Unit 15; Patient Safety and Positioning

Guidelines for Preventing Falls

- Leave the bed in the lowest horizontal position when you have finished giving care. - Keep brakes locked on beds at all times except when the bed is being moved. - Check the care plan to find out whether the side rails are to be used. - Check and adjust protruding objects such as bed wheels or gatch handles. - Do not block or clutter open areas with supplies and equipment. - Wipe up spills immediately. - Encourage patients to use the handrails along corridor walls while walking. - Monitor patients for signs of weakness, fatigue, dizziness, and loss of balance. - Monitor patients for safe practice if they independently: propel their wheelchairs, transfer (get out of bed), and ambulate (walk). - Provide adequate lighting. - Eliminate noise and other distractions that may increase confusion and create anxiety. - Avoid leaving patients alone in the tub or shower unless you are given specific permission to do so. - Check patient's clothing for fit and safety. Loose shoes and laces, long robes, and slacks increase the risk of falling. Footwear should be appropriate for the floor surface. In general, this means using non-skid shoes on tile floor surfaces. However, non-skid shoes may stick to carpeting, causing falls. A leather or synthetic shoe sole may be more appropriate for a carpeted surface. - Care for the patient's physical needs promptly. Many incidents occur when patients attempt to get out of bed to go to the bathroom. - Always use the correct technique for transferring and walking patients. - Use a gait belt when assisting patients to transfer or ambulate. - Follow the care plan when assisting patients with transfers and ambulation. - Elevate the rails if you must leave the bedside while the bed is in the high position.

Examples of Physical Restraints Include:

- Wrist/arm and ankle/leg restraints - Vests - Belts - Jackets - Hand mitts - Geriatric and cardiac chairs - Wheelchair safety belts, bars, and tables - Bed rails (if they meet the definition of a restraint) Restraints are medical devices. They should never be used as a form of punishment, or for the convenience of the nursing staff. An example of nursing convenience is when a unit does not have enough staff, or staff do not have enough time to monitor a patient. Another important concern is restraint size. A restraint that does not fit correctly will not hold the patient securely and increases the risk of injury. Using a restraint that does not fit correctly or is not applied according to manufacturer's directions creates a risk of very serious injuries. Manufacturers provide literature, teaching aids, and guidelines for restraint size, based on patient weight. The color of the trim (piping, binding) on a vest restraint is often a visual key to its size. This color coding does not apply to other types of restraints. Belts are usually one-size-fits-all. Before restraints are used, the registered nurse must assess the patient's capabilities and the reasons for restraint. If the cause can be identified and corrected, the need for a restraint may be eliminated. For example, an unsteady male patient gets up to use the bathroom at night, but does not call for help. His risk of falls can be modified by making sure a urinal is within reach and emptied regularly. The care plan will provide information about the type of restraint to use, the time the restraint is to be applied, and other special information and instructions.

Procedure 12: Moving a Patient to the Head of the Bed

1.) Carry out each initial procedure action. 2.) Ask a co-worker to assist from the opposite side of the bed. 3.) Lock the wheels of the bed. Raise the bed to a comfortable horizontal working height. Lower the side rails. 4.) Lower the head of the bed if the patient can tolerate this position. Remove the pillow. Place it at the head of the bed, on its edge, for safety. 5.) Lift the top bedding and expose the draw sheet. Loosen both sides of the draw sheet. 6.) Roll the draw sheet edges close to both sides of the patient's body. 7.) Face the head of the bed. Grasp the draw sheet with the hand closest to the foot of the bed. 8.) Position your feet 12 inches apart, with the foot that is farthest from the bed edge forward. 9.) Place your free hand and arm under the patients neck and shoulders, cradling the head from both sides. 10.) Bend your hips slightly. 11.) Together, on the count of three, raise the patient's hips and back with the draw sheet, while supporting the head and shoulders. Move the patient smoothly towards the head of the bed. 12.) Replace the pillow under the patient's head. 13.) Tighten and tuck in the draw sheet. Adjust the top bedding. 14.) Carry out each ending procedure action.

Procedure 11: Turning the Patient Away from You

1.) Carry out each initial procedure action. 2.) Lower the near side rail. Be sure the side rail on the opposite side of the bed is up and secure. 3.) Have the patient bend the knees, if able. Cross the arms on the chest. 4.) Place your arm nearest the head of the bed under the patient's head and shoulders. Place the other hand and forearm under the small of the back. Bend your body at the hips and knees. Keep your back straight. Pull patient toward the edge of the bed. 5.) Place your forearms under the patient's hips and pull them toward you. 6.) Move the ankles and knees toward you by placing one hand under the ankles and one hand under the knees. 7.) Cross the near leg over the other leg at the ankles. 8.) Roll the patient slowly and carefully away from you by placing one hand under the shoulder and one hand under the hips. 9.) Place your hands under the head and shoulders. Draw them back to the center of the bed. 10.) Move the hips to the center of the bed, as in Step 5. 11.) Place a pillow for support behind the back. 12.) Make sure that the patient's body is in good alignment. Support the upper leg with a pillow. Place the lower arm in a flexed position. Support the upper arm with a pillow. 13.) Replace the side rail on the near side of the bed. Return the bed to the lowest position. 14.) Carry out each ending procedure action.

Procedure 10: Turning the Patient Toward You

1.) Carry out each initial procedure action. 2.) Lower the side rail nearest to you. Cross the patient's far leg over the leg that is nearest to you. 3.) Cross the far arm over the patient's chest. Bend the near arm at the elbow, bringing the hand towards the head of the bed. 4.) Place your hand nearest the head of the bed on the patient's far shoulder. Place your other hand on the patient's hips on the far side. Brace your thighs against the side of the bed. 5.) Roll the patient toward you. Do it slowly, gently, and smoothly. Help the patient bring the upper leg toward you and bend it comfortably. 6.) Put up the side rail. Be sure it is secure. 7.) Go to the opposite side of the bed. 8.) Place your hands under the patient's shoulders and then the hips. Pull toward the center of the bed. This helps the patient maintain the side-lying position. Make sure the patient is not lying directly on the lower arm. The lower shoulder should be tipped slightly, so pressure is not centered directly over the joint. 9.) Make sure the patient's body is properly aligned and safely position. 10.) A pillow may be placed behind the patient's back. Secure it by pushing the nearest side under the patient to form a roll. 11.) If the patient is unable to move independently, position the arms and the legs. Support them with pillows between the shoulders, hands and knees, and ankles to prevent friction and contractures. If the patient has an indwelling catheter, make sure the tubing is not between the legs, to prevent traction on the catheter and to prevent pressure ulcers. 12.) Carry out each ending procedure action.

Changing a Patient's Position Involves Three Steps:

1.) Moving the person into proper body alignment. You may need to move the person up or to one side of the bed. If he or she will be positioned on the left side, move him or her to the right side of the bed. Move him or her to the left side of the bed if you will be returning him or her to the right side. This insures that he or she will not be too close to the edge of the bed after he or she is turned. 2.) Turning the patient onto the back, onto the abdomen, or onto the side. 3.) Placing the person's trunk and extremities in proper position and maintaining alignment with the use of support of devices.

Supine Position

1.) Start with the bed flat and the patient lying on the back. The patient's head should be about 2 to 3 inches from the head of the bed. 2.) Place a pillow under the patient's head. It should extend about 2 inches below the patient's shoulders, with the head in the middle of the pillow. 3.) Place a trochanter roll along the affected hip or along both hips if the patient has little control over the legs. A trochanter roll is devised by rolling a bath blanket into a shape about 12 inches long. The roll should be just long enough to reach from above the hip to above the knee. The trochanter roll prevents external rotation of the hip. Make a trochanter roll or support by: - Folding a bath blanket lengthwise in thirds. - Positioning the patient in the center of the folded bath blanket. The blanket should extend from mid to lower thigh to the waist. - Rolling each side of the blanket under and toward the patient until the blanket roll is firmly against the patient. Then tuck the roll inward toward the bed and patient to maintain the patient's position. 4.) Place pillows under the legs to reach from above the back of the knee to the ankle so that the ankles and heels do not rub on the sheets. 5.) Laying flat on the back is very uncomfortable for some people. This is especially true for persons with low back pain. Elevating the knees with a foam bolster or one or more pillows will relieve pressure on the back and reduce discomfort. 6.) If the care plans so indicates, position a footboard or place a folded pillow to support the patients feet. The ankles should be at 90° angles. 7.) Extend the patient's arms and place small pillows to reach from the elbow to below the wrists. The hand should be in alignment with the wrist and the palm should be down.

Positioning the Patient

After you have turned and move the patient into good alignment, you can place pillows and other supportive devices to help the person maintain the position. Directions are given here for the basic four positions and their variations.

Alternatives to the Use of Restraints

Alternatives to restraints should be tried before restraints are applied. Restraints are used only as a last resort in situations where a patient may harm himself or others. If you observe a condition that causes confusion or agitation, or discover an approach that is effective in eliminating or reducing the need for restraints, inform the nurse immediately.

Choking

Aspiration is the entry of food, water, gastric contents, or a foreign object into the trachea and lungs. It is usually accidental, such as when a patient "swallows down the wrong tube" or inadvertently inhales food or fluids. Because swallowing becomes less efficient as people age, choking and aspiration occurs more often in elderly persons. Those who are disoriented or who have impaired consciousness are also at risk. To prevent choking or aspiration, be aware of which patients have problems with swallowing. Follow the guidelines for feeding and poisoning in Unit 28. Know the procedure to clear an obstructed airway.

Body Alignment and Positioning

Body alignment means a position in which the body can properly function. Patients who are weak, have impaired consciousness, are disoriented, or are in pain have problems keeping good body alignment. Good posture is comfortable for the patient and enables him or her to function at the highest level of ability. Body systems will function more efficiently.

Body Mechanics for the Patient

Body mechanics for the patient are very similar to those for the health care worker. Good posture for the patient means that moving in bed, getting out of bed, standing, and walking are done safely. Patients should be well supported in good body alignment when sitting. Bed patients tend to slide toward the foot of the bed when the head of the bed is elevated. Patients who are dependent are not able to change their position. These patients need extra help to gain and maintain proper alignment.

Introduction to Procedures

Caring for patients safely means that you must carefully carry out specific routines. The normal manner of carrying out a task is called a procedure. Procedures are the practices and processes used when following facility policies and patient care. The procedure prioritizes and orders your responsibilities when doing the task. As you progress in your studies, you will learn the procedures for many nursing assistant tasks. You have already been introduced to the procedures for washing your hands and using PPE. The procedures that follow give you step-by-step directions for carrying out tasks that involve patient care. Actions that must be done before you begin patient care are called preprocedure or initial procedure actions. At the end of each procedure, you will carry out a standard series of ending procedure (procedure completion) actions. These are important and should not be omitted.

Right Lateral Position

For the right lateral position, reverse the directions for left lateral position. 1.) Start with the bed flat. Move the patient to the right side of the bed. Turn the patient to the left side, with spine straight. 2.) Place a pillow under the head so it extends beyond the patient's face and down to the shoulders. 3.) Position the right arm so the shoulder and elbow are flexed and the palm of the hand is facing up. 4.) Place the left arm so it is extended or only slightly flexed and rested on the hip, or bring it forward and place it on a pillow. The patient's shoulder, elbow, and wrist should be at approximately the same height. 5.) Place a pillow between the patient's legs, extending from above the knee to below the ankle. The patient's hip, knee, and ankle should be at approximately the same height. 6.) A pillow may be placed behind the patient to help maintain the position.

Enablers

Enablers are devices that empower patients and assist them to function at their highest possible level. Another term for this type of device is enhancers. Devices used as enablers that maintain body position and alignment and support non-functioning body parts are called postural supports. They give patients a higher degree of independence and enable them to perform tasks they were previously unable to do. For example, a Velcro strap used to hold and support a paralyzed arm to prevent it from sliding off the armrest of a wheelchair is an enabler, not a restraint. The wheelchair lap tray as a restraint alternative that is also used as an enabler. The tray is attached to the back of the wheelchair with Velcro straps. Patients can lean on it, and its surface can hold personal items or reading and writing supplies. If the tray allows the patient to perform a task, it is an enabler. If the person does not have the physical or mental ability to remove the tray, it is considered a restraint. If the person can safely remove the tray, it is a restraint alternative.

Prone Position

For prone position, start with the bed flat and the patient lying on the abdomen with the head turn to either side, spine straight and legs extended. 1.) Place a small pillow under the head so that it extends to the patient's shoulders and 5 to 6 inches beyond the face. 2.) Place a small pillow under the abdomen. This relieves pressure on the lower back and reduces pressure against a female patient's breasts. An alternate method is to roll a towel and place it under the shoulders. 3.) Place a pillow under the arms to reach from the elbow to below the wrists. The shoulders and elbows may be flexed or extended, whichever is more comfortable for the patient. 4.) Place a pillow under the lower legs to prevent pressure on the toes. The patient may be moved down in bed before starting the procedure, so that the feet extend over the end of the mattress. This allows the foot to assume a normal standing position.

Fowler's Position

Fowler's position, or a variation of it, is used for feeding patients in bed, for certain treatments and procedures, for the patients comfort while visiting or watching television, and for those who have trouble breathing. This position increases pressure on the buttocks and increases the risk of skin breakdown and pressure ulcers. Because of this, patients should not be left in Fowler's position for prolonged periods of time. Check the care plan for instructions. 1.) Start with the patient on the back, in the middle of the bed and in good alignment. Position the hips at the place where the bed bends when the bed head is rolled up. Elevate the head of the bed to 30° for semi-Fowler's, 45° to 60° for Fowler's, and 90° for high-Fowler's and orthopneic positions. 2.) Place one or two pillows behind the patient's head to extend 4 to 5 inches below this patient's shoulders. 3.) Flex elbows and place a pillow under each arm. 4.) Place a pillow under each leg to extend from above the knee to the ankle, to prevent pressure on heels. 5.) Place a footboard or folded pillow to keep the feet in position, if necessary.

Specialty Beds

Health care facilities use many types of specialty beds. Some of these are called low air loss beds. These are mattress overlays filled with air that are used for pressure relief. Low air loss mattresses pose a high risk of injury and entrapment if side rails are used. The surface of the mattress is flexible and can easily compress a body part between the mattress and bed frame or side rail. This often occurs when the bed is set for maximum air inflation. The bed should be used at the lowest setting that prevents bottoming-out of the mattress. Closely monitor patients who use low air loss beds.

Patient Safety

In Unit 14, you learned how to maintain a safe environment and how to avoid personal injuries. The prevention of patient injuries is another very important part of your job as a nursing assistant. Patients in health care facilities are at risk for incidents because of medical problems and other conditions, such as the effects of some medications. Because of these risk factors, the most common incidents in health care facilities are falls.

Guidelines for the Use of Restraints

In addition to the procedures described earlier in this lesson, follow these guidelines when restraints are necessary: - Use the right type and size of restraint. Do not use a restraint if it is frayed, torn, has parts missing, or is soiled. - Apply restraints over clothing, never next to bare skin. - After application, check the fit. You should be able to slip three fingers between the restraint and the patient's body. The device should never restrict breathing. - The straps must be smooth and not twisted. Position the strap so the person cannot reach the ties. Tie them with slip knots for quick release in case of an emergency. - Be sure the patient has a signal light and other needed items within reach. Visually check the person every 15 to 30 minutes for comfort and safety. Make changes if needed. - When the person is restrained in a wheelchair, lock the brakes when the chair is parked. Position the large part of the small front wheels facing forward. This changes the center of gravity of the chair, making it more stable and preventing tripping. - Release the restraint at least every two hours for ten full minutes for toileting, exercise, and/or ambulation. You may release restraints at other times when you are attending to the patient, such as during feeding. - Maintain good alignment. Position the person in a comfortable, functional position. - Do not use restraints in moving vehicles or on toilets unless you are sure the device is intended for that use by the manufacturer. (This does not apply to safety restraints that are part of the vehicle. Follow state laws).

Use of Physical Restraints

In the past, restraints were routinely use to prevent falls. Research has shown that this approach is ineffective. Many falls occur with side rails up and restraints intact. This can result in serious injury, entrapment, and even death. There are two types of restraints: physical restraint and chemical restraint. Chemical restraints are medications that alter the patient's mood and behavior. As a nursing assistant, you will be more concerned with the use of physical restraints. Physical restraints are procedures or devices that are attached or next to a person's body that he or she cannot easily remove and that restrict freedom of movement and normal access to the body. There are many complications of restraints. In general, their use is discouraged. The regulatory and accrediting agencies oversee the use of restraints in health care facilities. If restraints are needed, they are a treatment of last resort and there are many restrictions on use. Generally speaking, the least amount of restraint needed to keep the patient safe should be used for the least amount of time possible. Patients have the right to be free from restraints. Restraints may be used only to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time. A family request or threat regarding the use of restraints is not a justification for actual use.

Accidental Poisoning

Many common items, such as household chemicals, shaving lotion, plants, and cologne, are poisonous if ingested. Patients who are disoriented may eat or drink any of these items. To prevent accidental poisonings, keep chemicals and cleaning solutions in locked cupboards. Store patients' personal food items in the refrigerator in dated, labeled containers.

Prevention of Other Incidents

Many situations can result in an incident that may harm the patient. Incidents can be prevented when staff are aware of and follow preventive measures.

Moving Patients

Moving and transporting patients are major responsibilities of the nursing assistant. Using proper body mechanics and following safety rules will protect both you and your patients from injury. Always find out whether you will need help moving the patient before proceeding with your assignment. Check the care plan for special positioning instructions. A turning sheet or draw sheet (folded large sheet or half-sheet) may be placed under a heavy or helpless patient to make moving easier. In some facilities, a very large cloth bed protector is used instead of a sheet. All of these methods are effective. To be effective, the sheet must extend from the shoulders to below the hips.

Procedure 13: Logrolling the Patient

Nope: This procedure is performed when the patient's spinal column must be kept straight, such as following spinal surgery or spinal cord or vertebral column injury. It is a good procedure to use with any dependent patient. 1.) Carry out each initial procedure action. 2.) Get help from another nursing assistant. 3.) Raise the bed to waist height horizontal position. Lock the wheels. 4.) Lower the side rail on the side opposite to which the patient will be turned. Both assistants should be on the same side of the bed. 5.) One assistant places hands under the patient's head and shoulders. The second assistant places hands under the hips and legs. Then move the patient as one unit towards you. 6.) Place a pillow lengthwise between the legs. Fold the patient's arm over the chest. 7.) Raise the side rail. Check for security. 8.) Go to the opposite side of the bed and lower the side rail. 9.) Turning the patient to the side may be done by: a.) Using a turning sheet that was previously placed under the patient. -- Reach over the patient, grasping and rolling the turning sheet toward the patient. -- One nursing assistant should be positioned beside the patient to keep the shoulders and hips straight. -- A second assistant should be positioned to keep the thighs and lower legs straight. b.) If a turning sheet is not in position, the first assistant should position hands on the patient's far shoulder and hips. -- Second assistant position hands on the patient's far thigh and lower leg. 10.) At a specific signal, all the patient toward both assistants in a single movement, keeping the spine, head, and legs straight. If a turning sheet is used, grasp the sheet and move the patient as one unit, onto their side. 11.) Place additional pillows behind the back to maintain the patient's position. A small pillow or folded bath blanket may be permitted under the patient's head and neck. Leave a pillow between the legs. Position a small pillow or folded towels to support the arms. 12.) Carry out each ending procedure action.

Orthopneic Position

Orthopneic position is a variation of high-Fowler's position and is used for patients who have difficulty breathing. Like Fowler's position, the orthopneic position increases the risk of pressure ulcers. Special skin care may be necessary. Check the care plan or ask the nurse for further instructions. 1.) The position of the bed remains the same as high-Fowler's. (The head of the bed is raised as high as it will go.) 2.) Assist the patient to sit as upright as possible. 3.) Have the patient leans slightly forward, supporting him/herself with their forearms. Placing the overbed table in front of the patient and extending the arms over it provides a good means of support and helps ease respirations. This makes the thorax larger, enabling the patient to inhale more air. 4.) Place another pillow behind the patients lower back for support.

Sitting Position

Patients should be positioned in a comfortable, well-constructed chair, so that the head and spine are erect. The back and buttocks should be against the chair back. Stabilizing the feet on the floor or footrests is the first step in good positioning. Solid foot support also prevents forward sliding. For good posture and even weight distribution, position the feet at a 90° angle to the lower legs. Position the lower legs at a 90° angle to the thighs. The thighs should be positioned at a 90° angle to the torso. This is called the 90-90-90 position. 1.) Pillows or postural supports may be needed to maintain the position. 2.) A small pillow may be folded and placed at the small of the back to add comfort and support. 3.) Do not permit the back of the patients knees to rest against the chair.

Common Steps in All Procedures

Perform the steps in order, as appropriate to the patient and the procedure. This lesson calls these steps initial procedure actions and ending procedure actions. Because the initial procedure and ending procedure actions are the same for each patient care procedure, they are not restated as individual steps. Rather, a general reference is made to the steps at the beginning and end of each procedure. You must, however, learn and faithfully complete each of these steps for each patient care procedure you perform.

Initial Procedure Actions

Perform the steps, in order, at the beginning of every procedure. 1.) Wash your hands or use an alcohol-based hand cleanser. -- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination. 2.) Assemble supplies and equipment and bring them to the patient's room. -- Improves efficiency, organizes your time, and ensure that you do not have to leave the room. 3.) Knock on the door and identify yourself. -- Respects the patient's right to privacy. Informs the patient who is giving care. 4.) Identify the patient according to facility policy. -- Ensures that you are caring for the correct patient. 5.) Ask visitors to leave the room and advise where they may wait (as desired by patient). -- Respects the patient's right to privacy. Shows respect and courtesy to visitors. 6.) Explain what you are going to do and what is expected of the patient. Answer questions. (Maintain a dialogue with the patient during the procedure and repeat explanations and instructions as needed). -- Informs the patient what is going to be done and what to expect. Provides information about the procedure and shows respect. 7.) Provide privacy by closing the door, privacy curtain, and window curtain. (All three should be closed even if the patient is alone in the room). -- Respects the patient's right to privacy. Protect modesty and dignity. 8.) Wash your hands or use an alcohol-based hand cleanser. -- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination. 9.) Set up supplies and equipment at the bedside. Using overbed table, if possible or other clean area. Cover with a clean under pad, according to nursing judgment, to provide a clean work surface. Open packages. Position items for convenient reach. Position a container for soiled items so that you do not have to cross over clean items to access it. -- Prepares for the procedure and helps organize time period ensures that equipment and supplies are conveniently positioned and readily available. Reduces the risk of cross-contamination. 10.) Raise the bed to a comfortable working height. -- Prevents back strain and injury caused by bending at the waist. 11.) Position the patient for the procedure. Support with pillows and props as needed. Place a clean under pad under the area, as needed. Make sure the patient is comfortable and can maintain the position for the duration of the procedure. -- Ensures that the patient is in the correct anatomic position for the procedure. Ensure that the patient is supported, comfortable, and able to maintain the position throughout the procedure. 12.) Cover the patient with a bath blanket and drape for modesty. Fold the bath blanket back to expose only the area on which you will be working. (This step is essential even if the door, window, and curtains are closed). -- Respects the patient's modesty and dignity. Ensures that the patient is warm and comfortable. 13.) Apply gloves if contact with blood, moist body fluids (except sweat), secretions, excretions, mucous membranes, or nonintact skin is likely. -- Applies the principles of standard precautions. Protects the worker and patient from transfer of pathogens. 14.) Apply a gown if your uniform will have substantial contact with linen or other articles contaminated with blood, moist body fluids (except sweat), mucous membranes, secretions, or excretions. -- Applies the principles of standard precautions. Protects your uniform and skin from contamination with bloodborne pathogens. 15.) Apply a mask and eye protection if splashing of blood or body fluids is likely. -- Applies the principles of standard precautions. Protect the worker's skin, mucous membranes, and uniform from accidental splashing of bloodborne pathogens. 16.) Lower the side rail on the side where you will be working. -- Provides an obstacle-free area in which to work.

Ending Procedure Actions

Perform the steps, in order, upon completion of each procedure. 1.) Remove gloves. -- Prevents contamination of the patient, the environment, and clean supplies from used gloves. 2.) Reposition the patient to ensure that he or she is comfortable and in good body alignment. -- All body systems functions better when the body is correctly aligned. The patient is more comfortable when the body is in good alignment. 3.) Replace the bed covers, then remove any drapes used. Place use drapes in plastic bag to discard in trash or soiled linen. -- Provides warmth and security. Contains linen and drapes that have been contaminated during the procedure. 4.) Elevate the side rails, if used, before leaving the bedside. -- Prevents contamination of the side rail from gloves. Ensures patient safety. Prevents falls, accidents, and injuries. 5.) Remove other personal protective equipment, if worn, and discard in plastic bag or according to the facility policy. -- Prevents contamination of the patient, the environment, and clean supplies from used PPE. 6.) Wash your hands or use an alcohol-based hand cleanser. -- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination. 7.) Return the bed to the lowest horizontal position. -- Respect patient's right to a safe environment. Ensures patient safety. Prevents falls, accidents, and injuries. 8.) Open the privacy and window curtains. -- Privacy is no longer necessary unless preferred by the patient. 9.) Position the call signal and needed personal items within reach. -- Prevents accidents and injuries. Gives the patient a sense of security by ensuring that help is available. Enhances patient convenience. Eliminates the need to call out or reach for needed personal items (which could result in a fall). 10.) Wash your hands or use an alcohol-based hand cleanser. -- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination. (Although the hands were washed previously, they have contacted the patient and other items in the room. Washing them again before leaving prevents potential transfer of microbes to other patients, equipment, and surfaces outside the patients unit). 11.) Perform a general safety check of the patient and environment. -- Stays consistent with "think safety" motto when entering and leaving the room; decreases exposure to environmental risks and hazards; helps ensure patient safety. 12.) Remove procedural trash and contaminated linen when you leave the room. Discard in appropriate container or location, according to facility policy. -- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination. 13.) Inform visitors that they may return to the room. -- Shows respect, courtesy, and hospitality to visitors and patient. 14.) Document the procedure, your observations, and the patient's response to the procedure. -- Provides a legal record of ongoing progress and care. Provides a record of what has been done and observations of the patient's condition. Serves as a vehicle for communication for other members of the interdisciplinary team.

Turning (Moving) Sheet

See Draw Sheet

Side Rails as Restraints

Side rails are routinely attached to hospital beds. Rails can be full length, three-quarter length, half length, or quarter length. Half and quarter length rails may also be called split rails. The rails may be used in any combination. All bed rails can create a hazard in certain circumstances. All are considered restraints in certain situations. By definition, side rails are restraints. They can also be an enabler. Facilities write their own definitions of restraints. For example, some facilities consider the use of 3 half rails an enabler, and 4 rails a restraint. Some patients pull on rails to position and turn themselves in bed. Others feel more secure if the rails are up. Your facility's policy will define whether rails are restraints or enablers in this situation. Side rails must always be up for patients who are using physical restraints in bed. Serious injuries can occur if patients attempt to climb over elevated side rails and fall. This is a common cause of hip fractures in confused elderly patients. Leaving the rails down is a much safer alternative. If side rails are raised, monitor the patient frequently. Monitor the space between the rails, head and footboards, and the mattress. Hospital beds are used for years. Mattresses wear out and are replaced. Patients can become trapped between the mattress, side rails, and other parts of the bed if the replacement mattress is smaller than the original. Make sure that the gap between the mattress and side rails or other parts of the bed is not large enough to cause injury. If a gap is wide enough to entrap a person or body part, notify the nurse promptly. Another bed can be used or the mattress area modified to prevent injury. The nursing orders often specify the use of padded side rails for patients with certain conditions. Using a commercial side rail pad is the best solution, if they are available and your facility. Facilities and commercial manufacturers have developed many excellent alternatives to the use of side rails. Possible alternatives to the use of side rails are: - Beds that can be raised and lowered close to the floor. - Anticipation of reasons why the patient might get up, including need to use the bathroom, hunger, thirst, restlessness, and pain. Meet these needs and provide calm interventions when you are in the room. - Use of side rail bolster cushions or body pillows. - Pressure-sensitive alarms that sound when a patient attempts to get up. - Self-release belts that sounds an alarm immediately when the closure is released, so staff have time to respond before the person gets up. - Placement of mats on the floor next to the bed, so that if a fall does occur, the patient will fall on a padded surface. Some mats sound an alarm if the patient's feet or body touch the surface. Each health care facility has policies addressing when and how side rails may be used. Know and follow your facility's policies.

Sims' Position

Sims' position is a variation of the lateral position, with the patient on the left side, left leg extended and right leg flexed. This position is often used for rectal examinations and treatments and enemas. 1.) Place a pillow under the patient's head as for the lateral position. 2.) Start with the bed flat and the patient moved and turned onto the left side. 3.) Extend the patient's left arm and position it behind the patient's back. 4.) Flex the right arm and bring It forward. Support the arm with a pillow.

Supportive Devices

Supportive devices are used to maintain good alignment and body position in bed or in a chair. Supportive devices include: - Pillows and/or folded sheets, bath blankets, or mattress pads to support the trunk and extremities. - Splints and other specially-designed orthotic devices. Orthoses restore or improve function and prevent deformity. - Special boots or shoes that are worn in bed to keep the feet in alignment. - Bed cradles, which prevent pressure on the feet from the bed covers. - Footboards to maintain foot alignment.

Semiprone Position

The semiprone position is the opposite of the semisupine position. It is also a very comfortable position. Like the semisupine position, it eliminates pressure on the major areas at risk for pressure ulcer formation. Breathing is easier in this position than it is in full prone position. Begin the procedure by placing the patient prone. Lift the patient's chest and shoulders closest to you and place a pillow under them. Position the opposite arm behind the patient. Fold a second pillow in half and place it under the top leg. Keep the legs and spine straight. Turn the head to either side and position a small pillow for comfort. Follow your facility policy for use of the semiprone position. Like the prone position, some facilities require a doctor's order, because lying on the abdomen may make breathing more difficult for some patients. When this position is used, check the patient every 15 minutes to be sure that he or she can tolerate the position. 1.) Turn the patient into the prone position as described earlier. 2.) Turn the patient's head to the side facing you, or according to patient preference. 3.) Gently lift the patients near shoulder. Position a pillow under the chest and shoulder, with the arm resting on the pillow. Position the other arm behind (but not underneath) the patient. 4.) Fold a second pillow in half and place it under the top leg. 5.) Straighten and extend both legs for comfort. 6.) Monitor the patient frequently for signs of respiratory distress.

Semisupine Position

The semisupine position is also called the tilt position. It should not be confused with the lateral position. The patient in this position is not lying directly on the side. When correctly used, the semisupine position relieves pressure from the hip, sacrum, coccyx, and buttocks. The spine is straight and the patient is positioned so he is leaning against a pillow for support. Both legs are straight. The top leg is slightly behind the bottom leg. A pillow is placed under the top leg to keep it even with the hip joint. The lower shoulder is pulled slightly forward so that pressure is distributed over the back rather than the shoulder joint. The arms can be at the sides or folded across the abdomen. Begin the procedure with the patient in the supine position. It will be easiest if you move him or her to the side of the bed that will be behind his or her back when you have finished positioning. 1.) Turn the patient on the side, facing away from you. Leave about a 45° angle between the patient's back and the bed. 2.) Position a pillow behind the patient's back. Push the patient slightly back against the pillow, then roll and tuck it under to support the back and relieve pressure on the arm or shoulder. 3.) Pull the bottom shoulder slightly forward to prevent pressure on the shoulder joint. 4.) Position another pillow under the patient's top leg, level with the hip joint. 5.) Straighten both legs, positioning the top leg slightly behind the bottom leg and supported by a pillow. 6.) Position the patient's upper arm in a position of comfort. The wrist may rest on a pillow or the abdomen, according to patient preference.

Complications of Incorrect Positioning

The two most common complications of poor positioning are pressure ulcers and contractures. Pressure ulcers (bedsores) result when unrelieved pressure on a bony prominence reduces blood flow to the area. Pressure ulcers are dangerous and expensive to treat. Contractures occur when a joint is allowed to remain in the same position for too long. The muscles stiffen and shorten (atrophy), preventing the joint from moving fully. The joint freezes in position and cannot be moved. Usually, the joint becomes fixed in a bent position (position of flexion), but occasionally the joint is frozen in extension. Contractures are painful, permanent, and can interfere with mobility. They make caring for the patient much more difficult.

Basic Body Positions

There are four basic positions, with variations for each one: - Prone (on the abdomen), with a variation of semiprone - Supine (on the back), with a variation of semisupine - Lateral (on either side), with a variation of Sim's position - Fowler's position, with variations of low Fowler's, semi Fowler's, high Fowler's, and orthopneic position.

Mobility

ability to move or to be moved easily from place to place

Applying Restraints in Bed

When applying wrist, vest, poncho, jacket, or belt restraints to a patient in bed: - Center the person's hips in the middle of the bed. This is where the bed bends when the head is elevated. - Make sure the straps are not at an angle when extended over the edge of the mattress. If the straps are angled even slightly, they will loosen if the patient moves up or down in bed. - Wrap the strap around the frame deck (the movable part of the frame that supports the mattress) once or twice. - Never wrap the strap around the lower frame, or the restraint will tighten and inhibit respiration when the head of the bed is elevated. Never tie the end of the strap to the outside of the frame. This enables the patient to reach down and untie it. - Thread the strap through the bed springs at least 6 to 8 inches in from the side of the bed and 6 to 8 inches toward the head of the bed. (Manufacturers will supply an adapter for beds with a solid deck). - Loop the end of the strap around the spring. - Loop the strap around itself again and tighten it to form a slip knot. - Always raise the side rails when a patient is restrained in bed. Never fasten the straps to the side rails or loop or wrap the strap around the side rails.

Enabler

a device that empowers patients and assists them to function at their highest possible level

90-90-90 Position

a method of positioning the patient in good posture with the feet at the 90° angle to the lower legs, the lower legs at a 90° angle to the thigh, and the thighs at a 90° angle to the torso

Orthopneic Position

a position in which the patient must sit up to breathe comfortably. The patient sits as upright as possible and leans slightly forward, supporting him or herself with the forearms

Aspiration

a very serious condition in which food, water, gastric contents, or other materials enter the trachea and lungs. It is usually accidental, such as when the patient "swallows down the wrong tube" or accidentally inhales food or fluids. If you suspect that a patient has aspirated, inform the nurse promptly

When restraints are used, they must be released a. every 2 hours. b. Once each shift. c. every hour d. every 4 hours.

a. every 2 hours.

Initial procedure actions include a. handwashing. b. raising side rails. c. placing the call signal within reach. d. opening the door.

a. handwashing.

Supine position is a. lying on the back. b. laying on the abdomen. c. lying on the side. d. sitting in the chair.

a. lying on the back.

A trochanter roll is used to a. maintain the hip in alignment. b. maintain the feet in alignment. c. support the patient's back. d. prevent contractures of the hand.

a. maintain the hip in alignment.

A position used for patients who have trouble breathing is a. orthopneic b. semiprone c. lateral d. supine

a. orthopneic

Alternatives to restraints include a. taking patients to the bathroom regularly. b. giving medications to sedate the patient. c. playing music to distract the patient. d. using side rails when in bed.

a. taking patients to the bathroom regularly.

Lateral

away from the midline

Examples of supportive devices are a. belts b. pillows c. side rails d. vests

b. pillows

Correct body alignment will a. heal disease. b. prevent infection. c. help the body function more efficiently. d. be harmful in certain circumstances.

c. help the body function more efficiently.

Injuries caused by sitting in the same position for too long are called a. lacerations. b. bruises. c. pressure ulcers. d. aspiration.

c. pressure ulcers.

When restraints are used on patients in bed, a. there must be full side rails on the bed, in the raised position. b. the bed should be elevated to the high position. c. the restraints should be secured to the stationary part of the frame. d. the electric bed switch should be removed to reduce the risk of injury.

c. the restraints should be secured to the stationary part of the frame.

Patient falls can be prevented by a. encouraging patient to remain in bed. b. using restraints when the patient is up. c. keeping the side rails up at all times. d. meeting the patient's needs promptly.

d. meeting the patient's needs promptly.

Logrolling is a procedure performed for a. patients who have had both legs amputated. b. ambulatory patients. c. all conscience patients. d. patients who have had spinal surgery.

d. patients who have had spinal surgery.

Patients may be at risk for incidents because they a. ambulate in the hallway. b. use a wheelchair for long distances. c. keep one side rail up for turning independently when in bed. d. receive medications affecting coordination and mental status.

d. receive medications affecting coordination and mental status.

Postural Support

device used as an enabler that maintains body position and alignment

Physical Restraints

device used to prevent a patient from moving about or having access to his or her own body

Orthotic Devices (Orthoses)

devices that restore or improve function and prevent deformity

Supine

laying with the face upward

Semi-Prone Position

patient is positioned between the side and the abdomen

Semi-Supine Position

patient is positioned between the side and the back

Contracture

permanent shortening or contraction of a muscle due to immobility, spasm, or paralysis

High Fowler's Position

position in which the head of the bed is elevated to 90°, with the patient sitting upright

Modified Trendelenburg Position

position in which the head of the bed is lowered 20° to 30°

Prone Position

position in which the patient is on the abdomen, spine straight, legs extended, and arms flexed on either side of the head

Semi-Fowler's Position

position in which the patient is on the back with knees slightly flexed, and the head of the bed is elevated 30° to 45°

Sim's Position

position in which the patient is on the left side with left leg extended and right leg flexed, left arm is extended and brought behind the back, right arm is flexed and brought forward

Fowler's Position

position in which the patient lies on the back with backrest elevated 45° to 60°

Body Alignment

position of the human body in which the body can properly function

Transfer

procedure followed when changing a patient's location

Trochanter Roll

rolled sheet or bath blanket placed under the patient extending from the waist to mid-thigh, positioned against the hip to prevent lateral hip rotation

Draw Sheet

sheet folded under the patient, extending from above the shoulders to below the hips

Procedure

the practices and processes used when following facility policies in patient care. A procedure prioritizes and orders your responsibilities when doing the task

Ambulate

to walk

Splint

type of orthosis used to maintain position and prevent contractures of an extremity

Pressure Ulcer

ulceration due to ischemia; pressure sore

Chemical Restraints

use of medications to control behavior

Supportive Device

used to help maintain a patient's body in a specific position