring is appropriate for delegation. If the patient's condition changes frequently, this procedure should not be delegated to UAP. • Phlebotomy staff, registered nurses (RNs), and licensed practical nurses/licensed vocational nurses (LPNs/LVNs) are permitted to obtain venipuncture samples in accordance with agency policy and their state's nurse practice act. -The LPN/LVN should consult agency policy to determine who is permitted to draw blood. • The skills used to obtain throat, nasal, and nasopharyngeal cultures require the critical thinking and knowledge application unique to a nurse. Delegation of these procedures to UAP is inappropriate. • Collection of expectorated sputum specimens can be performed by UAP. -However, the skills used to collect a sputum specimen through sterile suction require the critical thinking and knowledge application unique to a nurse. -Delegation of this procedure by suction to UAP is inappropriate. • Obtaining a wound culture requires the critical thinking and knowledge application unique to a nurse. Delegation of this procedure to UAP is inappropriate. • UAPs are permitted to transport stable patients to the testing department. Monitoring vital signs after the procedures is possible to delegate to a UAP, but assessment is not. Monitoring during intravenous conscious sedation (IVCS) requires the critical thinking and knowledge application unique to a nurse. Delegation of this task to UAP is inappropriate • Diagnostic studies requiring the use of a contrast medium subject patients to potentially life-threatening complications. Direct the UAP to notify the nurse immediately of any complications (e.g., allergic reactions, bleeding, respiratory distress, or coughing up blood). • Electrocardiography often is performed by technicians specifically trained for this test. Nurses with advanced training often monitor patient electrocardiographic patterns continuously in an intensive care setting, in the emergency department, or on units where telemetry is used. It is acceptable for UAP to monitor the vital signs of stable patients. UAPs must notify the nurse immediately of complaints of chest pain or altered vital signs.

CH.23 Collection Methods *Vacutainer Collection Tubes Types of collection tubes. Labeling collection tubes. *Tourniquet

*Using a syringe andattached needle is one method. -Another is the use of a Vacutainer. With the syringe method, blood is drawn into the barrel by pulling back on the plunger. -After the blood is collected, it is transferred to a test tube. The Vacutainer system has a needle, a holder for the needle and tube, and one or more evacuated tubes with rubber stoppers (Fig. 23.5A). -In evacuated tubes, air is removed, which creates a vacuum. When a vein is punctured, blood flows into the tube (see Fig. 23.5B). -After a tube fills, it is removed from the holder, and a new tube is attached without withdrawal of the needle from the vein. -The Vacutainer system thus allows the collection of multiple blood specimens with one venipuncture. -Blood collection tubes come in different sizes. -The blood tests ordered determine the amount of blood needed. -Some tests require additives that are added to the collection tube and mix with the blood. -Some additives preserve the blood until testing; others aid in separating the blood cells from the plasma for testing. -In the VACUTAINER system, the tubes contain the necessary additives. -The rubber stoppers are color coded. Red, lavender, blue, green, gray, and yellow are common colors. -The color coding signals the type of additive, the amount of blood to collect, and the recommended blood tests to perform on the sample. -Color coding sometimes varies, and so agency procedures must be followed. -After the collection tubes are selected, they are placed in order of use. -The order is important for preventing tube contamination. - Different tubes have different additives. - The additive from one tube should not be transferred inadvertently to another through use in the wrong order. -Agency policy should be followed for the order in which to collect blood specimens. Labeling collection tubes. -After collection is completed and before the blood specimens are sent to the laboratory, the collection tube is labeled with the patient's identifying information (Fig. 23.6). -Labeling is necessary to make sure that the right tests are done for the right patient. -When wrong test results are reported for the patient, the wrong treatment will be given, and the patient is at risk for serious harm. -Box 23.5 discusses a patient's identifying information. Labels generally are generated using data stored in the patient's electronic health record (EHR). Selecting a Venipuncture Site -The basilic and cephalic veins in the antecubital space are the most common venipuncture sites (Fig. 23.7). -These veins are large and near the skin surface. Hand veins offer alternative sites. -Select the arm to be used before selecting the vein. -An arm on the side of a mastectomy, with a paralysis, with a hemodialysis access site, or with an IV site should not be used. -An arm with existing hematomas or skin impairment also should be avoided. A tourniquet is applied to the arm when the vein selection process begins (Fig. 23.8A). -A tourniquet is a constricting device traditionally applied to control bleeding. -It prevents arterial blood flow to the part below the TOURNIQUET and prevents venous blood from returning to the heart. -The veins fill with blood and distend, which makes them firmer and easier to see and palpate (see Fig. 23.8B); thus the tourniquet is useful for venipuncture. -The TOURNIQUET is removed after the blood specimen is collected but before the needle is withdrawn from the vein. -The tourniquet is applied 2 to 4 inches (5.08 to 10.16 cm) above the elbow. -One end is crossed tightly over the other, and then the upper end is tucked under the band to form a half bow (see Fig. 23.8A). -This allows for quick release. When used for obtaining a venous specimen, tourniquets prevent venous blood flow but not arterial blood flow. -Make sure the tourniquet is tight enough that the veins distend; however, the radial pulse should be palpable. -If the radial pulse is not detected, release and reapply the tourniquet. -The tourniquet should be in place for no longer than 1 to 2 minutes. -To select a vein in the antecubital space, a tourniquet is applied 2 to 4 inches (5.08 to 10.16 cm) above the elbow. -The patient is asked to open and close the fist. -While the patient's fist is closed, look and palpate for a vein. -A vein that is suitable for venipuncture is straight, feels full and firm, and is elastic and springs back after palpation (see Fig. 23.8B). -Veins with the following characteristics are avoided: • Small and narrow veins are usually fragile. • Weak veins are soft and do not rebound. • Sclerosed veins are hard and rigid. • Veins that are easy to roll when palpated are often difficult to pierce successfully with the needle. Perform the venipuncture (Skill 23.13). After the needle is withdrawn from the vein, apply pressure to the site to prevent bleeding. The patient should not bend the arm, because this may cause the formation of a hematoma.

Skill 23.2 Collecting a Midstream Urine Specimen Nursing Action (Rationale)

1. Refer to the health care provider's order. (Provides basis for care.) 2. Assemble supplies (see illustration). (Organizes procedure.) • Antiseptic wipes • Sterile specimen container with label • Non-sterile gloves • Additional PPE if indicated • Biohazard bag • Requisition slip 3. Introduce self. (Decreases patient's anxiety.) 4. Identify patient. (Ensures procedure is performed with correct patient.) 5. Explain procedure. Assess patient's understanding of procedure. (Decreases patient's anxiety, promotes patient's cooperation, and ensures accuracy.) 6. Prepare patient for procedure. (Facilitates procedure.) a. Close door and pull curtain. (Provides privacy.) b. Varying degrees of assistance are required by patients who are seriously ill, have difficulty standing, or are disoriented. Some patients need assistance in the bathroom, whereas others require a bedpan or urinal in bed. Older patients may have difficulty maintaining balance and raising or lowering toilet seats. 7. Perform hand hygiene and don nonsterile gloves. (Reduces spread of microorganisms.) 8. Allow the patient to cleanse self with the antiseptic wipes if the patient is able; instruct female patients to separate the labia well and cleanse the perineum in an anterior-toposterior direction. Instruct male patients to cleanse in a circular motion from the meatus outward; if the penis is uncircumcised, the foreskin should be retracted. If the patient is unable to cleanse the area, provide assistance. (Provides a cleaner specimen and prevents organisms at or near the meatus from being washed into the specimen. Cleansing from anterior to posterior aspect prevents microorganisms from the anus from entering through the urinary meatus.) 9. Guide female patients to straddle bedpan or toilet, if possible, to allow for labial spreading and to keep the labia separated during voiding. Request that patient (1) begin by voiding about 30 mL into the toilet, and then position the sterile specimen container, making sure the sides of the labia do not touch the container or each other; (2) without stopping flow, void a small amount into specimen cup; (3) remove cup and, without stopping flow, finish voiding into toilet. (Collects midstream urine specimen appropriately. The first 30 mL, containing the organisms washed away from the meatus, is discarded.) 10. Secure lid on container without touching the inside of the lid. (Prevents spillage and contamination.) 11. Remove gloves, discard them in proper receptacle, and perform hand hygiene. (Reduces spread of microorganisms.) 12. Cleanse and return toilet seat collector, or empty and flush bedpan or urinal if any of these are in use. (Prepares equipment for next use.) 13. Label specimen appropriately. Place in biohazard bag for transport to laboratory (see illustration for Skill 23.1, Step 11). (Ensures proper identification of specimen; ensures accuracy of results; prevents loss and potential delays in obtaining results.) Follow agency policy (see Box 23.5). 14. Ensure prompt delivery to laboratory with proper requisition slip (many facilities mandate delivery within 1 hour). (Ensures a fresh specimen for testing and prevents loss of specimen.) 15. Document procedure. (Provides communication of procedure and patient's response.) • Time • Type of specimen collected • Sent to laboratory with requisition • Patient's response (if appropriate) 16. Provide patient teaching (see the Patient Teaching box on specimen collection and diagnostic tests). PPE, Personal protective equipment.

When does discharge planning begin?

the moment a patient is admitted to a health care facility

10.9 Fire Sfaety Interventions & Safe Evacuation of Patients-Con't..

(e) Place your arms under the patient's arms, and clasp your hands over the patient's chest. (f) Back slowly down the stairs, constantly maintaining close contact with the patient, keeping one leg against the patient's back. (7) When considering the two-person swing, and all evacuation methods, take into consideration the patient's size and weight. (a) Two staff members grasp each other's forearms to form a seat for the patient to sit in (Fig. 10.2A). (b) Other personnel lift the patient into the seat formed and patient is removed from area (see Fig. 10.2B). 2. Follow-up a. Listen to the "All clear" announcement after a drill or follow specific instructions from the fire department or supervisor regarding the return of patients. ("This area is safe for patients and staff.") b. Reduce the potential for fire-related injuries by doing the following: (1) Follow and enforce the smoking policy. Most facilities have adopted a No Smoking policy to promote a smoke-free environment for patients and employees. (2) Know the location of fire alarm boxes and type of fire extinguishers available. (3) Know the location of the fire exits. (4) Be familiar with the hospital fire safety program and protocols for evacuation. (5) Keep hallways free of unnecessary supplies, furniture, and other obstacles. (6) Check to see that electrical equipment is operating safely. (Planning saves valuable time and improves overall performance.) c. Participate, when possible, in fire drills. Fire safety education programs are necessary to meet the requirements of accrediting agencies, such as The Joint Commission. (Learning experiences are provided through participation in fire drills and formal critiques of the activity.) 3. Evaluation a. The immediate environment of the patient is safe from potential fire hazards. (Fire safety practices help prevent fires.) b. In the event of a fire, established protocols are followed. (The emergency will be handled rapidly and appropriately.)

WORKPLACE SAFETY

*Active shooters are also a concern in the health care setting. An active shooter is defined by the US Department of Homeland Security (2008) as "an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims." *It was recognized that active shooter guidelines were geared toward schools, government, and business settings but not toward the health care setting. *The increased use of lasers in the health care setting requires specific safety precautions because a laser has the potential to cause skin and eye injury and start a fire, if used improperly *Therefore eye protection is necessary for the patient and the staff working with the laser. Personnel involved with laser-based procedures wear specially designed eyewear. Because a laser beam generates an enormous amount of energy, dry combustibles in the surgical field can accidentally ignite, posing a threat to the patient and staff. *Ensure that water and a halon fire extinguisher are readily available. For prevention of injury to patients, staff, and equipment, sufficient and appropriate fire extinguishers must be located in magnetic resonance imaging (MRI) areas. *Hospital workers frequently are exposed to blood and body fluids, contaminated needles, radiation, and vaccine-preventable diseases. Immunization programs help protect hospital personnel and, in turn, patients at risk of being infected by hospital personnel. *These recommendations also apply to student nurses because they are fulfilling clinical requirements in health care facilities. *Needlesticks are another source of potential injury to health care personnel. Intravenous tubing and accessories that do not require needles are available, thus reducing the risk of needlesticks. *A stray needle lying in bed linens or carelessly thrown into a wastebasket is a prime source of exposure to bloodborne pathogens. Overfilling a sharps container is another source of needlestick injuries. *Bloodborne diseases that can be transmitted through accidental needlesticks include hepatitis B and C and HIV. Current guidelines and recommendations by the CDC and Occupational Safety and Health Administration (OSHA) and safety needle devices have reduced dramatically the number of health care worker (usually nurses and laboratory technicians) needlestick injuries. *Studies by the CDC indicate a 95% reduction in health care workers (HCWs) infected with hepatitis B (HBV) from needlesticks from 1983 to 2001; 400 HCWs were infected in 2001 compared with 17,000 in 1983 *Current statistics indicate that the rate of HIV transmission to a health care worker from a needlestick is approximately 0.3% and 0.1% if contaminated blood is exposed to mucous membranes (i.e., the nose, eye, or mouth) of the health care worker. For hepatitis B, if the health care worker is not immunized the statistics indicate that the rate of transmission from a needlestick injury is 6% to 24% and 1% to 8% for hepatitis C *Housekeeping responsibilities include eliminating all unnecessary combustible material; - and maintenance responsibilities include ensuring the proper functioning of fire protection devices, such as alarms, extinguishers, and sprinklers. It is mandatory to identify, light, and unlock exits. *All employees need to know the telephone number or procedure for reporting a fire and the location of the nearest alarms and firefighting equipment. In addition, health care workers must know their roles in the overall hospital evacuation plan. Checking for fire hazards on an ongoing basis is a must *An important element in any fire safety program is an understanding of what type of fire extinguisher to use on different types of fires. *Use the appropriate fire extinguisher for each type of fire: • Paper, wood, and cloth fires require a type A fire extinguisher. • Flammable liquid fires, such as those caused by grease and anesthetics, require a type B fire extinguisher. • Electrical fires require a type C fire extinguisher. • Fire extinguishers marked ABC are acceptable for use on any type of fire Knowledge of which type of extinguisher is on the unit before a fire occurs is vital. Most fire safety programs afford health care workers the opportunity to handle the different types of fire extinguishers. * In the event of a patient on life support systems may be need a manual respiratory supportw/ an Ambu bag *Notify the maintenance department of any defects in the equipment, and report any shocks felt while using equipment. The nurse must enforce no smoking policies.

1. What is a safety reminder device?; RESTRAINTS 2. What needs to be done prior to using SRDs? 3.How do you assess your patient when using SRDs? 4. How often does the SRD need to be renewed?

1. a Safety Reminder Device (SRD), or restraint, is any of the numerous devices used to immobilize a patient or part of the patient's body 2. all other alternatives to keeping the patient safe and an order from the physician must be obtained 3.rremove the SRD every 2 hours for 30 min to assess the patient's skin 4. every 24 hours *wrist restraints, mittens *needs to have a doctors order cant give a restraint to patient for no apparent reason * if side rail is up, 4 up, considered restraint

culture and sensitivity

A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection.

difference between aseptic technique and surgical asepsis

Asepsis or aseptic means free from pathogenic microorganisms. ... Some authors have made a distinction between surgical asepsis or "sterile technique" used in surgery and medical asepsis or "clean technique" that involves procedures to reduce the number and transmission of pathogens.

Box 10.6 Mercury Spill Cleanup Procedure

In the event of a mercury spill, follow these steps while waiting for trained personnel to arrive: 1. Evacuate the room except for a housekeeping crew (if available). 2. Ventilate the area. Close interior doors and open any outside windows. 3. DO NOT VACUUM THE SPILL. After the mercury has been recovered: 4. Mop the floor with a mercury-specific cleanser (see agency policy). 5. Dispose of collected mercury according to local environmental safety regulations.

Box 10.13 Variations for Disaster Planning: Nursing Home

Nursing home residents also sometimes need evacuation and relocation in the case of an internal disaster. The successful nursing home disaster preparedness plan, like those for hospitals, outlines the sequence of events to be followed: • Residents need some type of identification (picture identification or identification bracelet, such as those used in the memory support unit for patients diagnosed with Alzheimer's disease). • At the designated triage site, nurses decide where residents will go. • Residents sometimes need admission to a hospital or other building, such as a school or church, for temporary shelter and care. • The disaster plan must include instructions and guidelines for what is to be done after the relocation is completed. • Notification of families and physicians is critical. • A log is kept to document events. List the name of the patient, who and how transported, and where patient was sent so family and physicians are aware of the patient's location and transfers as they occur.

Nursing Care Plan 10.1 Patient Safety This care plan has been adapted for the patient who is at risk for injury. Patient Problem Potential for Harm or Damage to the Body, related to disease process, weakness, lack of mental acuity, medications, or age

Patient Goals and Expected Outcomes: Patient or caregiver will demonstrate knowledge and understanding of potential hazards and will practice preventive measures or will be protected from injury as necessary during hospitalization Nursing Interventions: Assess the following: 1. Patient's mental, visual, and auditory acuity (fall assessment, see Box 10.2). 2. Patient's level of consciousness. 3. Patient's ability to perform activities of daily living (ADLs), exercise, and ambulation. -Prevent clutter; wipe up spills; provide adequate lighting. Orient patient to surroundings and assess effectiveness of reality orientation. -Maintain side rails (depending on facility policy) and bed alarm. -Maintain bed in low position when care is not being given. Place patient in room close to nurses' station. Assist patient with ADLs as needed. -Determine the need for assistive devices such as a walker, cane, or wheelchair. -Obtain medication history and administer medications according to agency policy. -Document nursing interventions for medications and monitor side effects. -Offer fluids q 2 hr while awake unless contraindicated. Offer use of commode, bedpan, or urinal q 2 hr while awake. Evaluation: -Patient demonstrates understanding of potential health hazards. -Patient practices injury prevention for self. -Patient remains injury free. Critical Thinking Questions 1. The nurse walking down the hall hears a patient calling out for help. The nurse assesses the situation and realizes that the patient does not remember how to use the call light. What factors possibly contribute to the patient's inability to remember, and how should the nurse teach the patient to use the call light? 2. The nurse enters the patient's room to answer the call bell and sees the patient frantically pointing to the trash can next to the bed. The nurse smells smoke and sees small flames. What should be done to help prevent fires, and what should the nurse do in this situation?

BOX 10.7 WORKPLACE ENVIRONMENT The term workplace violence refers to any intense extreme behavior used to frighten, intimidate, threaten, or injure a person or damage or destroy property. Legally, if by either threat or gesture, someone causes a person to fear being struck, an assault has occurred. Any unwelcomed physical contact from another person is battery. In other words, one does not have to be physically "hurt" to get protection under the law. According to the most recent statistics from the US Safety and Health Topics in 2010 more than 11,300 assaults occurred against health care and social assistance workers, with nearly 19% occurring in nursing and residential care facilities. Most workplace violence, including in the health care setting, results in nonfatal injuries Sometimes nurses do not report a violent incident because they are unsure what constitutes violence, do not know of the requirement to report the incident, or do not know whom to inform; sometimes they do not file a report because the injuries do not require emergency treatment or time off from work.

Risk factors for work-related assaults in health care agencies include the following: • On-site presence of patients, families, friends, and coworkers in the possession of handguns • Patients who are hospitalized and under police custody at the same time (people arrested or convicted of crimes) • On-site presence of acutely disturbed and violent people seeking health care • On-site presence of mentally ill people who do not take medicine, do not receive follow-up care, and are not hospitalized unless they are an immediate threat to themselves or others • On-site presence of upset, agitated, and disturbed family members and visitors • Long emergency department waits that increase a person's agitation and frustration • On-site agency pharmacies that are a source of drugs and therefore a target for robberies • Gang members and substance abusers having access to agencies as patients or visitors • Staff being alone with patients during care or transport to other agency areas during examination or treatment • Low staffing levels during meals, during emergencies, and at night • Poorly lighted parking areas or distant parking areas • Lack of staff training in recognizing and managing potentially violent situations OSHA provides guidelines for violence identification and prevention programs with a goal of eliminating or reducing employee exposure to situations that have potential to cause death or injury. *Prevention strategies are developed and implemented. Furthermore, employees are required to receive safety and health training per facility protocol. The nurse's responsibility in violence prevention programs include the following: • Understand and follow the workplace violence prevention program. • Understand and follow safety and security measures. • Voice safety and security concerns. • Report violent incidents promptly and accurately. • Serve on health and safety committees that review incidents of workplace violence. • Take part in training programs that focus on recognizing and managing agitation, assaultive behavior, and criminal intent. • Practice the following safety measures when dealing with agitated or aggressive people: • Stand away from the person. Judge the length of the person's arms and legs. Stand far enough away that the person will not be able to hit or kick you. • Position yourself close to the door. Do not allow yourself to become trapped in the room. • Note the location of panic buttons, call bells, alarms, closed-circuit monitors, and other security devices. • If you wear your identification badge around your neck, be sure it will break away if pulled. • Keep your hands free. • Stay calm. Talk to the person in a calm manner. Do not raise your voice or argue, scold, or interrupt the person • Do not touch the person. • Tell the person that you will get the supervisor to speak to the person. • Leave the room as soon as you are able. Be sure the person is safe. • Notify the supervisor or security officer of the situation. • Complete an incident report according to agency policy.

CH.23 Collecting Specimens From the Nose and Throat

When collecting nose and throat specimens, perform the following: • Assess the condition of and drainage from nasal mucosa and sinuses. (Reveals physical signs that indicate possible infection or allergic irritation.) • Determine whether patient has experienced postnasal drip, sinus headache or tenderness, nasal congestion, or sore throat. (Further clarifies nature of problem.) • Assess the condition of posterior pharynx (see Chapter 13). • Assess for systemic indications of infection, including fever, chills, and malaise. • Do not let the culture swab come in contact with the buccal mucosa, tongue, or teeth, because such contact contaminates the specimen.