Fundamentals of Nursing – Ch 27 Patient Safety

List factors that contribute to the risk of falls
History of previous falls
Gait, balance, and mobility problems
Difficulty communicating because of impaired vision, hearing, or speech
Impaired cognition

What is an NAP?
nursing assistive personnel

When delegating safety measures to the NAP, you need to stress the importance of the following:
-The patient’s mobility limitations and any specific measures to minimize risks
-Identifying patient behaviors (e.g., disorientation, wandering, anxiety) that are precursors to falls and that should be reported immediately
-Environmental safety precautions to take (e.g., bed locked and in low position, call light and personal items within reach, clear pathway, nonskid footwear)
-What to do when a patient starts to fall while being assisted with ambulation (i.e., ease patient into a sitting position in a chair or gently ease patient to floor, then alert you)

List the medications that increase the risk for falls.
antidepressants, anticonvulsants, antihypertensives, antihistamines, antipsychotics, benzodiazepines, corticosteroids, diuretics, nonsteroidal anti-inflammatory drugs, hypoglycemics, antiparkinson drugs, and histamine (H2) receptor blockers, and for multiple medications.

What are risk factors in the health care facility that pose a threat to patient’s safety
attached to equipment, poor lighting, cluttered pathways, wet floors

List the steps in the timed “Get Up and Go” test.
-Have patient rise from sitting position without using arms for support.
-Instruct patient to walk 10 feet (3 m), turn around, and walk back to the chair.
-Have patient return to chair and sit down without using arms for support. Look for unsteadiness in patient’s gait.

(longer than 30 seconds are dependent and at risk for a falls)

What is the purpose of a wedge cushion?
protects patient from sliding out of chair

Side rails should be up if the patient is …
weak, sedated, or confused

What should the nurse do if the patient is unable to identify safety risks?
Reinforce identified risks with the patient or involve a family member/friend and review the safety measures needed to prevent a fall.

What should the nurse do if the patient starts to fall while ambulating with a caregiver?
-Put both arms around the patient’s waist or grasp the gait belt. Stand with feet apart to provide a broad base of support.
-Extend one leg and let the patient slide against it to the floor.
-Bend your knees to lower the body as the patient slides to the floor.

What should the nurse do it the patient suffers a fall despite all measures taken?
-Call for assistance.
-Assess the patient for injury.
-Stay with the patient until assistance arrives to help lift the patient to the bed or to a wheelchair.
-Notify the physician.
-Document pertinent events related to the fall and resultant treatment in the medical record.
-Follow the institution’s incident reporting policy.
-Reassess the patient and environment to determine if the fall could have been prevented.
-Reinforce the identified risks with the patient, family, and health care professionals and review the safety measures needed to prevent a fall.

What should the nurse do if the patient displays behaviors that substantially increase the risk for falls?
-Intensify supervision of the patient and notify the physician. It may be necessary to have one-on-one staff to patient supervision.
-Review the episodes for a pattern (e.g., activity, time of day) that indicate alternatives that could eliminate the behavior.
-Engage in creative thinking with all caregivers and support service personnel for alternative interventions that promote safe, consistent care.

A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient?
Explain the use of the call light.
Keep the bed in the low, locked position.
Ensure that the pathway to the bathroom is clear.
Necessary items such as eyeglasses should be placed within the patient’s easy reach, such as on the over-bed table (not bedside table)

You are walking down the hospital corridor. As you glance into the room of one of your assigned patients, you see the patient’s feet and legs sticking out from the bathroom entrance. You immediately go into the room and see that the patient has fallen. What actions should be taken?
Call for assistance.
Assess for injury.
Notify the physician.
Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.).
Fill out an incident report.

Which of the following patients is at greatest risk for experiencing a fall?
A confused patient with a history of a previous fall.

A _____ is any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely

The Centers for Medicare and Medicaid Services requires that a restraint be used only under what circumstances?
(1) to ensure the immediate physical safety of the patient, a staff member, or others;
(2) when less restrictive interventions have been ineffective;
(3) in accordance with a written modification to the patient’s plan of care;
(4) when it is the least restrictive intervention that will be effective to protect the patient, staff member, or others from harm;
(5) in accordance with safe and appropriate restraint techniques as determined by a hospital’s policies; and
(6) it is discontinued at the earliest possible time.

List the serious complications that can happen with the use of restraints.
Pressure ulcers
Hypostatic pneumonia
Urinary and/or fecal incontinence

Assessment of patient’s behavior, level of orientation, need for restraints, appropriate type to use, and the assessments required while a restraint is in place cannot be delegated to _____
nursing assistive personnel (NAP).

Restraint application and supportive care can be delegated to _____
nursing assistive personnel (NAP).

The nurse directs the NAP on restraint application and supportive care by ….
-Reviewing correct placement of the restraint.
-Review how often to check the patient with a restraint.
-Review how often to remove restraint.
-Instructing NAP to notify nurse if there is a change in skin integrity, circulation of extremities, or patient’s breathing.
-Instruction to provide range of motion (ROM), nutrition and hydration, skin care, toileting, and opportunities for socialization.

The NAP reports that her pediatric patient began to remove her wound dressing so she applied elbow restraints. What should you do next?
-Assess the patient and remove the restraints.
-Inform the NAP that determination of whether the patient requires restraints is your responsibility.

Each original restraint order and renewal are limited to ….
4 hours for adults, 2 hours for children ages 9 through 17, and 1 hour for children under age 9. Original orders may be renewed up to a maximum of 24 hours. If a nurse or qualified health practitioner restrains a patient in an emergency situation because of violent or aggressive behavior that presents an immediate danger, a face-to-face physician assessment within 1 hour is necessary.

Before the application of restraints, conduct a focused patient assessment that includes the following:
1. Assess patient’s behavior for signs of confusion, disorientation, restlessness, or combativeness; repeated removal of tubing, dressings or other therapeutic devices; and inability to follow directions.
2. Review agency policies regarding restraints. Check the physician’s order for the purpose, type, location, and time or duration. Determine if a signed consent is needed.
3. Review the manufacturer’s instructions for restraint application and determine the most appropriate size restraint.
4. Inspect the area where the restraint is to be placed, including the condition of the skin, presence of sensation, ROM, and the adequacy of circulation.

List types of restraint options.
Elbow Restraint
Belt restraint
Extremity (ankle or wrist) restraint
Mitten restraint

A 3 year old pulls at the dressings covering his wound. What is the appropriate type of physical restraint that could be used?
Mitten restraint

A confused victim of a motor vehicle accident is trying to pull out sutures on his forehead. What is the appropriate type of physical restraint that could be used?
Elbow Restraint

A schizophrenic patient becomes combative, swinging his fists at you. What is the appropriate type of physical restraint that could be used?
Extremity (ankle or wrist) restraint

An elderly patient who received a sedative is drowsy and disoriented. What is the appropriate type of physical restraint that could be used?
Belt restraint

_____ ______ focus on protecting the patient from injury and maintaining the prescribed therapy.
Expected outcomes

An incontinent and confused patient pulled out his Foley catheter for the second time. You notify the physician, who instructs your to insert a new catheter and apply mitten restraints on the patient. Which of the following expected outcomes would be appropriate for this patient?
-the patient will be free of injury
-the prescribed catheter will continue without interruption

What is required to use restraints?
physician’s order

If a patient has restraints, how often should they be released?
Every 2 hours

T/F: When applying restraints, you double knot the ties for security.

T/F: When applying restraints, you check that two fingers can be inserted under the restraint.

T/F: When applying restraints, you apply a belt restraint at the patient’s chest.

T/F: When applying restraints, you leave the call light within the patient’s reach when leaving.

T/F: When security extremity restraints, you attach the straps to the movable part of the bed frame.

Following application of a physical restraint, evaluate patient’s condition for signs of injury every _____.
15 minutes

The physician, licensed independent practitioner (LIP), or RN trained according to Center for Medicare Services requirements needs to evaluate the patient within either ______ after initiation of restraints, depending on hospital’s Medicare status.
1 or 4 hours

After ____ hours, before writing a new order, a physician or LIP who is responsible for the patient’s care must see and assess the patient to ensure that restraint application continues to be medically appropriate.

You are evaluating the use of mitten restraints. Which of the following would be an appropriate evaluation measure?
-you observe the condition of the patient’s hands and wrists and note that they are warm and pink and the skin is intact
-the patient’s IV line is intact and infusing at ordered rate
-you observe the patient trying to pull at his IV when the mittens are removed and determine that they will need to be reapplied

What should the nurse do if the patient experiences impaired skin integrity due to physical restraints?
-Assess the skin and provide appropriate therapy.
-Notify the physician and reassess the need for continued use of restraint.
-Consider whether alternatives to restraint can be used.
-Ensure the correct application of the restraint, pad the skin under restraints, and remove restraints more frequently.

What should the nurse do if the patient has altered neurovascular status to an extremity (cyanosis, pallor, coldness of the skin, or complaints of tingling, pain, or numbness)?
-Remove the restraint immediately.
-Notify the physician.

What should the nurse do it the patient exhibits increased confusion, disorientation, or agitation?
-Identify the reason for the behavior change and attempt to eliminate the cause.
-Attempt restraint alternatives.

What should the nurse do if the patient escapes from the restraint device and suffers a fall or injury?
-Attend to the patient’s immediate physical needs and inform the physician.
-Reassess the type of restraint used, then verify the correct application and whether alternatives can be used.

The nursing students are in post-conference after their clinical day in the nursing home. Two of the students had been assigned to the Alzheimer’s unit. Discussion takes place regarding nursing interventions to prevent falls in the elderly with cognitive impairment. Which of the following would be appropriate nursing interventions to include in such a plan of care?
-be sure patient’s sensory aids such as hearing aid or glasses are clean and functioning
-utilize a bed alarm and/or personal safety (tether) alarm
-check on the patient frequently, assisting with toileting needs, etc
-keep personal items within reach

Mrs. Albertson has Alzheimer’s disease with notable impaired cognition. You tried the use of a bed alarm, but Mrs. Albertson climbed out of bed and fell despite the quick response of the health care team. After an x-ray was taken, the physician ordered the application of a belt restraint for 12 hours until an enclosure bed is available. The restraint was applied and Mrs. Albertson seemed to become more agitated, yelling loudly and picking at her hospital gown with her hands. One hour later, you returned to check Mrs. Albertson and found her standing naked next to her bed. What should you do?
-ask Mrs. Albertson how you may help her, attend to her physical needs, and assist her in putting her clothes back on
-reassess the type of restraint used
-determine if a restraint alternative can be used
-assess the potential cause for agitation

A hospitalized elderly patient is disoriented to time and place, and the NAP reports the patient has been pulling at the indwelling catheter. The nurse just replaced the Foley catheter an hour ago after the patient pulled it out. After a focused assessment of the patient, the nurse determines the use of restraints is appropriate. What action should the nurse take next?
Have the NAP stay with the patient and call the physician.

The nurse and NAP are applying extremity restraints to a patient. Which action, if made by the NAP, would require correction?
The NAP attached the restraint to the side rail of the bed.

The NAP is reviewing with the nurse how to apply a belt restraint. Which statement, if made by the NAP, indicates further teaching is needed?
“I should place the belt restraint around the chest or abdomen.”

Which of the following would be a correct action of the NAP in regard to the application of restraints?
The NAP removes one restraint at a time in a patient who is violent.

Who may require a temporary restraint?
-A patient who is at risk for falls when nonrestrictive measures have failed.
-A patient who may be at risk to self or others.
-A confused patient who may interrupt prescribed therapy, such as a nasogastric tube.

The nurse has applied extremity restraints on a patient. What should the nurse assess on a regular basis?
-Skin integrity and ROM.
-Pulse and temperature of restrained body part.
-Readiness for discontinuation of restraint.
-Therapy (e.g., IV catheters, drainage tubes) remains uninterrupted.

(It is not necessary with an extremity restraint to assess patient’s breathing.)

Why are many health care agencies no longer using vest (jacket) restraints?
Because they have been associated with fatal injuries.

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