Chapter 23 Treas

prevent take home toxins

Most preventive measures for toxins apply to the workplace. However, you can teach clients who are at risk to remove work clothing and to shower, preferably in an open-air shower, before leaving work. If shower facilities are not available, patient advocacy may be appropriate. (To learn about advocacy, see Chapters 41 and 43.) If exposed workers have not showered at work, they should remove their clothing and shower immediately before entering their home. When handling contaminated clothes or objects, they should wear gloves to reduce the risk of skin transmission. Laundering may not be effective in removing certain toxins in clothes.

motor vehicle accidents

Motor vehicle accidents (MVAs) are a leading cause of accidental death in the United States. Teens and young adults aged 15 to 29 years accounted for 38% of the Emergency Room visits for treatment of injuries following an accident (Bergen, Peterson, Ederer, et al., 2014). Older drivers are at higher risk of being injured or killed in a car crash. Every day, on average 500 people over age 65 are injured in an automobile accident.

planning interventions/implementation

NIC standardized interventions will be determined by the nursing diagnosis you use. A few examples of NIC interventions include the following: Aspiration Precautions Dementia Management Emergency Care Environmental Management: Safety Fall Prevention First Aid Home Maintenance Assistance Sports-Injury Prevention: Youth Surveillance: Safety To see the more than 50 interventions in the NIC Safety domain (category),

What are never events?

Never events, also known as Serious Reportable Events (SREs), are healthcare-acquired complications that (1) can cause serious injury or death to a patient and (2) should never happen in a hospital. The list of never events has been expanded over time to mean events that are (1) clearly identifiable and measurable, (2) serious, and (3) usually are prevented. You can gain insight into healthcare facility hazards by examining the following list of never events (National Quality Forum, 2011). Be aware that this list may grow and change more over time. Foreign object (such as a sponge) left in patients after surgery Air embolism Administering the wrong type of blood Severe pressure injuries Falls and trauma Infections associated with urinary catheters Infections associated with intravenous catheters Symptoms resulting from poorly controlled blood sugar levels Surgical site infections following certain elective procedures (e.g., certain orthopedic surgeries, bariatric surgery for obesity) Deep vein thrombosis or pulmonary embolism following total knee and total hip replacement procedures. The Institute for Healthcare Improvement (IHI) (n.d.b), an independent, not-for-profit organization, recently completed the 5 Million Lives Campaign as a follow-up to its 100,000 Lives Campaign. The IHI Campaign recommended healthcare changes to reduce morbidity and death in American healthcare. At least three of the 5 Million Lives goals supported the list of never events: Prevent adverse drug events, prevent central line infections, and prevent surgical site infections. To read the entire list of recommendations and the results of the campaign,

fatal incidents of suffocation

Nonfood items (e.g., latex balloons and plastic bags) cause the majority of suffocation deaths in young children.

chronic effects of mercury exposure

Numbness or tingling of the hands, lips, and feet; behavior and personality changes Other Fatigue, weakness, anorexia, weight loss, and gastrointestinal disturbances

prevent home fires

Nursing interventions include teaching families how to prevent fires and measures to take should a fire occur. Stress the following: Have a warning system. Have working smoke alarms and change batteries at least every six months. Keep a phone near the bed or chair for people who have limited mobility. Have an escape plan. Develop a fire escape plan and practice it at least twice a year. Keep a rope or other type of ladder for escape from rooms above ground level. Have a fire extinguisher in the home and know where it is located and how to use it. Check fire extinguishers regularly and replace them when they become outdated. Have a preventive frame of mind. When decorating Christmas trees and the exterior of your home, always use fire-safe lights. Do not leave old light sets hung on the outside of your home year after year. Always unplug Christmas tree lights before leaving home and remove the Christmas tree from the home when it becomes dry. Other cautions include the following: Never leave burning candles unattended. Do not use candles near curtains or other flammable materials. For charcoal grills, use only charcoal starter fluids designed for barbecue grills. For gas grills, be sure that the hose connection is tight and check hoses for leaks. Store flammable materials (e.g., oil-soaked rags) in appropriate containers (e.g., metal container with a tight lid. Do not smoke, especially in bed—and especially in a home where oxygen is in use. Never use an open flame when oxygen is in use. Promote electrical safety in the home. Make sure electrical outlets have covers. Routinely inspect electrical appliances for damaged cords; replace frayed cords. Do not place electrical cords under carpets and make sure cords do not hang off tables and countertops. Know what to do if a fire occurs. The actions you take to extinguish a small fire depend on the source of the fire. For example, never pour water on a grease fire and never discharge a fire extinguisher into a pan fire. If there is an oven fire, turn off the heat and keep the door closed. If there is a microwave fire, keep the door closed and unplug the microwave. KEY POINT: If the house is on fire, follow your escape plan. Crawl or stay low to the floor as much as possible to avoid the smoke.

Culture of safety

A positive nursing unit culture helps improve patient outcomes. Culture is a way of thinking, behaving, or working in a place or organization. KEY POINT: In a culture of safety, nurses practice in an environment where all staff work together to create a safe unit, disclose errors without fear, and address any safety concerns. Key components of a culture of safety include (Helbling & Huwe, 2015): team empowerment communication transparency accountability

biological hazards

As a nurse, you will place a high priority on the biological safety of patients. Institutionalized patients are at especially high risk from infectious microorganisms, some of which are highly resistant to antibiotics. To learn about or review healthcare-related infections, asepsis, and infection control, refer to Chapter 22.

Extinguisher Classifications

Extinguisher Classifications You should know where the extinguishers are located in your facility and know how to use them. Most agencies use multipurpose (Class ABC) extinguishers. Class A Wood, paper, rubber, textiles, plastics Class B Flammable liquids, gases, oils, solvents, paints, or greases Class C Live electrical wires or equipment Class D Combustible metals (e.g., potassium, magnesium, titanium) Class K Kitchen fires involving cooking oils and fats

get up and go test

Get Up and Go Test Use if there is a history of falls. If patient or caregiver reports a single fall or risk factors, conduct the Get Up and Go test to identify whether the patient needs further evaluation. Have the patient do the following: Move from a sitting position and stand without using his arms to help him rise and stand. Walk several paces, turn, and return to the chair. Sit back in the chair without using his arms for support. Those who have difficulty or demonstrate unsteadiness performing this test require a focused, comprehensive falls assessment.

institute of medicine on safety

Institute of Medicine's (IOM) report To Err Is Human: Building a Safer Health System brought public attention to patient safety. It stated that it is simply not acceptable for patients to be harmed by the same healthcare system that is supposed to offer healing and comfort. The report identified five critical principles to ensure safe healthcare systems: Provide leadership, recognize human limits in process design, promote effective team functioning, anticipate the unexpected, and create a learning environment (IOM, 2001). To learn what is meant by the "culture of safety" in the healthcare setting, read the accompanying Safe, Effective Nursing Care box.

ingestion of mercury

Intestinal obstruction

Skin

Irritation and allergic dermatitis

eye exposure to mercury

Irritation and corrosion

Hazards to healthcare workers

Nursing is an active profession, and workplace injuries are all too common. Common accidents include back injuries, needlestick injuries, radiation injury, and violence. Nurses sometimes hesitate to report an injury because they fear consequences such as being labeled a complainer or troublemaker or being denied opportunities for promotion. However, OSHA (1) requires that employers show employees how to report a workplace injury and (2) prohibits discrimination against employees who make such reports. You should always report an injury. By doing so, you help (1) pinpoint trends and areas of need in safety and (2) ensure you will receive necessary treatment and follow-up.

Back injury for nurses

Nursing personnel are consistently listed in the top 10 occupations for work-related musculoskeletal disorders (MSDs). Most often the MSD involves the shoulders and back (Bureau of Labor Statistics, 2012). The ANA reports that 52% of nurses report chronic back pain (ANA, 2013), likely because many nursing tasks require bending and twisting of the torso, activities that can cause injury when the nurse does not use correct body mechanics. Among the most stressful activities are transferring patients (e.g., from toilet to chair), weighing patients, lifting a patient in bed, repositioning patients in beds or chairs, and changing bed linens. Healthcare facilities have not consistently implemented safe patient handling guidelines and laws. In response, the ANA (2013) developed national standards to guide healthcare agencies in this regard. The ANA aims to: Create a culture of safety by requiring employers to develop a safe handling and moving program with policies, appropriate equipment, training and accommodations for injured employees. Empower nurses to (1) actively participate in creating and implementing safe handling measures and (2) promptly report hazards, incidents, and injuries in a "blame free" environment. Refer to Chapter 33 for information about body mechanics and how to safely lift and move patients. For more information about ANA's campaign to prevent musculoskeletal injuries,

communication

Open and honest lines of communication are needed between the team members and from the team to other hospital units.

restraint is sometimes necessary

Organization guidelines differ slightly, depending on whether restraints are used to support medical healing or for a behavioral health reason (e.g., when a patient is irrational and pulling out his intravenous [IV] lines). Use restraints only as a last resort. Better anticipation of patient needs and the use of technology (such as bed alarms) should be used instead of restraints. If you must use restraints, Medicare, The Joint Commission, and other regulators require both of the following: Restraints must be medically prescribed. You must first try all less restrictive interventions.

other insects and vector borne pathogens

Other insects, such as roaches, fleas, sand flies, lice, and ticks (which are, technically, arachnids and not insects) can also transmit serious diseases and produce a wide variety of allergens. Allergic sensitivity to cockroaches, for example, is a predictive factor for asthma severity (Salo, Jaramillo, Rose, et al., 2015).

preventing falls in healthcare facility

Perhaps the most important thing you can do to prevent falls is to identify those who are at risk for them. Nursing interventions to prevent falls are based on the risk factors identified at the initial assessment. You will find other interventions in Box 23-3. For a summary of interventions, review the Example Problem: Falls. To see a care plan and care map for Risk for Falls,

pollution

Pollution is any harmful chemical or waste material discharged into the air, water, or soil. Examples of pollutants are gaseous fumes, asbestos, carbon monoxide, and cigarette smoke. Each year Americans generate 254 million tons of trash. Of this, they recycle or compost about 87 million tons (U.S. Environmental Protection Agency [EPA], 2015).

preventing the need for restraints

Preventing the Need for Restraints KEY POINT: Restraints are a last resort. The current standard of care is restraint free. The following nursing interventions provide less restrictive alternatives to using restraints for patients who are confused or otherwise cognitively impaired. Provide Consistency Keep the environment and the caregivers as consistent as possible. To help relieve anxiety, encourage family and friends to: Remain with the patient around the clock for a few days after admission. Help with the patient's care. Bring familiar objects from home. Review the Patient's Medications Determine whether they may affect mental status or balance. Provide Relaxation and Relieve Anxiety Relieving anxiety helps to prevent wandering. You may wish to try some of the following measures: Orient patients and families to their surroundings; reorient as often as necessary. Provide consistency of caregivers and environment, as discussed above. Use therapeutic touch and relaxation techniques, such as massage. Use the least invasive and most comfortable method to deliver care. For example, use a toileting schedule or provide a bedpan instead of inserting a urinary catheter, or encourage and provide oral fluids to avoid inserting an IV for hydration. Discontinue treatments that cause discomfort or agitation as soon as possible. For example, some patients become agitated and pull at or try to escape sensations from indwelling catheters, intravenous catheters, and nasogastric tubes. Provide Frequent Assessment and Surveillance Use one-to-one supervision as needed and encourage family members and friends to stay or to hire sitters for clients who need supervision. Place near the nursing station those patients with cognitive deficits or who need supervision for other reasons. Check on them frequently. Assess all patients regularly for cognitive changes. Find Ways to Communicate This is essential, even though it may be difficult to communicate with patients who have cognitive deficits. Assess the patient's communication abilities to determine whether he can let you know what he needs and wants. You will need to be especially alert for body language, such as gestures, nods, and eye contact, as these may be the patient's only way of communicating. Speak clearly, calmly, and slowly. Smile and face the patient. Ask the patient directly what he needs, for example, "Do you need the bathroom?" Word questions so the patient can answer with a yes or no. Modify the Environment Some simple ways to prevent agitation and confusion are to: Reduce noise on the unit and provide adequate light. Use music therapy for a calming effect. Use wedge cushions and body props for patients sitting in chairs to help them maintain good posture in the chair. These help keep them from slumping and falling out of the chair. Use low beds for patients who are likely to fall or wander. It may be best to remove bed rails in some situations. Keep doors to the unit locked if this is feasible and acceptable. In long-term care facilities, also lock outside doors. Have a staff member at main entrances and exits. For types of alarms and specific instructions about using bed alarms, see Procedure 23-1. Anticipate Unmet Needs Often patients try to get out of bed because they have a need they cannot express. The best way to achieve restraint-free care is to individualize care to avoid the risky behavior. Look for the meaning of disruptive behaviors (e.g., is the wandering patient thirsty or in pain)? The following are examples of actions to anticipate patient needs: Plan an elimination routine based on the patient's history. Patients often try to get out of bed because they need to go to the toilet. Provide pain relief and other comfort measures to decrease agitation. Provide diversional activities. KEY POINT: Sometimes restraints are necessary to ensure the immediate physical safety of the patient or others. When that occurs, follow organization policies and always use the least restrictive restraint that ensures safety. To learn more about applying and using restraints, see Clinical Insight 23-2, What You Should Know About Using Restraints, and Procedure 23-2, Using Restraints, later in the chapter.

Quality and safety education for nurses on safety

Quality and Safety Education for Nurses (QSEN), a task force to improve nursing education, identified and described six competencies that all nursing students should have by graduation. Safety is one of those competencies (Cronenwett, Sherwood, Barnsteiner, et al., 2007; Cronenwett, Sherwood, & Gelmon, 2009).

Radiation injuries for nurses

Radiation is the process of emitting radiant energy in the form of waves or particles. Ionizing radiation is used in computerized tomography (CT scans) in diagnostic radiology, linear accelerators in radiotherapy, and positron emission tomography (PET scans) in nuclear medicine. Patients are deliberately exposed to radiation during diagnostic tests and certain medical treatments. Healthcare workers who care for these patients are unavoidably exposed to small doses of radiation. Take precautions to avoid excessive radiation exposure for the patient and yourself during x-ray procedures. KEY POINT: Follow the principles of time, distance, and shielding when caring for a patient who is being treated with an internal radioactive implant: Time: Organize nursing care to limit the amount of time with the patient. Distance: Perform near the patient only the nursing care that is absolutely necessary. Shielding: Wear protective shielding (e.g., a lead apron), if available. If you deliver care that regularly exposes you to radiation, wear a film badge to indicate any radiation exposure.

restraint free environments

Research indicates that less restraint use saves time and money and reduces patient injuries (Chan, LeBel, & Webber, 2012; Cleary & Prescott, 2015). The American Nurses Association and other healthcare organizations have established evidence-based guidelines. These show that a restraint-free environment is the standard of care. When the decision is made to avoid restraints, alternatives must be provided for keeping the patient safe. KEY POINT: Restraints never resolve the underlying problem; addressing the reason behind the patient's behavior is key to calming the patient (Said & Kautz, 2013). To provide the safest possible care environment, The Joint Commission encourages healthcare facilities to do the following: Promote a commitment to reduce the use of restraints and seclusion among all direct-care staff. Educate caregivers before they take part in any restraint-related activity. Document restraint episodes specifically, in detail. Maintain one-to-one viewing of patients in restraint and seclusion. Include staff members when deciding whether to explore new technology that is considered a safe alternative to traditional restraint devices. Budget for an adequate number of qualified staff to attend to patients.

inhalation of mercury

Respiratory damage, wakefulness, muscle weakness, anorexia, headache, ringing in the ears, chest pain, inflammation of the mouth, and pneumonitis

Understanding Errors in Healthcare: Root Cause Analysis

Root cause analysis (RCA) tries to solve problems by identifying and correcting the underlying causes of events as opposed to simply addressing their symptoms. The goal is to decrease the likelihood that the problem will recur. A root cause is typically a finding related not to individual error but to a process or system that has a potential for redesign to reduce risk. Therefore, a root cause finding is usually used for the purpose of redesigning a process or system, rather than preventing an individual error. RCA provides an organized structure for analysis of errors and is designed to answer three basic questions: 1. What happened? 2. Why did it happen? 3. What can be done to prevent it from happening again?

SBAR

S: Situation B: Background A: Assessment R: Recommendation

Safety

Safety is a basic human need, second only to survival needs such as oxygen, nutrition, and fluids. As a nurse, the concept of safety is fundamental to providing safe, effective, high-quality care to your clients. Nurses contribute to patient safety, in any setting, by coordinating and integrating the multiple aspects of quality into the nursing care, and across the care delivered by others. You must also be concerned with your own safety and the safety of other care providers. Many accidental injuries can be prevented by being aware of hazards and taking reasonable precautions.

Caring Is Creating a Culture of Safety

Safety is a basic need for all persons. Your commitment to safety is one way for you to show caring. As the person closest to and most constantly with the patient, you can facilitate a culture of safety by: Speaking up for Safety. Use CUS words: C—state your concern U—say why you are uncomfortable S—state "this is a safety issue"; explain how and why Stopping the line (e.g. calling for a pre-procedure "timeout" when there is a concern) Escalating the safety issue when needed, communicating through the appropriate chain of command Being open and transparent with patients/families/colleagues Participating in safety huddles (quick conversations with a focus on safety) Opening all meetings with the topic of Safety, allowing time for stories/concerns Using SBAR (Situation, Background, Assessment, Recommendation) communication Validating and Verifying when unsure (have second nurse check) 200% accountability (calling other nurses or healthcare disciplines on hand washing or use of personal protective equipment) Reporting both actual and "near miss" medication errors, policy deviations, treatment and outcome variations and adverse events Participating in your organizations Patient and Caregiver Safety committee

water-borne pathogens

Sanitation refers to measures to promote and establish favorable health conditions, especially those related to the community's water supply. People who live in substandard housing may not have safe drinking water, hot water for washing, or adequate methods of waste disposal. People in rural areas often depend on private wells, which may not be adequately maintained and tested for pathogens such as Giardia lamblia, Cryptosporidium, and Escherichia coli. These are primarily community health problems.

adolescent safety

School-age children have developed more refined muscle coordination and control, and improved decision-making skills. However, because they become more involved in activities outside the home, bone and muscle injuries are common. Injuries are often related to sports, skateboarding, bicycle riding, and playground injuries. Most school-age children are less fearful than are toddlers and are ready to try any new skill with or without practice or training. Exposure to the wider school and neighborhood environment also increases the safety risks for children from people outside the home (e.g., abduction). Accidental deaths—Motor vehicles continue to be the leading cause in this age-group. Nonfatal injuries—Falls are the leading cause of nonfatal injuries.

school-age child safety

School-age children have developed more refined muscle coordination and control, and improved decision-making skills. However, because they become more involved in activities outside the home, bone and muscle injuries are common. Injuries are often related to sports, skateboarding, bicycle riding, and playground injuries. Most school-age children are less fearful than are toddlers and are ready to try any new skill with or without practice or training. Exposure to the wider school and neighborhood environment also increases the safety risks for children from people outside the home (e.g., abduction). Accidental deaths—Motor vehicles continue to be the leading cause in this age-group. Nonfatal injuries—Falls are the leading cause of nonfatal injuries.

developmental factors on safety

The type and incidence of accidents vary among age-groups. You will find interventions for all age-groups integrated into the topics throughout this chapter. The descriptions given for each age-group are characteristics common to most people in that group. However, individuals progress through developmental stages at their own pace, so there will always be people who do not fit the group description closely. For supplemental discussion of safety needs during different developmental stages, review Chapters 9 and 10.

safety hazards in the community

This section discusses four hazardous agents: motor vehicle accidents, pathogens, pollution, and weather hazards. These are a major contributor to illness, disability, and death worldwide.

timed go test

Timed Up and Go Test If the patient is seeking care because of a fall or if you observe any difficulty with ambulation, refer him to a practitioner with advanced skills and experience for a Timed Up and Go test and a comprehensive fall evaluation. This is a version of the Get Up and Go test, in which the patient is asked to get up and walk 8 feet in 8.5 seconds or less. Primary care providers should annually perform a Timed Up and Go test for fall risk assessment for all patients over age 65 (American Academy of Neurology, n.d.a, n.d.b; Kenny, Rubenstein, Martin, et al., 2011; Podsiadlo & Richardson, 1991). To see the Timed Up and Go test,

treatment for poisoning

Treatment choice depends on the poison ingested. For most poisonings, the most effective intervention is professional administration of activated charcoal orally or via gastric tube. However, charcoal is not effective for ethanol, alkali, iron, boric acid, lithium, methanol, or cyanide. Depending on the situation, other options for medical treatment include gastric lavage, dialysis, administration of antidotes, and forced diuresis.

preventing needlestick injury

Use needleless systems (e.g., retractable needles) when possible. More than 80% of needlestick injuries can be prevented with the use of safe needle devices (ANA, 2002). Before beginning a procedure: Provide adequate lighting and space to perform the procedure. Place the sharps container near the work area, if it is moveable. Obtain assistance if there is a risk that the patient may be uncooperative, combative, or confused. Inform the patient about the procedure and explain the importance of avoiding any sudden movement. During the procedure: Be sure you can see the sharps container at all times. When handling a sharp, be aware of other persons in the immediate area. Do not hand-pass exposed sharps from one person to another. When using a safety needle, observe for audio or visual cues that the feature has engaged. Handling needles: Do not shear or break contaminated needles. Avoid recapping, bending, or removing contaminated needles and other sharps unless there is no feasible alternative. When you must recap a sterile needle, use a mechanical recapping device or a modified "scoop" technique (see Procedure 25-10). Never carry syringes in your uniform pocket. Sharps containers: Keep puncture-proof needle disposal containers in every room. Place sharps containers at eye level; do not overfill the container. Make sure the container is large enough to hold the entire sharp device. Dispose of sharps immediately. Do not wait until you have finished the procedure. Inspect sharps and waste containers for protruding sharps. If found, notify safety personnel for removal of the hazard. If your agency does not use needleless systems or protective devices, you should do the following: Explain the OSHA Bloodborne Pathogens Standard (BPS) to your employer, including the need to provide needleless systems or protective devices for blood products and parenteral medication administration. Refer your employer to the OSHA Web site at http://www.osha.gov/needlesticks/needlefaq.html OSHA requires worker involvement in evaluating, selecting, and implementing the use of safer needle products; volunteer to serve on that committee. Ask your agency for a copy of their exposure control plan, which is required by the BPS for monitoring compliance with the new law. Keep a record of needlestick injuries on your unit and of "near-misses" (e.g., overfilled sharps containers, sharps left on bed or overbed table). Submit written concerns to your employer. If your employer refuses to purchase safety devices, you may want to file an OSHA complaint. If you do, refer to whistleblowing in Chapter 43. Complaints can be filed anonymously. For complaint filing,

Assessing for Example Problem: Falls

Use of a standardized falls prevention tool has been shown to decrease fall rates (Coppedge, Conner, & Sin Fan, 2016). You will find more information in the Example Problem: Falls. Assess all inpatients for falls risk when they are admitted to the healthcare setting. For patients at risk for falls, repeat the risk assessment every 8 hours and increase the frequency of monitoring. Be sure to identify medications that increase the risk for falling. Most institutions have policies and guidelines for assessing risk for falls. The following are methods you might use: Morse Fall Scale The Morse scale is a rapid and simple method of assessing a patient's likelihood of falling. Ideally, the scale should be calibrated specifically for each nursing unit so that fall prevention strategies are targeted to those most at risk. Institutions implementing the Morse scale should train personnel in the proper use of the scale (Morse, 1997, 2008, 2009).

Vector-borne pathogen

Vectors are organisms that transmit pathogenic bacteria, viruses, and protozoa from one host to another. The following are examples: mosquitoes other insects animals

Adult safety

Workplace injury may be a significant concern. Other injuries to adults are related to lifestyle (e.g., excessive alcohol use), stress, carelessness, abuse, and decline in strength and stamina. Accidental death—Unintentional poisoning causes more deaths than do motor vehicle accidents (CDC, 2015a). Accidental injuries—For many, work and family responsibilities leave little time for regular physical activity, increasing the risk of musculoskeletal injury in the so-called weekend athlete.

Assessing the Risk for Violence

You can be prepared to intervene and perhaps even prevent violence if you recognize risk factors and early warning signs (Arnetz, Hamblin, Essenmacher, et al., 2015; Woodrow & Guest, 2012).

responding to fires

You must know your agency's procedures for responding to a fire, including how to evacuate patients from the building. Remember: R-A-C-E. Rescue the patient. Remove the patient from immediate danger. Move patient(s) into the corridor and close doors to the affected area. Activate the alarm. Report the location and kind of fire and identify yourself. Activate the nearest alarm. Confine the fire. Close all doors and windows. Turn off all oxygen valves after coordinating with the charge nurse. Extinguish the fire. Use the proper extinguisher. Stay between the fire and the path to safety. Keep low. KEY POINT: If you discover a fire, your first instinct may be to contain or put out the fire. Fight that instinct! Your first action is to rescue the patient. You should try to extinguish (the E step) the fire only after the R-A-C steps are completed, and only if it is a small fire that is contained to one area, such as a trash can. If the fire gets out of control, leave the area immediately.

Preventing poisoning in the home

Young children will eat and drink almost anything. Most victims of accidental poisoning are children younger than the age of 5. Tips to prevent poisoning include the following: Careful Words and Actions Never leave a small child unattended near household cleaning supplies or medicines. If you must answer the phone or doorbell, take the child with you. Children act fast; it takes only a moment for them to swallow something. Avoid taking medicines in front of children. Children tend to imitate adults. Never call medicines or vitamins "candy." Instead, use the correct name (e.g., "cough medicine"). Careful Storage Store medicines or household chemicals on high shelves or in locked cabinets and drawers. Never leave them on kitchen or bathroom counters. Store all household chemicals away from food. Keep medicines and household chemicals in their original containers. Leave the original labels on them. Do NOT store chemicals in containers that normally hold food. Use child-resistant packaging for medicines and household chemicals. Close the container securely after each use. Do not assume your child is safe around substances in child-resistant containers. Research has shown that many toddlers and preschoolers can open them. Careful Disposal Teach clients to take advantage of community programs that take back medications for safe disposal (e.g., call the local trash service or a local pharmacy for options in your area). Teach clients how to safely dispose of outdated prescription medications: Crush the medication or add water to dissolve it. Mix the drugs with an undesirable substance such as kitty litter or used cooking grease To make it less desirable for pets and children to eat. Place the mixture in an empty can or resealable bag and put it in the trash. Remove all identifying information from prescription labels before throwing containers in the trash or recycling them. If disposal options are not available, medicines can be flushed down the sink or toilet when they are no longer needed (Food and Drug Administration, 2015). For a list of medicines recommended for disposal by flushing, Careful Environment Checks Verify that house plants are nontoxic. Examples of toxic plants are rhododendron, philodendron, English ivy, holly, mistletoe, and lily of the valley. Find out whether any plants growing in your yard are poisonous, and, if so, remove them. Teach children that they must never eat berries, wild mushrooms, or other edible-looking plants in yards, fields, and forests. A wide variety of plants can cause illness and even death in young children. Warn parents to keep children from chewing on windowsills and to carefully clean up flakes of paint. Advocate for clients who need to have lead-based paint replaced in their homes. Lead-based paint can still be found in older homes, and some soil contains a high lead content. Young children often put dirt in their mouths and chew on furniture and windowsills, especially when they are teething.

take home toxins

are hazardous substances transported from the workplace to the home. The National Institute for Occupational Safety and Health (NIOSH) reports that pathogenic microorganisms, asbestos, lead, mercury, arsenic, pesticides, caustic farm products, and dozens of other agents cause significant morbidity and mortality in workers' homes (NIOSH, 2003, updated 2014). These toxins are most likely transported on the workers themselves, on their clothing, or on objects brought from the workplace. In the home, contamination occurs via any of three sources: Direct skin-to-skin contact or direct contact with contaminated clothing Arthropod vectors, such as ticks On dust particles that are inhaled (e.g., anthrax spores, arsenic in mine and smelter dust)

Scald injuries

are the most common cause of burns in children younger than age 3. Scalding burns (especially on both feet or both hands) and cigarette burns in children and vulnerable older adults should always prompt you to assess for abuse (see Procedure 9-1).

etiologies

cause of disease may include enironmental hazards and developmental and individual risk factors IE Correct: Risk for Falls r/t cluttered home environment and joint instability Risk for Falls r/t poor vision secondary to cataracts Risk for Falls r/t to muscle weakness, joint instability, and poor sense of balance Incorrect: Risk for Falls r/t environmental and physical factors

Smoking

e.g., cigarettes) is the leading cause of fatal home fires.

poison often ingested by children

househeld cleaners, medicine, houseplants,cosmetics, pesticides, chemicals (kerosene gas, lighter fluid), alchool beveragrs, wild plants./mushrooms, rodent poison

home oxygen administration equippment

in 75% of the home fires involving oxygen, smoking materials are the ignition source.

other causes of fire

include unsupervised children playing with matches, improper use of candles, and faulty wiring.

a home safety check list

is a convenient way for clients to identify potential hazards. Many such lists are available in an Internet search for "home safety checklist."

choking rescue maneuver

is an emergency procedure for removing a foreign object lodged in the airway. It lifts the diaphragm and forces enough air from the lungs to create an artificial cough. The cough should move and expel the obstruction from the airway. The Heimlich maneuver makes use of abdominal thrusts only. The American Red Cross (2011) alternates five back blows with five abdominal thrusts until the blockage is dislodged. For adults-If you suspect airway obstruction in an adult, do the following: 1. Determine whether the victim is able to speak or cough forcefully (other signs include noisy breathing, loss of consciousness, and dusky skin, lips, and nailbeds). 2. Ask, "Are you choking?" 3. If the person cannot speak or indicates he is choking, perform the Heimlich or choking rescue maneuver. You can obtain an summary and illustration of the Heimlich from the U.S. National Library of Medicine, MedlinePlus, at https://medlineplus.gov/ency/image-pages/18152.htm There is also a YouTube video at https://www.youtube.com/watch?v=XOTbjDGZ7wg&feature=youtu.be Infants under 1 year—Management of choking is different for adults and children. Do not use the Heimlich maneuver for infants under 1 year of age. For a summary and illustration of choking first aid for an infant under one year, go to MedlinePlus, at https://medlineplus.gov/ency/presentations/100221_1.htm

The safety assessment scale (SAS)

is an objective way to evaluate the dangers incurred by people with memory and cognitive deficits who live alone at home. You can use the short version of the SAS (Fig. 23-2) to assess risk status and decide whether the person should have an in-depth evaluation. In addition to assessing risk for injury, this scale evaluates whether the cognitively impaired person is capable of taking medications and performing other activities of daily living (ADLs) independently.

heating equipment

is equally responsible during the winter.

warming food or formula in the microwave

may cause the food to become hotter than intended, leading to burns in infants and young children.

contact burns

may occur from contact with metal surfaces and vinyl seats when cars are parked in the sun. The risk of contact burns in all age-groups is greater in the presence of heating devices such as kerosene heaters, wood-burning stoves, and home sauna heating elements. People may use these as heat sources when they cannot afford the cost of traditional furnace fuels.

air pollution

occurs indoors as well as outside. Outdoor air pollution—Motor vehicle emissions are a major cause in the United States. Other toxic outdoor air pollutants include asbestos, toluene; metals such as mercury and lead compounds, and emissions from sources such as factories and power plants. Indoor pollutants include radon, carbon monoxide, and allergens from dust mites, cockroaches, mold, rodents, and pets. Passive exposure to tobacco smoke is associated with respiratory disease and cancer, and environmental air pollution is linked to cardiovascular disease and respiratory viral infection (Kit, Simon, Brody, et al., 2013; U.S. Department of Health and Human Services, 2014).

Leading causes of unitentional deaths

poisoning and exposure to noxious substancs motor vehicles firearms falls drowning fires, flames, and smoke

r/t

related to

Chemical burns

such as acid, alkali, or other organic compounds, can also cause localized burns.

poisoning and asafety

young children are poisoned most often: house hold chemcials, medicnes, vitamins, cosmetics, lead. poor and immigrant populations are higher lead poisoning risk older children and adolescents may attemp0t suicide by OD or accidentally when experimenting with recreational or prescription drugs adults experience poisoning as a result of illegal drug use, misuse of perscriptinoi drugs

carbon monoxide exposure

-odorless, tasteless, toxic -exposure cuases headaches, weakness, nausea, vomiting, -prolonged exposure leads to seizures, dysrhythmias, unconsciousness brain damage, and death. -cause of 500 unintentional deaths a year -most occcur at home -CO poisoning accounts for the majority of deaths at the scene of fires and is also a relatively common method of suicide. Many CO deaths occur during cold weather among older adults and the poor who seek nonconventional heat sources (e.g., gas ranges and ovens) to stay warm.

pathogens

A pathogen is any microorganism capable of causing an illness. Pathogens can enter the body through several sources in the environment: food, mosquitoes, and other insects; rodents and other animals; and unclean water.

Restraints

A restraint is a device or method used for the purpose of restricting a patient's freedom of movement or access to his body, with or without his permission. The most obvious form of restraint is the use of physical force by another person. A restraint may also be (1) a mechanical device, material, or equipment, such as a cloth vest or siderails; or (2) a chemical restraint (e.g., sedatives and psychotropic medications) given to control disruptive behavior. Devices such as casts and traction are not considered restraints (Centers for Medicare & Medicaid Services, 2008; The Joint Commission, 2009). Physical holding of a patient is not always considered restraint. Sometimes it is necessary to use devices or methods that involve the physical holding of a patient for routine physical examinations or tests. Restraints are classified according to the reason for their use: medical-surgical restraints or behavior management restraints. Medicare has specific guidelines for each circumstance. Guidelines are more restrictive when restraints are used for behavior management. Nurses traditionally restrained highly dependent older adults, patients with poor mobility, and impaired cognition, and others they judged to be at risk for falls. However, it has been found that restraints make care more time consuming and do not reduce falls. Restraints are themselves a safety hazard, and actually increase the likelihood of injury. A restrained person has a natural tendency to struggle and try to remove the restraint. As a result, the person can become entangled, suffer nerve damage or circulatory impairment, and even suffocate. Potential Physical Effects. Restraint-imposed immobility can cause pressure injuries, contractures, and loss of strength and affect nearly every body system. Potential Emotional Effects. The person may suffer anger, fear, humiliation, and diminished self-esteem.

preschooler safety

After age 3 years, children are a little less prone to falls because their gross and fine motor skills, coordination, and balance have improved. However, as they begin to play outside more often (e.g., playgrounds, pools, front yards) there are additional safety concerns. Accidental deaths—Motor vehicle injuries are a major cause, along with drowning, fires, and poisoning. Nonfatal injuries—Falls are the primary cause of nonfatal injuries. Although preschoolers become more aware of dangers and limitations, adult supervision is essential.

What you should know about using restraints

Agency policy, professional guidelines, and state laws should guide restraints use. Use restraints only for safety to ensure the immediate physical safety of the patient or others. You must obtain a medical prescription from a physician or other licensed care provider. No standing orders or "as needed" orders for physical restraint are allowed. You must renew restraint prescriptions every 24 hours (more often for behavioral restraints). You must modify the plan of care to reflect the application of restraints and the plan for monitoring. Explain the need for the restraints if you must use them. Obtain consent from the patient and family when feasible. Medications are considered a restraint when they are used to restrict the patient's freedom of movement or to manage behavior. Physical holding of a patient is not always considered restraint. Sometimes it is necessary to use devices or methods that involve the physical holding of a patient for routine physical examinations or tests. Monitor and reassess. These are critical components of caring for patients in physical restraints. Assess restraints every 30 minutes (more frequently for patients with behavioral restraints, who may need continuous monitoring). Remove restraints for assessment, feeding, toileting, and skin care every 2 hours. Patients in medical-surgical restraints should be evaluated by an RN at least every 2 hours. Those in behavioral restraints require more frequent monitoring. Always use the least restrictive restraint that ensures safety. Remove the restraint as soon as possible.

2. Assess for signs of anxiety:

Agitation and restlessness Pacing Talking loudly, speaking rapidly Gesturing widely Verbal aggression, such as threats, sarcasm, and swearing

Analysis/Nursing Diagnosis. for describing safety probleans

Agitation and restlessness Pacing Talking loudly, speaking rapidly Gesturing widely Verbal aggression, such as threats, sarcasm, and swearing

older adult safety

Although many older adults have intact senses and continue to enjoy life as they age, physiological changes do occur (e.g., reduced muscle strength and joint mobility; slowing of reflexes; decreased ability to respond to multiple stimuli; and sensory losses, particularly hearing and vision). These changes increase the older adult's risk for falls, burns, car accidents, and other injury. Accidental death—Falls are the most common cause of accidental death for adults aged 65 and older (CDC, 2015b).

Example Problem: Falls

Although most falls occur in the home, they are a major concern in healthcare facilities as well. Falls are by far the most common incident reported in hospitals and long-term care facilities. As a result, most agencies have established procedures and safety features to prevent falls. Infants and older adults are especially at risk for injury from falls. Many cases involve falling from a bed, and falls occur more frequently at night and on weekends and holidays. For risk factors, see the Example Problem: Falls, later in the chapter.

motor vehicle safety

Anticipatory guidance and educational programs are important measures for improving motor vehicle safety for all age-groups. You may also wish to become politically active on the issue of motor vehicle safety. For instance, you might petition your city council for a stop sign at a dangerous intersection or a reduced speed limit on a highway. Also teach clients the following measures for avoiding motor vehicle injuries: Be cautious when walking or bicycling on the roadway and observe the laws. Do not drink alcohol or take unprescribed or recreational drugs and drive. Have a designated driver. Do not engage in distracting activities while driving (e.g., using cell phones, texting, changing the music, applying cosmetics). Observe the speed limits. Always wear seat belts and periodically check them to ensure safe operation. Buckle children properly in age-appropriate safety seats in the back seat of the car. If in doubt about how to use safety seats, ask the local police department to check the installation. See Table 23-4. Older Adults Age-related changes increase the risk for injury or death in a car crash, especially after age 70. But driving helps older adults maintain mobility and independence. Urge them to have regular vision checks and to leave a large distance between themselves and the car in front of them.

Assessing older adults for falls

As a part of the routine assessment of all older adults, ask the patient (or caregivers) about falls. For a flowchart summarizing falls assessment for older adults, refer to Figure 23-1. EXAMPLE PROBLEM: Falls Complications of Falls Falls may cause serious injuries, disability, loss of independence, and even death. Risk Factors • History of falls • Age > 80 years • Impaired vision • Weakness/dizziness • Gait or balance problems • Pain • Hypotension • Cognitive impairment • Chronic conditions (e.g. arthritis) • Medication side effects • Polypharmacy • Home hazards • Unfamiliar environment • Alcohol use KEY POINT: Clients usually have multiple risk factors.

which safety interventions can i delegate?

As nurse manager or a primary care nurse, you may need to delegate safety promotion interventions to nursing assistive personnel (NAP). For all delegation decisions, refer to the discussion and guidelines in Chapter 7. Restraints. One safety activity you might delegate is applying restraints. You must first be sure that the NAP is competent to perform the skill. Although you may delegate the application of the restraints, you may not delegate the assessment of the patient's status nor the evaluation of her response to the restraints. You may assign the NAP to (1) remove and reapply restraints to provide skin care and allow for supervised movement and (2) observe for skin excoriation under or around restraint location and report it to you. Other Measures. You should be sure assistive personnel are aware of and follow all safety measures and institutional procedures. For example, you can expect the NAPs to remove clutter and spills in patient rooms, to provide patients with nonskid slippers, and to lock beds and wheelchairs.

do not depend on side rails

Based on Medicare standards, siderails can be viewed as a restraint. A full-length siderail is a restraint when it is used to prevent the patient from getting out of bed regardless of whether he is able to do so safely. A half- or quarter-length upper siderail can be an aid to independence if it is used by the patient for the purpose of getting into and out of bed. Split rails are not considered restraints if a client requests them in order to feel more secure. Remember that older or cognitively impaired adults may regard siderails as a barrier rather than as a reminder that they need assistance. KEY POINT: Several studies have shown that siderails may lead to serious falls and injuries. These findings have led healthcare providers to recommend that siderails not be used routinely (Cleary & Prescott, 2015; Kirk, McGlinsey, Beckett, et al., 2015).

prevent suffocation

Clients should recognize and teach children the universal sign for choking: grasping the neck between the thumb and index finger or clutching the neck with both hands (Fig. 23-3). It is also important to teach clients the following measures to prevent suffocation or asphyxiation: Inspect toys for small, removable parts. Do not attach pacifiers, rattles, or other infant toys to ribbons or strings. Do not use sweatshirts or jackets with necktie strings. Position mobiles well above the crib, and remove once the baby begins to push up on his hands and knees or by age 5 months, whichever comes first. Keep window blind cords out of a child's reach. Store plastic bags away from young children in a secure place. Ensure that the crib is designed to meet federal regulations: Crib slats must be less than 2⅜ in. (6 cm) apart, and the mattress must fit snugly. When feeding children meat, cheese, or other firm foods, cut the food into very tiny pieces. Do not give a young child hard candy, chewing gum, nuts, popcorn, grapes, or marshmallows. Supervise children's balloon play and dispose of burst balloons promptly.

water contamination

Contamination in lakes, rivers, and streams affects both recreation and food production. Pollution occurs when inadequately treated or inappropriate quantities of human, industrial, or agricultural wastes are released into the water systems. If the pollution is severe enough, the water may become unsafe for human consumption.

provide safe environment to prevent falls

Determine the appropriate use of siderails based on the patient's cognitive and functional status. Recent research suggests that removing or lowering siderails may help to prevent falls that occur when patients climb over them (Capezuti, Wagner, Brush, et al., 2007). Keep the bed in a lowered position, except when giving care; lock wheels. Locking bed. Make sure to lock wheels of wheelchairs, especially during patient transfer. Safety locks on wheelchairs. Provide nonskid slippers. Applying nonskid slippers. Keep water, urinal, bedpan, and tissues within easy reach of the patient. Place the call light within reach. Have the patient demonstrate the ability to call for the nurse. Provide a night-light. Keep floors dry and free of clutter. For patients at risk for falls, place a warning sticker on the chart or door. Assess, Teach, and Support Review and suggest needed modification of medications, especially psychotropic medications. Provide gait training and advice on the appropriate use of assistive devices. Orient the person to the surroundings (e.g., bathroom, chairs; you may need to label items). Offer to assist with toileting and transfer activities. Educate the patient and family regarding fall prevention strategies. Policies, Procedures, Routines Consider instituting hourly rounds on your unit. This has proved effective in reducing the number of falls. Place disoriented patients in rooms near the nurses' station. Provide regular nursing surveillance of hospitalized older adults. Research suggests that this can significantly reduce patient falls rate (Pappas, Davidson, Woodard, et al., 2015). Ask patients at risk for falling to wear red or brightly colored socks to alert caregivers. Communicate falls risk status during handover and transfer reports. Document changes in the patient's condition in the patient record.

Prevent drowning

Drowning is a form of suffocation but is discussed separately here for convenience. Teach clients the following water safety measures: Supervise activity when the child is near any source of water. Children up to age 4 should never be left unattended in or near a bathtub, hot tub, swimming pool, or other source of water. Even wading pools, toilets, and mop buckets hold enough water to drown a small child. Do not allow children to run around a pool or to dive in shallow areas. If you have a pool, be sure it has a barrier (e.g., tall fence) to prevent children from gaining access. Insist that children use personal flotation devices (e.g., lifejackets, not float toys). This is controversial, however. Some authorities regard flotation devices as toys that provide false security; others say anything that reduces a child's fear of the water is positive, because it is the fear reaction that leads to drowning.

Ages 1 to 18 yera (suffocation

Drowning is an important cause of accidental death in children age 1 to 18 years. KEY POINT: Children up to age 4 years are especially at risk for drowning.

prevent firearm injuries

Education is an essential intervention to prevent unintentional firearm injuries involving children. The American Academy of Pediatrics and other groups have mounted efforts to educate parents so that they will be able to make smart choices related to gun safety. You can help by teaching gun owners that it is important to store firearms unloaded and in a secure, locked container when not in use, and to store ammunition in a different location from the firearm. Suggest that they participate in gun safety courses and know the following rules for safe gun handling (National Rifle Association Headquarters, n.d.a): Always keep the gun pointed in a safe direction so that even if it were to go off it would not cause injury or damage. Never put your finger on the trigger until you are ready to shoot. Always keep the gun unloaded until ready to use it. Before cleaning a gun, make absolutely sure that it is unloaded. If you do not know how to open the gun and inspect the chamber(s), leave it alone and get help from someone who does. Teaching Children Even if parents do not have guns in their own home, it is possible that children will encounter them in other places. Urge parents to teach children safe behavior around firearms and to be sure children know what to do if they see a gun (e.g., at a friend's house or in school): 1. Stop. 2. Don't touch it. 3. Leave the area. 4. Tell an adult (National Rifle Association Headquarters, n.d.b).

Reducing electrical hazards in healthcare facility

Electrical hazards are a major cause of fires in healthcare agencies. The following interventions help reduce electrical hazards: Before use, have all electrically powered equipment and accessory equipment evaluated by facilities management. The Joint Commission standards mandate that all employees participate in education and training programs for electrical safety. If you suspect an electrical safety hazard, clearly label the malfunctioning equipment and send it for inspection. Use three-pronged electrical plugs whenever possible. Observe for breaks or frays in electrical cords.

using bed and chair monitory devices

Equipment Bed or chair exit monitoring device At least four types of notification systems are used to warn caregivers that a patient is leaving a bed or chair: (1) pressure sensitive, (2) posture indicators, (3) motion sensors, and (4) pull-cord and combination alarms. Delegation As the nurse, you must determine whether a monitoring device is needed. You must also select the appropriate device and provide ongoing evaluation of its effectiveness. You may delegate to a nursing assistive personnel (NAP) the installation of the device, after verifying the NAP has the necessary knowledge and skill. Pre-Procedure Assessments Assess for intrinsic factors that increase the risk for falls. Older than age 75 History falling Bowel or bladder incontinence (particularly urge bladder incontinence) Cognitive impairment Mood changes, lability Dizziness Functional impairment Medications (especially new medications or changes) Comorbidities (e.g., dementia, hip fracture, Parkinson's disease, arthritis, and depression) Assess for factors that increase risk for more severe injury in the case of a fall. These include use of anticoagulants (e.g., Coumadin, Plavix or aspirin) and osteoporosis. Assess for extrinsic (environmental) factors that increase the risk of falling. Use of an assistive device Equipment in the room Wet or uneven floors Use of physical restraints Poorly fitting footwear Poor lighting Lack of grab rails and bars in the bathroom Furniture and adaptive aids that are in disrepair or unstable (e.g., bed rails, IV poles) Clothing that may cause tripping Check the alarm on the monitoring device to ensure that it is working properly. When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Apply the device. Variation: Bed or Chair Monitor Place sensor pads under the patient's buttocks. The sensor will alarm when the patient attempts to get out of the bed or chair; it alarms when there is no weight on it for more than a few seconds. For some devices, you may need to set alarm sensitivity. For example, you may set the system to alarm when the patient exits the bed, when the patient attempts to exit the bed, or even when the patient moves in the bed. Variation: Leg Sensors Place sensors on the patient's thigh. The alarm will sound when the leg assumes a near-vertical position. Variation: Infrared Beam Detector Attach next to the bed or on the wall. Variation: Cord-Activated Sensor Attach one end of the cord (clip) to the patient's garment. Attach the other end to the control unit. The cord should be long enough to allow moderate movements but short enough to prevent false alarms. Be sure the cord is free to pull straight out from the monitor and is not blocked by pillows, bedding, or bedrails. The alarm is activated when the patient's movement causes the cord to be detached from the control unit. Some patients will deactivate the alarms, including removing the alarms clipped to their garments. 2. Connect the control unit to the sensor pad. Variation: Bed or Chair Monitor Mount the control unit on the bed or chair. Variation: Leg Sensor Mount the control unit directly on the leg sensor. Variation: Infrared System Mount the control unit next to the bed or on the wall. Variation: Cord-Activated System Mount the control unit next to the bed or on the wall. 3. Connect the control unit to the nurse call system, if possible. Allows for a quicker response; however, not all call systems will accommodate this. 4. Before assisting the patient out of the bed or chair, disconnect or turn off the alarm. Prevents false alarms. Some systems have a standby setting to allow the alarm to be temporarily suspended. 5. Reactivate the alarm after assisting the patient back to the bed or chair. Helps improve the timeliness of staff response, which may prevent patient falls. 6. Be sure the patient can access the nurse call light easily. Evaluation Assess the sensitivity of the monitoring device, and adjust as needed to ensure that the alarm is activated if the patient tries to get out of the bed or chair. Continue to assess fall risk per agency policy and as indicated by the patient's physical and/or mental status. In the event of a fall, perform a post-fall assessment to identify possible causes. Monitor patients closely for 48 hours after a fall. Patient Teaching Explain to the patient and family that a bed or chair exit monitoring device alerts the staff when the patient tries to get out of the chair or bed. Explain that the purpose of the device is to help prevent falls using the least restrictive method possible to reassure the patient and family. Explain to the patient that she will need to call for assistance when she wants to get up. Calling for assistance will prevent the alarm from sounding. Summoning for help can prevent the patient from falling. Documentation Document the initial sensor placement, including type of sensor used and the location of placement. After documenting initial placement, follow agency policy for documenting the use of bed exit monitor. Usually, the minimum documentation for exit monitors is every 8 hours. Place the patient on fall risk precautions according to agency policy. Document on the fall risk assessment sheet, restraint flow sheet, and nursing notes according to agency policy. Sample documentation: 9/06/18, 1230. Continues to be confused and to stand up without assistance. Wheelchair exit alarm placed on wheelchair and monitoring clip attached to back of client's gown. Notified client's daughter, June Kennedy, via telephone. Daughter agreed the exit alarm would help keep her father from falling. — Mary Clinton, RN Practice Resources Gray-Micelli, D., & Quigley, P. (2011); National Guideline Clearinghouse (2012); Park, M., & Tang, J. (2007).

Equipment-Related Accidents

Equipment-related accidents usually occur because of equipment malfunction or improper use—for example, when suction devices and infusion pumps are not working properly, oxygen cylinders are transported incorrectly, or wheelchairs and beds are not locked during transfer activities.

team empowerment

Every individual has the opportunity to be heard, feel important, and be a valued team member for the contribution offered.

interventions for example problem: preventing falls in the home

Exercise Regularly Exercise at least 30 minutes every day. Any activity is better than none; the amount depends on age, physical condition, and the intensity of the exercise. See Chapter 33 for more specific information. Tai chi, yoga, and weight training are ways to improve balance, coordination, flexibility, and strength. Learn to use assistive devices, such as walkers and canes, safely. Be sure rubber tips are not worn. Keep the walking aid by the bed at night. Take Your Time You are more likely to fall when you are tired, sick, rushed, or emotionally upset. Walk carefully without hurrying; be careful not to be distracted while walking about. Do one thing at a time; complete it before going on to the next task. Get out of bed or a chair slowly and check your balance before standing or walking. Postural hypotension and dizziness on rising may be caused by medications for high blood pressure and other conditions. Lighten Loads—Brighten Paths Carry things in small loads so that you are able to see over them, especially on stairs. Carry several small loads rather than one very large load. Use bags with handles instead of large boxes or laundry baskets to carry items. Have your eyes checked at least once a year. Clean eyeglasses frequently. Make sure rooms are adequately lighted, use dim light (e.g., a night-light) at night, and turn on the lights before entering a room. Don't Trip Yourself Up Ensure that shoes fit properly and wear slippers with nonskid soles. Do not go barefoot. Avoid loose, trailing clothes. Keep hems of clothing at a length to prevent tripping. Older adults with leg or hip stiffness and pain may shuffle when walking; use of a cane or walker may help. Tips of assistive devices, such as canes, walkers, and crutches, should have intact nonskid covers. Use a ladder or step stool; do not stand on the top step of a stepladder; never climb on a chair. Clear the Floor Tape or otherwise fasten phone and electrical equipment cords to the baseboard. Arrange furniture to provide wide walking areas. Keep clutter (e.g., toys, magazines, clothing) out of the walkways. Remove all scatter or throw rugs (or at least be sure they have nonskid padding under them). Wipe up all foods and fluids from the floor immediately. Apply an ice-melt product, salt, or sand to icy sidewalks, steps, and porches. Use Caution on Stairs Keep stairs well lit. Keep stairs free of clutter. Install sturdy handrails and slip-resistant floor coverings on staircases. For older adults and those with vision problems, paint the top and bottom steps white or put white stripes on the front edges of steps. Minimize Bathroom Hazards Use shower chairs and raised toilet seats. Install grab bars and use a nonskid mat in the shower and tub. Install handheld shower attachments to make it easier to sit while showering and minimize the need to move and turn. Childproof the Home Install window guards; never leave a window wide open. Use gates at the top and bottom of stairways for small children. Never leave a child alone on a changing table, even for a moment. Supervise young walkers to protect from falls. Remove chairs near counters or other areas where young children would be likely to climb. Push chairs all the way under dining table tops. Teach children to pick up their toys. Be sure that children wear helmets and other appropriate protective gear for bicycling, skateboarding, and other active sports. For Older Adults or Those With Limited Mobility: Use beds that are low to the floor. Keep a cordless phone in each room and by the bedside to make it easier to call for help if needed. Ask your doctor or pharmacist to review your medicines—both prescription and over the counter—to reduce side effects and interactions that might interfere with balance and coordination. This is especially important for psychotropic medications. Get treatment for postural hypotension and cardiovascular disorders, including dysrhythmias.

Alarm Fatigue

Failure to recognize and respond to actionable clinical alarms ... in a timely manner" is second highest-ranked patient safety risk (ECRI Institute, 2016). Missed alarms cause harm most commonly when (1) the medical device does not detect the alarm condition, (2) the alarm is not communicated to a medical practitioner, or (3) it is communicated but not adequately addressed. Thousands of alarms go off every day in hospitals. Alarm fatigue occurs when nurses become overwhelmed by the number of alarm signals and begin to ignore, delay response to alarms, or even deactivate them. Missed alarms or delayed responses have resulted in sentinel events, including patient deaths. The Joint Commission has named alarm desensitization a National Patient Safety Goal and requires that healthcare facilities provide the following: A comprehensive alarm management program that includes input from nurses, other healthcare workers, and management Education for staff about the purpose and proper operation of alarms systems for which they are responsible (The Joint Commission, 2015)

causes of fatal automobile accidents

Failure to use seat belts and proper child car seats are the major contributing factors. Air bag deployment when young children are improperly placed in the front passenger seat also causes severe injuries and death. Driver distraction, especially due to cell phone use is a major concern. In most states, laws curtail or ban cell phone use while driving. However, a survey of drivers revealed at that 21% of respondents in the UK and 69% in the United States had done so at least once in the previous 30 days. Drivers who had read or sent emails at least once in the past 30 days ranged from 15% in Spain to 31% in Portugal and the United States ("Mobile Device Use," 2013). Other risk factors for MVAs and related injuries and deaths include speed, alcohol, and nonuse of motorcycle helmets.

falls

Falls are the third leading cause of injury-related deaths—the leading cause for older adults. An average of 4 in 100 people experience a nonfatal fall for which they seek medical advice. More than half of all falls occur in the home, and about 80% of home falls involve people aged 65 years and older. The rate triples for adults older than 75 years (Adams, Barnes, & Vickerie, 2008). See the Example Problem: Falls, later in the chapter, for more information.

Fires and Electrical Hazards

Fire in a healthcare agency is more often related to anesthesia or improperly grounded or malfunctioning electrical equipment than to smoking. Most healthcare agencies have policies for preventing electrical hazards. Nevertheless, patients and visitors do break the rules, so smoking cannot be discounted as a hazard. When a fire occurs, an announcement is made over the communication system. Often, words such as "Code Red" or "Code Yellow" are used in an effort to prevent panic among patients and visitors. The announcement may ask visitors to leave the building.

prevent scalds and burns in the home

Fire is not the only cause of thermal injuries. Teach clients how to avoid scalds and burns from other causes: Turn pot handles toward the back of the stove so that children cannot grab and tip them over. Never wear loose-fitting clothing (e.g., wide sleeves) when cooking. KEY POINT: Avoid warming infant formula and food in the microwave. Many parents ignore this advice; therefore, tell them to always check the temperature of formula and food carefully before giving it to the child. Remove coverings from microwaved food carefully. Do not smoke, use matches, or drink hot liquids while holding an infant. Do not leave burning cigarettes unattended. Always check bath water temperature for children and older adults and set water heater temperature low enough to prevent scalds. Place guardrails in front of radiators and fireplaces. Wear protective clothing and sunscreen when outside.

non fatal incidents of suffocation

Food items (e.g., hot dogs, raw vegetables, popcorn, hard candies, nuts, and grapes) are responsible for most nonfatal choking.

food borne pathogens

Food poisoning is a nonspecific term that describes illness caused by ingesting bacteria and other microorganisms, or their toxins, in food. Improper food storage and preparation are a major cause of food poisoning. Raw foods are commonly associated with food-borne illness, for example raw meat, poultry, eggs, shellfish, raw fruits and vegetables, and unpasteurized milk and fruit juice. Poisonous chemicals in the environment, such as mercury, arsenic, zinc, and potassium chlorate, may also contaminate foods.

using restraints

For steps to follow in all procedures, refer to the Universal Steps for All Procedures found on the page facing the inside back cover Caution: This procedure describes Medicare standards, but state and agency policies may be more restrictive. Equipment Restraint of the appropriate size: belt, vest, wrist or ankle, or mitt Soft gauze or cotton padding for bony prominences Delegation As the nurse, you must determine whether restraints are needed in each specific situation. You must also select the least restrictive type of restraints, evaluate their effectiveness, and continue to assess for complications that may occur. You may delegate to the NAP the application and periodic removal of ordered restraints, after verifying that the NAP has the knowledge and skill to do so. Pre-Procedure Assessments Assess the patient's risk for falls, including mobility status and level of awareness. Assess for need for restraints: The immediate physical safety of the patient, a staff member, or others is threatened. If a patient must be temporarily restrained so that a procedure may be performed, this is not considered "restraint." Determine that all less restrictive interventions have been tried unsuccessfully. Identify the appropriate restraint: The least restrictive possible Does not interfere with care or exacerbate patient's medical condition Does not pose a safety risk to the patient Can be changed easily to keep it clean When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Determine whether dangerous behaviors continue despite attempts to eliminate causal factors using less restrictive interventions. 2. Obtain a prescription for restraint, including type of restraint, indications for use, site of restraint application, and duration. Determine if the restraint is being used for medical-surgical or behavioral reasons. Federal and state regulations and laws permit healthcare facilities to use restraints only when they are medically needed. Restraints can be used only with a physician's or advanced practice nurse's order for a specified and limited time. When you apply restraint in an emergency, obtain the order as the restraint is being applied or as quickly as possible afterward. When the restraint prescription expires (maximum 24 hr), physician assessment and a new prescription are needed. 3. Notify the family of the change in patient status and the need for restraints. Obtain patient and family consent when clinically feasible. Patients have the right to refuse treatment. Consent may not be necessary if there is an immediate threat to patient safety; however, as a rule, the family must be notified of the use of restraints if the patient has cognitive impairment. Many times family members prefer to sit with the patient as an alternative to restraint. 4. Pad bony prominences and apply the appropriately sized restraint, using appropriate knotting techniques. Use a quick-release knot, such as the half-bow, when tying restraints to the bed frame or wheelchair. Do not tie restraints to the siderails. A quick-release knot is used to prevent patient injury and for ease in caring for the patient. Tie the knot on an immovable part of the bed to prevent injuring the patient if the siderails or head of bed are lowered. A quick-release knot will not tighten or slip when the patient moves about, but it will untie quickly when you pull on the loose end. Variation: Belt Restraint a. Place the belt restraint at the patient's waist, removing any wrinkles. b. Make sure that the belt is snug but does not constrict the patient's waist. c. Some belts have a key-locked buckle to prevent slipping. A belt restraint is used mainly to prevent a patient from falling when getting up from a chair or wheelchair and may be used to remind a patient not to get out of bed unassisted. Variation: Vest or Jacket Restraint a. Place the patient in the vest restraint. A zipper-style vest is preferred. A vest restraint with a rear zipper is less likely to accidentally strangle the patient. b. Attach the vest straps to the bed or wheelchair. A vest restraint is used mainly to prevent a patient from falling out of a chair or wheelchair and sometimes to prevent a patient from getting out of bed unassisted. Variation: Wrist or Ankle Restraint a. Apply the padded portion of the wrist or ankle restraint around the patient's wrist or ankle. b. Make the restraint snug enough to prevent the patient from being able to slip it off but not tight enough to impair circulation. c. Attach the restraint strap to the bed frame. Do not attach to bed rails. A wrist restraint is used mainly to prevent an agitated patient from pulling at tubes, such as IV sites and nasogastric tubes. Variation: Mitt Restraint a. Place patient's hand in the mitt restraint, ensuring that fingers are slightly flexed in the mitt. b. Attach restraint strap to the bed frame if necessary. A mitt restraint is used mainly to prevent a patient from pulling at tubes, such as IV sites and nasogastric tubes. Mitt restraints limit the use of the fingers, which may be enough to prevent the patient from grasping the tube. If this is the case, mitts that are not tied to the bed frame are the least restrictive restraint. Variation: Enclosed Bed a. Place patient in the bed and zip all sides. Be sure zippers are completely closed and zipper tabs are positioned in the upper aspects of the net panels out of the patient's reach. b. Adhere to the manufacturer's minimum height and weight recommendations. c. Never leave the bed in the high position with the patient unattended. An enclosed bed is a canopy-like padded bed that is used mainly to keep a patient from wandering or from falling out of bed. The bed has nylon netting on all four sides, with zippered panels that can be opened to provide care. The patient has full freedom of movement and access to all parts of his body. Patients in enclosed beds have a higher risk of becoming entrapped between the bed rails and the mattress, risking suffocation. The dangers are greater for smaller patients and when the bed is left in a high position. 5. Adjust the restraint to maintain good body alignment, comfort, and safety. You should be able to slide two fingers under a wrist or ankle restraint. The restraint should be snug enough to prevent it from slipping off, but not tight enough to impair circulation. 6. Release restraints at least every 2 hours to provide skin care, passive and active range of motion (ROM), ambulation, toileting, hydration, and nutrition. Assess for the continued need for restraint. Prevents impaired circulation and injury. Medicare- and Medicaid-certified healthcare agencies must ensure that a patient's abilities do not decline unless the decline cannot be avoided because of the patient's medical condition. Patients often lose the ability to bathe, dress, walk, toilet, eat, and communicate when they are regularly restrained. If restraints are necessary, they must be used in a way that does not cause these losses. 7. Place the patient on fall risk precautions according to agency policy. Patients who are restrained have a higher incidence of falls. What if ... I must apply a restraint in an emergency, for the safety of the patient or others? In such an emergency, an RN may initiate a restraint. When you apply restraint in an emergency, obtain the order as the restraint is being applied or as quickly as possible afterward. Evaluation Assess the initial restraint placement, circulation, and skin integrity. Observe for pallor, cyanosis, and coolness of extremities when extremities are restrained. Check the restraint every 30 minutes (more often for a behavioral restraint). Release the restraint to assess circulation, the patient's response to the intervention, and the need for continuing the use of the restraint every 2 hours; remove it when it is no longer needed. KEY POINT: Patients in behavioral restraints require more frequent monitoring and in some circumstances require continual observation. Ensures that the restraint is still functioning as intended. Monitoring and reassessment are critical components of caring for patients in physical restraints. Frequency of monitoring is determined by the type of restraint (behavioral vs. medical-surgical). Check every 24 hours to see that the restraint prescription has been renewed. Remove the restraint as soon as possible. Modify the plan of care to reflect the application of restraints and the plan for monitoring. Patient Teaching Explain to the patient and family the need for the restraints. Explain that the restraints will be removed as soon as possible. Home Care The same guidelines apply to clients in the home. Evaluate caregivers' knowledge and skill in using restraints and provide teaching as needed (e.g., regarding padding bony prominences and the need to periodically release restraints). If an enclosed bed is used in the home, instruct the caregiver in safe use. Documentation Document the following: All nursing interventions that were done to eliminate the need for the restraint (e.g., moving patient closer to the nurses' station, asking a family member to remain with the patient, reorienting the patient) Reasons for placing the restraint (e.g., patient behaviors) The initial restraint placement, location, circulation, and skin integrity The teaching session with the patient and family members Circulation checks, range of motion, and restraint removal per agency protocol Entries on fall risk assessment sheet, restraint flow sheet, and nursing notes according to agency policy Sample documentation: 1/24/18 1230. Continues to be confused, pulling at IV lines. Physician notified and evaluated patient. Mitt estraints ordered and placed on bilateral hands. Fall risk precautions initiated. Mitt restraints explained to patient and wife. Wife agreed that mitt restraints would help keep her husband from removing IV lines. —— Mary Clinton, RN Practice Resources American Nurses Association (2012); Centers for Medicare & Medicaid Services (2006b, revised 2015).

general interventions related to safety

General Interventions Related to Safety Specific nursing activities are designed to monitor and manipulate the physical environment to promote safety. The following general activities provide an overview of your role in safe, effective nursing care (Thinking, Doing, Caring) in all types of settings and circumstances: Assess and continually monitor the safety needs of patients, based on their level of physical and cognitive function and past history of behavior. Provide client education to foster informed decisions, to promote involvement in care, and to facilitate post-discharge health. Evaluate and use techniques/processes to avoid medical/nursing errors in the delivery of client care. Remove hazards from the environment or modify the environment to minimize hazards and risk. Use technology to deliver safe effective care Establish mutual goals with clients and teach clients about specific safety measures. If an accident or injury occurs in the healthcare setting, file an incident report according to agency policy. See Chapters 18 and 44 for more information on this topic. Urge patients to be active members of the healthcare team For more information to help patients participate in their care, Go to The Joint Commission (TJC), Speak Up: Know Your Rights Web site at http://www.jointcommission.org/multimedia/speak-up-know-your-rights/

firearm injuries

Gun ownership is a controversial issue, so keep that in mind when you address patients. Some people keep guns in the home for protection and/or recreation (e.g., hunting, target shooting). However, guns are a source of unintentional injury and death. Gun safety and security are especially important when there are children or someone in the home who abuses substances. Household access to firearms has been implicated as a risk factor for youth and domestic homicide, as well as unintentional injury (Fowler, Dahlberg, Haileyesus, et al., 2015; Weinberger, Hoyt, Lawrence, et al., 2015). Because of the frequency and severity of unintentional firearm injuries involving children, the American Academy of Pediatrics and other groups have mounted efforts to educate parents about firearm safety.

health care culture

Healthcare has traditionally been a hierarchy with the physician at the top. However, healthcare professionals, including nurses, have been taught to practice with autonomy. This combination of factors sets the stage for a culture that does not respond well to questions about possible problems with patient care, particularly from subordinates. It is clear that such a culture needs to be repaired, and many healthcare organizations are working to address disrespectful behavior, staff reluctance to speak up about risks and errors, and blatant disregard of expressed concerns.

Needlestick inury for nurses

Healthcare workers, mostly nurses and housekeeping staff, suffer up to 1 million injuries per year from needles and other sharps, putting them at risk for infectious diseases, such as hepatitis B and AIDS. The operating room is a high-risk area; surgeons experience about a quarter of all "sharps" injuries (Waljee, Sunitha, & Chung, 2013). The federal Needlestick Safety and Prevention Act and OSHA standards require employers to maintain a log of sharps injuries and to purchase needleless systems and safer medical and needle devices. Needlestick injuries declined by more than 36% during the 3-year period following passage of that law. Nevertheless, OSHA (2013) estimates that each year 385,000 needlestick injuries and other sharps-related injuries occur. This is an average of approximately 1,000 sharps injuries per day in U.S. hospitals. The risk of needlestick injury increases for nurses who: Work in stressful environments Work varying or long shifts (12 consecutive hours or longer) Have low skill level, based on education or experience Other risk factors include a lack of protective equipment, recapping needles and working in an area that requires higher than average use of needles. Although OSHA has fined hospitals for noncompliance, some employers still have not complied completely with the regulations. For suggestions about how you can prevent needlestick injuries, see Clinical Insight 23-1.

high reliability organizations

High reliability industries are everywhere; most people just don't realize it—they range from amusement parks and zoos to oil drilling rigs, air traffic control, and nuclear submarines. High reliability is the ongoing safe operation of an organization without a mishap or adverse event (Chassin & Loeb, 2013). The concept has been slow to catch on in the healthcare industry. In healthcare, being a high reliability organization means having no preventable harm incidents and causing no harm to patients (The Joint Commission Center for Transforming Health Care, n.d.). High reliability is an ongoing journey, not a one-time achievement. It is a commitment to a culture of patient safety and quality healthcare.

Fires

Home fires are a major cause of death and injury. Older adults and children under age 5 have the greatest risk of fire death. Cooking fires are the number one cause of home fires and home fire injuries. Most fatal home fires occur while people are asleep, and most fire-related deaths occur from smoke inhalation. The following are other common causes of fire in the home:

resoinding to mercury spills

If a mercury spill is not properly cleaned, the mercury can remain in cracks and crevices for long periods of time and cause continuous exposure to mercury vapors. Large spills usually must be cleaned by a pollution control agency and can be very costly. It is especially difficult to remove mercury spills from carpets, so they usually have to be disposed of as hazardous waste. If you must clean mercury spills of 25 mL or less, consult Box 23-4. BOX 23-4 What to Do If There Is a Mercury Spill Do not touch mercury droplets. Mercury vaporizes; the toxic vapors can be inhaled or absorbed through the skin. In the Healthcare Agency If you are not trained in the procedure, do not attempt to clean up a mercury spill. Notify the environmental services department. Keep people and animals away from the area. Clean the spill promptly. If you are trained, use a commercially made mercury spill kit. All healthcare facilities should have them. Spill kits should contain gloves, protective glasses, mercury-absorbing powder, special mercury sponges, and a disposal bag. Some kits have filtered vacuum equipment. Follow agency guidelines and instructions in the kit. Clean beads off skin, clothing, and disposable items. Place cleaning materials and disposable items in the disposal bag and seal. Follow agency policy for laundering clothing. On hard surfaces, use a flashlight to search for beads. Change clothing that has been contaminated. Wash well. Shower and wash your hair as soon as possible so you do not unknowingly carry mercury home. Ventilate the area well to reduce the concentration of mercury vapors. Promote exhaust ventilation if possible. Complete an occurrence report. In the Home and Community If you do not have a spill kit, wear rubber gloves and eye protection; use paper towels for cleanup and a plastic bag for disposal. Keep people and pets away from the area. Wipe beads off skin, clothing, and disposable items. Place disposable items in the plastic bag and seal with tape. On hard surfaces, use cardboard to scrape up the beads and pour them into a can or jar with a lid. Then wash the area. Shower or wash well. Keep the area well ventilated for several days. Do not use a broom or vacuum cleaner. These will just spread the mercury around and they will become contaminated by it. Do not flush mercury or cleaning materials down a toilet or drain. Do not wash and reuse contaminated materials.

prevent carbon monoxide poisoning

If carbon monoxide (CO) intoxication is suspected, the person should be treated with 100% humidified oxygen. A simple blood test may be done to confirm CO levels in the blood. Teach prevention measures, such as the following: Buy, install, and maintain a home CO detector. Ensure that gas or wood-burning appliances are adequately vented to the outside. Repair rust holes or defects in vehicles that could allow exhaust fumes to enter the passenger compartment. Do not use a kerosene heater, gas oven, or gas range to heat a house, even for a short time. Never operate gasoline-powered engines such as automobiles, generators, or lawn mowers near open doors or windows or in confined spaces, such as garages or basements. Never burn charcoal inside a home, cabin, recreational vehicle, or tent—not even in a fireplace.

soil

Improper waste disposal and excessive use of pesticides can contaminate soil. Agricultural, industrial, and manufacturing processes create solid and toxic waste. Animal, radioactive, and medical wastes pose special problems. Household products (e.g., paints, cleaners, oils, batteries, and pesticides) contain corrosive or toxic ingredients that contaminate the environment when disposed of improperly.

individual risk factor

In addition to developmental stage, individual factors also influence a person's risk for unintentional injury. These include lifestyle, cognitive awareness, sensoriperceptual status, ability to communicate, mobility status, physical and emotional health, and awareness of safety measures. Table 23-2 summarizes individual risk factors.

prevent poisoning in the home

In all cases of suspected poisoning, call 911 or the local emergency number right away. Even if the person is having no symptoms, call the poison control center (PCC) as soon as possible. The National PCC number is (800) 222-1222; they will connect you to a local PCC. Never induce vomiting when the ingested material is acidic or caustic to the esophagus. Although the American Academy of Pediatrics no longer recommends inducing emesis (e.g., with syrup of ipecac), some practitioners may still do so. The National Poison Control Center does not support routinely stocking ipecac in households with young children. It should be given only on specific recommendation from a poison center or qualified medical personnel (American Academy of Pediatrics, 2003). For Children Nursing interventions focus on teaching parents how to childproof the home and what to do if someone ingests a poisonous substance. All homes should be equipped to handle an emergency if poisoning occurs. Teach parents: To keep the telephone number for the nearest PCC easily accessible. If they suspect a child has ingested a poisonous substance, it is crucial to obtain help immediately so there is less time for the substance to enter the child's system. For Adults Unintentional poisoning can affect people at all ages and from all walks of life. However, it may surprise you that middle-aged adults have the highest unintentional poisoning death rates. Advise clients of the following: Take only medications prescribed by a healthcare professional. Never take larger or more frequent doses of medications to try to get faster or better relief, particularly prescription pain medications. Never share or sell your prescription drugs. Be sure to follow directions on the medications and read all warning labels. Advise families with older adults to prevent accidental overdose or misuse of prescribed medications by using a medication organizer with compartments for the days/times the pills are to be taken. The patient or a family member may fill the organizer once a week. For steps to prevent poisoning, see the Home Care box Preventing Poisoning in the Home. For actions to take if poisoning occurs at home,

Infant and todler safety

Infant/Toddler Infants and toddlers are completely dependent on others for their care. They are able to walk and manipulate objects before they have the judgment to recognize dangers. Infants and toddlers are curious and tend to explore the environment by putting objects in their mouth. This is why the incidence of choking is highest between 6 months and 3 years of age. As mobility continues to improve, toddlers gain more freedom, and their curiosity leads them to explore cupboards, stairs, open windows, swimming pools, and other hazards (CDC, 2012). Drowning is the leading cause of death for children aged 1 to 4, followed by motor vehicle accidents ("Vital Signs," 2012). Falls, choking, sudden infant death and ingesting poisons are other critical safety concerns.

quality nursing care

KEY POINT: Because nurses are the healthcare professionals who spend the greatest amount of time with patients, research documents what physicians, patients, and nurses themselves have long known: The quality of nursing care affects patient health and outcomes and sometimes can be a matter of life and death. In providing quality care and patient safety, nurses are indispensable. Studies have shown that: Greater numbers of patient deaths are associated with fewer nurses to provide care (Aiken, Clarke, Sloane, et al., 2001; Brennan, Daly, & Jones, 2013; Kutney-Lee & Aiken, 2015). Less nursing time provided to patients is associated with higher rates of infection, gastrointestinal bleeding, pneumonia, cardiac arrest, and death from these and other causes (Kalisch, Tschannen, & Lee, 2012; Stimpfel & Aiken, 2013; Unruh & Zhang, 2012).

assessing for home safety

Many accidents occur in the home (e.g., fire, poisoning). Everyone should take a few minutes to check for environmental safety hazards.

medicare on safety

Medicare is a federal agency that has identified "never events" or hospital-acquired conditions (HAC): costly errors that cause serious injury or death, and that are mostly preventable (falls, injuries from restraints). Medicare will no longer pay institutions for care required to treat the effects of such errors (Centers for Medicare & Medicaid Services, 2006a, modified 2015).

1. Assess for factors that increase the risk for aggression:

Mental disorders, such as dementia, delirium, schizophrenia, and bipolar disorder Being under the influence of alcohol or other drugs Withdrawal from alcohol or other drugs History of violence Clinical conditions such as high fever, epilepsy, head trauma, and hypoglycemia

mercury exposure

Mercury is a heavy, odorless, silver-white liquid metal. Mercury is toxic in both acute and chronic exposure. It can be inhaled, ingested, or absorbed through the skin. It accumulates in muscle tissue and can cause renal and neurological disorders, especially in fetuses and neonates. Because of its shiny color and ability to form beads or balls, mercury is appealing to curious children. See Table 23-3 for potential health effects. Products containing mercury include thermometers, thermostats, batteries, fluorescent light bulbs, blood pressure devices, and electrical equipment and switches. Since 1998, the American Hospital Association and the EPA have sponsored a program to eliminate mercury-containing waste in the healthcare industry and prevent it from entering the environment via incinerators, landfills, and wastewater. Thermometers and Sphygmomanometers. Mercury thermometers are no longer being made in the United States. However, some people may still have them in their homes. Most, but not all, healthcare facilities have eliminated mercury thermometers and sphygmomanometers. Some hospitals conduct thermometer exchanges, providing free or low-cost nonmercury thermometers to anyone who brings in a mercury thermometer. Mercury Spills. Healthcare facilities must have policies and procedures for hazardous waste spills, as required by The Joint Commission, the EPA, the Occupational Safety and Health Administration (OSHA). You are not likely to encounter mercury exposure in acute care and ambulatory agencies.

Weather Hazards

More than 1,000 people die each year in the United States as a result of weather hazards. The most likely killer is heat. The number of deaths caused by lightning, tornadoes, and hurricanes has fallen steadily during the 21st century, and deaths related to floods have declined because of advances in technology and warning systems (National Weather Service, 2015). For additional information about weather hazards,

mosquitoes and vecor borne pathogens

Mosquitoes The severity of the reaction to a mosquito bite depends on the degree of allergy to the mosquito's saliva. In addition to the discomfort caused by bites, infected mosquitoes can transmit diseases such as West Nile virus and malaria. They can also transmit parasites to domestic animals (e.g., canine heartworm, equine encephalitis).

coping with violence

Some agencies have a "public safety room." Patients who have been arrested and brought to the hospital for blood and urine testing for alcohol and drug levels, or any hostile patient who has risk factors for violence, should receive care in the public safety room. The following are other interventions for preventing and protecting yourself from violence (Ackley & Ladwig, 2010; Bulechek, Butcher, Dochterman, et al., 2012; Doenges, Moorhouse, & Geissler-Murr, 2010; Flores, 2008; Wilkinson & Barcus, 2017). Intervene to relieve anxiety. Anxiety often precedes violent behavior. Treat underlying medical conditions. For example, give medications or check blood glucose levels. Administer sedatives such as diazepam or lorazepam. There may be standing prescriptions for these. Use a calm, reassuring approach. Avoid using threatening, aggressive body language. Don't respond to anger with anger. Don't defend when the patient is verbally aggressive. Don't wear a stethoscope around your neck, dangling jewelry, or anything a patient might use to hurt you. If you know you will be receiving an angry patient, remove objects from the room that could be used as a weapon. Don't go into a room alone with an angry patient. Keep the room door open; do not let the patient get between you and the door. Remain at least an arm's length away from the angry patient. Do not turn your back on an angry patient. Do not touch the patient without permission, unless you intend to physically restrain him. Protect others in the environment. Follow the department's safety guidelines. As a last resort, use mechanical restraints if ordered and as necessary. Your priority must be your own safety and the safety of others in the area.

accountability

Staff claim ownership for human error and are willing to disclose the error and help prevent similar errors

animals and vector borne pathogens

Structural defects in a building (e.g., roofs and walls) permit entry of birds, rodents, and other small animals, and dead spaces in walls permit their circulation among apartments in multiunit dwellings. Rodents and other animals can also act as vectors and allergens. Examples include the following: Rabies can be spread through the bite of a rabid animal. Some fungal diseases can spread via the inhalation of bird droppings. Mouse proteins have been implicated in the occurrence of asthma.

noise

Substantial exposure to noise is associated with various adverse health effects, including hearing loss, stress, elevated blood pressure, and loss of sleep. Noise is pervasive in our society, caused by, among other sources, road traffic, airplanes, garbage trucks, construction equipment, lawn mowers, and loud music. People who live or work near major roads, bus depots, airports, and trucking routes are at greater risk, as are those in certain work environments (e.g., railroad workers).

suffocation/asphyxiation

Suffocation by smothering is the leading cause of death for infants younger than 1 year. Suffocation may be caused by drowning, choking on a foreign object, or inhaling gas or smoke.

infants (suffocation)

Suffocation of infants is often related to bed or crib hazards, such as excess bedding or pillows, or toys hung from long ribbons inside the infant's crib. Infants can become entangled in cords from window blinds or in the ribbon or string used to hang a pacifier around an infant's neck.

toxicity of mercury

Symptoms of chills, nausea, malaise, chest tightness and pain, dyspnea, coughing, stomatitis, gingivitis, excess salivation, and diarrhea. High levels can cause severe respiratory irritation, digestive disturbances, and severe renal damage.

Choking rescue

Teach adults the universal sign for choking (Fig. 23-3) and basic first aid for choking, but explain that choking rescue is a skill that is best taught using supervised practice with a mannequin. Recommend that clients attend classes presented by organizations such as the Red Cross or the American Heart Association. KEY POINT: The most important thing to remember when someone is choking is to have someone call 911 immediately.

food safety

Teach clients safe food handling and other preventive measures, such as the 4 Cs of food safety: Clean, Cook, Combat cross contamination, Chill. For further explanation of the 4 Cs, refer to the Self-Care box Food Safety. Food Safety Clean Wash hands and surfaces often. Always wash your hands with soap and water before handling or preparing food and before eating. Don't be a source of food-borne illness yourself: Avoid preparing food for others if you yourself have a diarrheal illness. Avoid changing a baby's diaper while preparing food. Wash produce. Rinse fresh fruits and vegetables in running tap water to remove visible dirt. Remove and discard the outermost leaves of a head of lettuce or cabbage. Never use a cutting board, knife, or other object that was used to prepare meat, poultry, or fish for any other purpose until it has been thoroughly washed in hot, soapy water. Be careful not to contaminate foods while slicing them up on the cutting board. Bacteria grow well on the cut surface of fruits or vegetables. Wash hands with soap after handling reptiles, birds, or baby chicks and after contact with pet feces. Cook Use a thermometer to measure the internal temperature of meat. Cook to temperatures sufficient to kill bacteria. Ground beef to an internal temperature of 160°F (71°C) Leftovers and casseroles, 165°F (74°C) Beef, lamb, and veal, 145°F (63°C) Pork and ground beef, 160°F (71°C) Whole poultry and thighs, 180°F (82°C) Poultry breasts, 170°F (77°C) Ground chicken or ground beef, 165°F (74°C) Stuffed fish, 165°F (74°C) Roast meats at an oven temperature of 300°F (149°C) or above Cook eggs until the yolk is firm. Do not eat raw or partially cooked eggs. Hold hot food above 140°F (60°C) and do so for no more than 2 hours. Combat Cross Contamination (Separate) Avoid cross contaminating foods by washing hands, utensils, and cutting boards after they have been in contact with raw meat or poultry and before they touch another food. Put cooked meat on a clean platter, rather than back on one that held the raw meat. Chill Refrigerate leftovers within 4 hours. Bacteria multiply quickly at room temperature. Avoid leaving cut produce (e.g., fruits, vegetables) at room temperature for a prolonged time. Chill cooked foods rapidly in a shallow (2 in. in depth) container. Large volumes of food will cool more quickly if they are divided into several shallow containers for refrigeration. Do not buy partially thawed items. Be sure they are frozen solid. Use a cooler to transport foods when the temperature is above 80°F (27°C). Store deli meat for only 1 or 2 days. Use thermometers in the refrigerator and freezer. Keep freezer temperature at 0°F (-18°C) or below. Keep refrigerator temperature at 40°F (4°C) or below. Thaw foods in the refrigerator or under cold running water. Use the microwave to thaw foods only if you are going to continue cooking them at that time. Pack lunches in insulated containers. You can refrigerate or sometimes freeze sandwiches before packing to keep them cold. Store Cover and date food. Store vegetables and fruit separately from uncooked meats. Do not store food in decorative containers unless they are labeled safe for food. Some crystal and pottery, for example, have high lead content. Store cleaning supplies away from food. Report Report suspected food-borne illnesses to your local health department, which is an important part of the food safety system. Often calls from concerned citizens are how outbreaks are first detected. Other Never eat any food that has an odor or that might be spoiled. Be aware that some imported folk remedies, such as greta (which is used by some Hispanic patients for colic), may be contaminated with lead. Observe sanitation reports for selecting eating establishments in the comm

weather hazard safety measures

Teach clients that if they are aware of what weather event is about to impact their area, they are more likely to survive it. Before severe weather strikes, suggest that clients: 1. Develop a disaster plan at home, work, school, and when outdoors. The American Red Cross offers planning tips and information on a putting together a disaster supplies kit at: the American Red Cross Web site, http://www.redcross.org/ 2. Identify a safe place to take shelter. For information on how to build a Safe Room in your home or school, Go to the Federal Emergency Management Agency Web site at https://www.fema.gov/safe-rooms 3. Know the county/parish in which you live or visit and in what part of that county you are located. The National Weather Service issues severe weather warnings on a county/parish basis or for a portion of a county/parish. 4. Keep a highway map nearby to follow storm movement from weather bulletins. 5. Have a Weather Radio receiver unit with a warning alarm tone and battery backup to receive warning bulletins. 6. Check the weather forecast before leaving for extended periods outdoors. Watch for signs of approaching storms. 9. If severe weather threatens, check on people who are elderly, very young, or physically or mentally disabled. Don't forget about pets and farm animals.

intervention for example problem: prevent falls at the home

Teach clients, especially older adults, measures for increasing the safety of their home environment. Use the material in the Home Care box Preventing Falls in the Home and also the material found in Example Problem: Falls.

reducing pollution

Teach families they can help to reduce solid pollution and hazardous wastes as well as air and noise pollution of the environment. Refer to the following tips: Air Pollution To help reduce air pollution, pay attention to air quality warnings, and restrict time spent in high-traffic areas. You might also participate in car pools or use public transportation whenever possible. Noise Pollution Two specific interventions you can teach clients to help prevent irreversible hearing loss are to (1) avoid exposure to high noise levels and (2) wear protective devices (e.g., ear plugs) in environments with a high noise level. Hazardous Waste The following are tips for safe disposal: Information. Contact the local refuse disposal company for instructions about proper disposal of hazardous waste (e.g., paints, solvents, pesticides, cleaners, rechargeable batteries). Product. Use nonhazardous or less hazardous products; use only the amount necessary for a project. Share leftover materials with neighbors. Motor Oil. Never dump motor oil into storm drains. Instead, call your local waste management company, a local quick-lube, or tire dealer for recommendations regarding disposal. You can also, Go to http://www.valvoline.com/auto-resources/motor-oil-faq-recycled Batteries. Talk to an automotive dealer or repair service about recycling or trading in car and other batteries. Solid Waste Proper disposal and recycling of solid wastes helps to prevent pollution. Remember the 4 Rs: Reduce, Reuse, Recycle, and Respond. Reduce the amount of trash discarded (e.g., don't buy products that have unnecessary packaging). Reuse containers, bags, and products; sell or donate instead of throwing items out. Recycle by using and buying recyclable and recycled products; compost yard trimmings. Respond by educating others, expressing preferences for less waste (e.g., to manufacturers, merchants).

transparency

Team members are united in their efforts to eliminate rumors and operate with only the facts, contributing to mutual team goals.

Reducing alarm fatigue

The American Association of Critical-Care Nurses suggests the following nursing actions: Provide proper skin preparation for ECG electrodes. Change ECG electrodes at least daily. Set alarm parameters and levels on ECG monitors to meet individual needs. Collaborate with the interprofessional team to customize delay and threshold settings on oxygen saturation via pulse oximetry (SpO2) monitors. Provide education about devices with alarms. Establish interprofessional teams to address issues such as the development of policies and procedures related to alarms. Monitor only those patients with clinical indications for monitoring, as determined by the interprofessional team. For more explanation about the AACN strategies to reduce alarm fatigue and improve patient safety,

American nurses association on safety

The American Nurses Association's (ANA) ANA's Health System Reform agenda (2010) recommends six major public policy changes that can raise the quality of healthcare. Quality Aim 1 is safe healthcare.

Safety hazads in the healthcare facility

The Institute of Medicine (IOM) (1999) estimated that as many as 98,000 people die as a result of medical injuries each year in U.S. hospitals. The estimated number of deaths has grown over time to more 400,000 people each year as a result of medical errors, which are the third leading cause of death in the United States (Leap Frog Group, 2015). This increase may be due in part to better reporting and measuring of outcomes. Healthcare facilities embody several safety hazards for residents and workers. We have already discussed the hazard of infection in Chapter 22. Box 23-2 lists The Joint Commission's National Patient Safety Goals for 2016, which should give you an idea of the types of accidents that occur in healthcare agencies. If you would like to see a full explanation of the patient safety goals. Organizational factors contribute to errors and to safety problems in healthcare, including the following: Poor design Maintenance failures Unworkable procedures Shortfalls in training Less than adequate tools and equipment Inadequate staffing Disruptive behavior and intimidation in the workplace Culture of disrespect among healthcare professionals

joint commision on safety

The Joint Commission, the accrediting body for healthcare facilities, each year publishes National Patient Safety Goals. For example, the 2016 goals include improving the accuracy of patient identification, improving the safety of medication use, reducing the risk of healthcare-associated infections, and preventing mistakes in surgery. For a link to the 2016 National Patient Safety Goals,

Morse Fall Scale

The Morse Fall Scale uses the following questions to assess a person's risk for falls: 1. Does the patient have a history of falling? 2. Does the person have more than one medical diagnosis? 3. Does the person use ambulatory aids such as crutches or a walker? 4. Does the person have an IV line or a saline lock? 5. Is the person's gait normal or stooped or otherwise impaired? 6. What is the person's mental status (e.g., disoriented, forgetful)? You can easily score, tally, and record those six variables on the patient's chart. The risk of falling varies greatly with different patient populations, different times of day, and different stages of the patient's illness. Age alone is not a predictor of falls, but the items scored by the scale are more common in older adults (Morse, 2001).

planning outcomes/ evaluations

The NOC standardized outcomes you use will depend on the nursing diagnosis. The following are some examples: Aspiration Prevention Community Disaster Response Fall Prevention Behavior Parenting: Infant/Toddler Physical Safety Personal Safety Behavior Physical Injury Severity Respiratory Status: Airway Patency Safe Home Environment Thermoregulation Individualized goals/outcome statements you might write for a client's safety diagnoses include the following examples: The child will be free of injury. (Client) will experience no physical injury due to environmental hazards. Family members will describe their planned escape routes in case of fire.

fighting vecotr borne pathogens

The following are points you can use to teach clients about strategies to combat the vectors, mosquitoes, ticks, and rodents (CDC, 2015c; U.S. Environmental Protection Agency, 2016). Mosquitoes Public strategies to control mosquitoes include spraying programs and digging ditches to promote drainage from stagnant areas. Individuals can help by taking the following actions: Remove sources of stagnant water. Empty standing water in old tires, buckets, toys, or other outdoor containers. Change water in birdbaths, fountains, wading pools, and potted plant trays at least once a week to destroy mosquito habitats. Keep rain gutters unclogged. Treat swimming pools with the proper chemicals and keep the water circulating. Kill or repel mosquitoes. Use "bug zappers" or citronella candles for evening outdoor activities. Use EPA-registered mosquito repellents when necessary and follow label directions carefully. All repellents and pesticides should have the name and amount of active ingredient on the label. No pesticide is 100% safe, so use them cautiously. Avoid mosquitoes, if you can. Repair holes in window and door screens. Replace outdoor lights with yellow "bug" lights. They will attract fewer mosquitoes, but they are not repellents. In areas with high mosquito populations (e.g., salt marshes, deep woods), use head nets, long sleeves, and long pants. If there is a mosquito-borne disease alert, stay indoors during the evening, when mosquitoes are active. Consult the experts. Contact your local health department if you have questions about mosquitoes or about a spraying program. Ticks When walking in tick-infested areas: Use DEET-containing insect repellant. Reapply it every few hours (or according to the label). Formulations as high as 50% are recommended for adults and children over age 2 months. Use with caution for children. Wash off repellent at night before going to bed. When wearing sunscreen, apply sunscreen first and then repellent. Remove sources of stagnant water. Empty standing water in old tires, buckets, toys, or other outdoor containers. Change water in birdbaths, fountains, wading pools, and potted plant trays at least once a week to destroy mosquito habitats. Keep rain gutters unclogged. Treat swimming pools with the proper chemicals and keep the water circulating. Kill or repel mosquitoes. Use "bug zappers" or citronella candles for evening outdoor activities. Use EPA-registered mosquito repellents when necessary and follow label directions carefully. All repellents and pesticides should have the name and amount of active ingredient on the label. No pesticide is 100% safe, so use them cautiously. Avoid mosquitoes, if you can. Repair holes in window and door screens. Replace outdoor lights with yellow "bug" lights. They will attract fewer mosquitoes, but they are not repellents. In areas with high mosquito populations (e.g., salt marshes, deep woods), use head nets, long sleeves, and long pants. If there is a mosquito-borne disease alert, stay indoors during the evening, when mosquitoes are active. Consult the experts. Contact your local health department if you have questions about mosquitoes or about a spraying program. Ticks When walking in tick-infested areas: Use DEET-containing insect repellant. Reapply it every few hours (or according to the label). Formulations as high as 50% are recommended for adults and children over age 2 months. Use with caution for children. Wash off repellent at night before going to bed. When wearing sunscreen, apply sunscreen first and then repellent.

keeping equipment safe

The following interventions help ensure safe use of equipment: Seek advice if you are unsure how to operate the equipment. Make sure medical equipment has been properly inspected. Be alert to signs that the equipment is not functioning properly. Make sure that rooms are not cluttered with equipment. Follow agency policies regarding equipment brought from the patient's home (e.g., hair dryers, electric shavers, radios); usually these should be inspected for proper grounding and safe cords.

Violence injuries for nurses

The impact of violent acts on healthcare workers is widespread and results in injuries, higher-than-average staff turnover, increased requests for medical leaves, unusually high levels of time-off and attendance issues, and stress-related illnesses (Papa & Venella, 2013). Hospital security may not be sufficient to protect you from injury if violence breaks out among patients, visitors, and/or staff. This is especially true in the following situations: A crowded or chaotic environment—For example, the emergency department (ED), which has 24-hour accessibility, is often both crowded and chaotic. Anxiety and anger—Under the stress of an acute illness, patients and family members may become anxious and angry and act out in unpredictable ways. KEY POINT: Violence typically begins with anxiety and escalates in stages through verbal aggression and then physical aggression. If you can relieve a patient's anxiety, you may be able to halt the progression to physical violence. Certain emotional and physical conditions—These often increase the risk for patient aggression (refer to Assessing the Risk for Violence). Gang activity—Now widespread in many U.S. cities, gang activity is another potential source of violence. As gangs increase, so does the likelihood that gang members will be treated in the ED or admitted to the hospital (Gillespie, Gates, & Berry, 2013; Taylor & Rew, 2011).