Gait, balance, and mobility problems
Difficulty communicating because of impaired vision, hearing, or speech
-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)
-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)
-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.
-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.
-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.
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)
Assess for injury.
Notify the physician.
Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.).
Fill out an incident report.
(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.
Urinary and/or fecal incontinence
-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.
-Inform the NAP that determination of whether the patient requires restraints is your responsibility.
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.
Extremity (ankle or wrist) restraint
-the prescribed catheter will continue without interruption
-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
-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.
-Notify the physician.
-Attempt restraint alternatives.
-Reassess the type of restraint used, then verify the correct application and whether alternatives can be used.
-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
-reassess the type of restraint used
-determine if a restraint alternative can be used
-assess the potential cause for agitation
-A patient who may be at risk to self or others.
-A confused patient who may interrupt prescribed therapy, such as a nasogastric tube.
-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.)