Nur 321 Exam 2 Blueprint Please remember this is just a blue print and it does not include every topic that will be tested. It does however cover a large portion of the exam. Remember some questions cover several topics. Chapter 40 1. Explain how personal hygiene relates to health and well-being 2. Identify factors influencing personal hygiene practices. 3. Discuss the nurse’s role in determining a patient’s self-care ability. 4. Identify when it is appropriate to delegate hygiene activities to the NAP. 5. Discuss routine assessments made by the nurse when providing hygiene care. 6. Differentiate between types of baths and when it is appropriate to use each one. 7. Apply the nursing process to common hygiene related problems. 8. Identify how culture can affect the nursing needs of patients and their families. Chapter 28 1. Identify precautions to prevent transmission of infection. 2. Discuss the factors that increase the risk for infection. 3. Describe additional precautions taken for standard, reverse, contact, droplet, airborne disease transmission and when the nurse uses these precautions. 4. Multi-drug resistant organisms 5. Hand washing, PPE 6. Develop a plan of care for a patient who has an infection 7. Teaching and wellness promotion Chapters 9, 22, 24 1. Basic levels of communication. 2. Describe the process of communication and the five elements involved. 3. List characteristics of verbal and nonverbal communication. 4. Analyze factors that influence the communication process. 5. Compare and contrast techniques that enhance or hinder communication. 6. Identify appropriate communication styles across varying scenarios. 7. Phases of the therapeutic relationship. 8. Communicate with patients who have impaired speech, hearing or cognition or whose culture or language is different. 9. Plan nursing care for a patient experiencing impaired communication. 10. Ethical principles Care of patients in restraints and delegation! 3 math questions Infection Prevention and Control Health Care-Associated Infections (HAI) According to WHO: HAI is also called “nosocomial” and defined as: − − an infection acquired in hospital by a patient who was admitted for a reason other than that infection. an infection occurring in a patient in a hospital or other health-care facility in whom the infection was not present or incubating at the time of admission. A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer’s disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as: A. restraints. B. poor hygiene. C. Foley catheter bag. D. improper positioning. Main Routes for infections − − − − Urinary tract infections (UTI) Catheter-associated UTIs are the most frequent, accounting for about 35% of all HAI. Surgical infections: about 20% of all HAI Bloodstream infections associated with the use of an intravascular device: about 15% of all HAI Pneumonia associated with ventilators: about15% of HAI The Infectious Process Defenses against infection − − − Normal floras Body system defenses Inflammation Health care–associated infections (HAIs) occur as the result of − − − − Invasive procedures Antibiotic administration Multidrug-resistant organisms (MDROs) Breaks in infection prevention and control activities Impacts of Health Care-Associated Infections (HAI) HAI can: − − − − − − Increase patients’ suffering. Lead to permanent disability. Lead to death. Prolong hospital stay. Increase need for a higher level of care. Increase the costs to patients and hospitals. What is Infection Control? Identifying and reducing the risk of infections developing or spreading The Usual Bacteria Suspects: Multidrug-resistant Organisms (MDROs) Antibiotic Resistant Microorganisms - Normal flora gone bad! − − Problem exists because of overuse and inappropriate use Resistant to multiple antibiotics − − − − Reduced options for treatment Require isolation precautions Examples: MRSA, VRE, MDR TB Solutions: more appropriate antibiotic use, better infection control and prevention Survival of Select Microbes on Environmental Surfaces MDROs Can Hang Around Vancomycin-resistant Enterococci (VRE) detected on surfaces indicated – cultures done AFTER discharge cleaning/disinfection Reservoir: – − − − − Where pathogens live and multiply May be living Humans, animals, insects May be nonliving Food, floors, equipment, contaminated water Portal of Exit/Entry: − − − − − − Skin and Mucous Membranes- seeping wound Respiratory Tract- sneezing, Coughing Urinary Tract Gastrointestinal tract- Diarrhea Reproductive Tract Blood Modes of Transmission: − − − − − Contact (Direct & Indirect) Direct: Touching, kissing, sexual contact Indirect: Contact with a fomite Droplet Airborne Susceptible Host: Susceptibility (Resistance to infection) Factors which influence susceptibility: − Age − − − − Nutritional status Chronic disease history Trauma Smoking Nursing Process: Assessment − − − − − − − Through the patient’s eyes Past experiences Knowledge of infection Risk factors Clinical appearance Status of defense mechanisms Medical therapy Travel history Laboratory data Occupation You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient’s WBCs are elevated. You should: A. start antibiotics. B. notify the provider. C. document the findings and reassess in 2 hours. D. place the patient on isolation precautions. Lab Data − − − − WBC Count Sedimentation Rate Cultures of sputum, urine, blood Differential Count Nursing Process: Nursing Diagnosis - Nursing diagnoses for infection: − − − − − Risk for Infection Impaired Nutritional Status: Deficient Food Intake Impaired Oral Mucous Membrane Social Isolation Impaired Tissue Integrity Nursing Process: Planning - Goals and outcomes Common goals of care often include: − − − − Preventing further exposure to infectious organisms Controlling or reducing the extent of infection Maintaining resistance to infection Verbalizing understanding of infection prevention and control Setting priorities − Establish priorities for each diagnosis and for related goals of care. Teamwork and collaboration − Collaborate with patients and interprofessional team Nursing Process: Implementation Health Promotion − − − − Nutrition Hygiene Immunization Adequate rest and regular exercise Acute Care − − Eliminate the infectious organism Support the patient's defenses Medical Asepsis − − − − − Control or elimination of infectious agents: Cleaning / Disinfection and sterilization Protection of the susceptible host Control and elimination of reservoirs of infection Control of portals of exit/entry Cough etiquette Control of transmission Hand hygiene My Five Moments for Hand Hygiene (put diagram) Hand Washing 1. Time 2. Water 3. Soap 4. Friction 5. Drying Hand Washing Guidelines − − − Wash for at least 15 sec in nonsurgical setting; 2 to 6 min in surgical setting. Remove jewelry and clean beneath fingernails. Use a bactericidal solution or use water if hands are visibly soiled. − Use warm water, not hot. − Apply soap to wet hands. − Use friction. − Rinse soap. − Towel or hand dry. − Scrub soiled hands with a cleansing brush or sponge. − Quiz Which action violates a principle that is key to proper hand washing at the bedside? A. Washing your hands for 1 min B. Shaking your hands dry over the sink C. Using warm, not very hot water D. Using the soap provided by the agency B Shaking your hands will not completely remove the excess moisture, allowing for the reacquisition of bacteria on the area. Nursing Process: Implementation Isolation and isolation precautions – – – – – – – Standard precautions Transmission-based precautions: Airborne, Droplet, Contact, and Protective Environment Psychological implications of isolation Personal protective equipment: Gowns, masks, eye protection, gloves Specimen collection Bagging trash or linen Transporting patients Standard Precautions – – – – Guidelines for preventing exposure to blood, body fluids, secretions, excretions (except sweat), broken skin, or mucous membranes Based on the concept that body fluids from ANY patient can be infectious Should be used on every patient Use necessary PPE for protection CDC guidelines requires us to use category-specific isolation (ex – TB isolation) in addition to Standard Precautions when a patient is known or suspected to have an infection What PPE to Wear and When? – – – Based on the type of task being performed Anticipated contact with blood and/or body fluids, or pathogen exposure Prevention of fluid penetration from splashing/sprays When to Wear Gloves Any anticipated contact with: – – – – – Blood or body substances—fluids and solids Mucous membranes—oral, nasal, conjunctival, rectal, genital Non-intact skin—wounds, surgical incisions Indwelling device insertion site—urinary catheter, IVs, feeding tube Handling potentially contaminated items in the resident’s environment – Visibly soiled equipment, supplies or linens that may have been in contact with blood or body fluids – Shared equipment moving between residents Masks and Eye Protection – – Wear during procedures likely to generate splashes, sprays, or droplets of blood and body fluids Masks – Dressing changes for PICC/central vascular access devices – Dressing changes on large open wounds – Care of residents with new onset or exacerbation of respiratory condition with increased sputum or nasal sections – Consider when emptying urine collection bags (splash) or inserting/changing urinary catheters (spray) – Mask and goggles/face shield – Irrigation of open wounds (infected or non-infected) – Oral or tracheal suctioning When to Wear Gowns : When anticipating contact of clothing or exposed skin with blood or body fluids, secretions or excretions – – – During procedures likely to generate splashes, sprays or droplets of blood and body fluids (e.g., catheter insertion, emptying urine collection bags) When in contact with non-intact skin (e.g., large wounds, rashes, burns) Handling fluid containers likely to leak, splash or spill when moved (e.g., bedside commodes, bedpans, urinals, emesis basins) Glove Use: Putting On and Taking Off Putting on gloves − If wearing gown, then extend to cover wrist of gown Removing gloves Remember: outside of gloves are contaminated. – – – Grasp outside of glove with opposite gloved hand; peel off. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist. Gown Use: Putting On and Taking Off Putting on Gown: – – Put on before gloves. Fasten at back of neck and waist. Removing gown: Remember: outside of gown is contaminated. – – – – Remove gloves first. Unfasten neck, then waist ties. Remove gown using a peeling motion; gown will turn inside out. Hold removed gown away from body, roll into a bundle and discard in room. Transmission-based Precautions – – – – – Specific practices added to standard precautions when the spread of infection or organisms is not completely stopped using standard precautions alone These practices are used based on how organisms spread in health care settings: – Contact Precautions—exposure to “touching/oozing” – Droplet Precautions—exposure to “sneezing, dripping” – Airborne Precautions—exposure to “coughing” Contact Precautions Prevention of transmission of infectious pathogens that are spread by direct or indirect contact with a resident or their environment Contact Precautions are indicated when a resident has: – uncontained excessive wound drainage; – – – uncontained fecal incontinence or other body fluids; and/or infection or colonization with MDROs or other epidemiologically significant organisms. Examples: MRSA, VRE, resistant gram-negative bacilli such as ESBLs or CREs, C. difficile and scabies In addition, contact precautions require that you: – – – – – – Don’t share non-critical equipment (such as stethoscopes and thermometers) between patients If a piece of equipment is used with a patient in contact isolation, then the equipment must be properly cleaned and disinfected prior to use on another patient Place a patient on airborne, contact, or droplet precautions in a private room, If a private room is not available, the patient may be placed with another patient who has the same (but no other) infection Droplet precautions (Influenza, Meningococcal meningitis, some pneumonias, vaccine preventable diseases: rubella, mumps, pertussis) Pathogen is spread via moist droplets - Coughing, sneezing, touching contaminated objects Precautions include – Same as those for contact – Addition of mask and eye protection within 3 ft of client Droplet Precautions – – – – – Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.” “Pathogens requiring droplet precaution do not remain infectious over long distances in a healthcare facility and so do not require special air handling and ventilation to prevent droplet transmission.” Don face mask (NOT N-95 respirator) prior to entering patient room Spatial separation ≥ 3 feet Place face mask on patient for transport outside of room Airborne Precautions – – “Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (measles, chicken pox, TB)” Patient must be placed in an airborne isolation infection room (AIIR): this is a single-patient room equipped with special air handling and ventilation capacity that complies with specific regulatory guidelines: – monitored negative pressure relative to the surrounding area – 6 or 12 air exchanges/hour – Air exhausted directly to the outside or recirculated through a HEPA filtration system before return – Door MUST remain closed – Staff must wear N-95 respirator mask or PAPR – Visitors entering must wear surgical mask Airborne Isolation - Basic Components: – – – – negative air pressure isolation room door remains closed fit-tested N95 respirator yes… HANDWASHING! How to Don a Particulate Respirator − − − − − Select a fit tested respirator Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with elastic Adjust to fit and perform a fit check − Inhale – respirator should collapse − Exhale – check for leakage around face But what’s missing in the discussion? STANDARD PRECAUTION – – – Apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status Designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infections Under standard precautions, blood and body fluids of all patients are considered potentially infectious The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement: A. Contact precautions B. Droplet precautions C. No precautions D. Airborne precautions A Contact precautions are used when “contact” with the infected drainage could lead to transmission of the infection. Protective Isolation - “Protective environment” – – – – – – – Protects the client from organisms Used in special situations with immune-compromised client population Precautions include Room with special ventilation and air filters; no carpeting; daily wet-dusting Avoiding standing water in the room (e.g., humidifier) Nurse not assigned to other clients with active infection Standard and transmission-based precautions, plus mask and other personal protective equipment (PPE) (to protect patient) Do’s and Don’ts of Glove Use − − − − − Work from “clean to dirty” Limit opportunities for “touch contamination” – protect yourself, others, and the environment Don’t touch your face or adjust PPE with contaminated gloves Don’t touch environmental surfaces except as necessary during patient care Change gloves – During use if torn and when heavily soiled (even during use on the same patient) – After use on each patient − Discard in appropriate receptacle – Never wash or reuse disposable gloves Face Protection − Masks – protect the nose and mouth; should fully cover the noise and mouth and prevent fluid penetration Goggles – protects eyes − Should fit snuggly over and around eyes − Personal glasses are not a substitute for goggles − Face shields – protect face, nose, mouth, and eyes − – Should cover forehead, extend below chin and wrap around side of face “Contaminated” and “Clean” Areas of PPE − − − Where to Remove PPE at doorway, before leaving patient room or in anteroom* Remove respirator outside room, after door has been closed* *Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub Safety Guidelines for Nursing Skills – – – – – – Apply Standard Precautions. Use clean gloves when you anticipate contact with body fluids and nonintact skin or mucous membranes. Use gown, mask, and eye protection when there is a risk for splash. Keep bedside table surfaces clutter-free, clean, and dry when performing aseptic procedures. Clean all equipment that is shared between patients. Ensure that patients cover mouth and nose when coughing or sneezing, use tissues to contain respiratory secretions, and dispose of tissues in waste receptacle. Communication and Nursing Practice Communication – – – – A lifelong learning process Essential for establishing nurse-patient relationships and delivering patient-centered care Helps to reduce the risk of errors Maintains effective relationships Therapeutic communication – – Promotes personal growth Helps patients reach their health-related goals Communication and Interpersonal Relationships – – – – – – – – Nurses demonstrate caring by being with, doing for, and enabling patient well-being Becoming sensitive and supportive to self and others. Being present and encouraging the expression of positive and negative feelings. Developing caring relationships. Instilling faith and hope. Promoting interpersonal teaching and learning. Providing for nursing care needs in a supportive way. Respecting and allowing for spiritual expression. Developing Communication Skills – – – – Nurses who develop critical thinking skills make the best communicators They form therapeutic relationships to gather relevant and comprehensive information about their patients. Then they draw on theoretical knowledge about communication and integrate this knowledge with knowledge previously learned through personal clinical experience. They interpret messages received from others to obtain new information, correct misinformation, promote patient understanding, and plan patient-centered care. Levels of Communication – – – – – Intrapersonal: Conscious internal dialogue, sometimes known as self-talk, it can be positive or negative Interpersonal: Between two or more people Small group: With many people at the same time Public: Unique form of group communication Electronic You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is: A. public. B. intrapersonal. C. transpersonal. D. small group. Elements of the Communication Process Match the basic elements of communication. 1. Referent A. One who encodes and one who decodes the message 2. Sender and receiver B. The setting for sender-receiver interactions Answers: 1.D 2.A 3. Message C. Message the receiver returns 4. Channels D. Motivates one to communicate with another 5. Feedback E. Means of conveying and receiving messages 6. Interpersonal variables F. Factors that influence communication 7. Environment G. Content of the message 3.G 4.E 5.C 6.F Forms of Communication − Verbal communication – Vocabulary – Denotative and connotative meaning 7.B – – Pacing – Intonation – Clarity and brevity – Timing and relevance Nonverbal – Personal appearance – Posture and gait – Facial expressions – Eye contact – Gestures – Sounds – Territoriality and personal space, touch Professional Nursing Relationships – Nurse-patient caring relationships – – Phases of the helping relationship – – – – – Encourages patients to share their thoughts, beliefs, fears, and concerns with the aim of changing their behavior Nurse-family relationships – – Pre-interaction phase - Gathering information prior to meeting client Orientation phase- Meeting the client; introductions; establishing rapport and trust Working phase-Active part of the relationship Termination phase- at the end of the nurse’s shift or on the client’s discharge from the unit Motivational interviewing – – Caring relationships are the foundation of clinical nursing practice; they are created with skill and trust Use the same principles as one-on-one helping relationships Nurse-health care team relationships – Affects patient safety and the work environment – Hand-off reports – SACCIA/SBAR SBAR – – *Ineffective communication poses a significant threat to the safety of hospitalized patients. * SBAR is a useful and effective communication tool that allows healthcare professionals to share concise but important information in a short amount of time. SBAR – why it is important to use – – According to the Joint Commission, communication issues are the leading cause of sentinel events in hospitals. Improving the exchange of information between nurses and physicians have been cited as a key element to preventing medical errors and promoting a safe environment. – Miscommunication leads to patient safety issues. Helping relationships serve as the foundation of clinical nursing practice. Contracts for a therapeutic helping relationship are formed during the: A. orientation stage. B. working stage. C. termination stage. D. pre-interaction stage. Elements of Professional Communication – – – – – Courtesy Use of names Trustworthiness Autonomy and responsibility Assertiveness Nursing Process: Assessment – – – – Physical and emotional factors Developmental factors Sociocultural factors Gender Nursing Diagnosis Nursing diagnoses for communication – – – – Communication barrier Difficult coping Powerlessness Impaired socialization Planning – – – – – Involve the family Allow adequate time for practice Goals and outcomes: Specific and measurable Setting priorities Teamwork and collaboration Implementation Therapeutic communication techniques – – – – – – – – – – – – – – – – – Active listening: being attentive to what a patient is saying both verbally and nonverbally Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Using touch Using silence Providing information Clarifying Focusing Paraphrasing Validation Asking relevant questions Summarizing Self-disclosure Confrontation Nontherapeutic communication techniques – – – – – – – – – – – Asking personal questions Giving personal opinions Changing the subject Automatic responses False reassurance Sympathy Asking for explanations Approval or disapproval Defensive responses Passive or aggressive responses Arguing − Adapting communication techniques for the patient with special needs – Use thought and sensitivity – Adapt to unique circumstances, developmental level, or cognitive and sensory deficits − Quick Quiz 5. While admitting a patient, during the initial interview, a family member tells you, “My mom really means that she does not understand her medical diagnosis.” The communication form used by the family member is: A. focusing. B. clarifying. C. summarizing. D. paraphrasing. Ethical Principles – Purpose of ethical principles – – – – Autonomy – – – – – Establish common ground among nurse, patient, family, other health care professionals, and society for discussion of ethical questions and ethical decision making Permit people to take a consistent position on specific or related issues Provide an analytical framework by which moral problems can be evaluated Principle of respect for the person: primary moral principle Unconditional intrinsic value for all persons People are free to form their own judgments and actions as long as they do not infringe on the autonomous actions of others Concepts of freedom and informed consent are grounded in this principle Beneficence – – – To promote goodness, kindness, and charity To abstain from injuring others and to help others further their own well-being by removing harm; risks of harm must be weighed against possible benefits Nonmaleficence – – – – Veracity – – – – – Loyalty The promise to fulfill all commitments The basis of accountability Includes the professional’s faithfulness or loyalty to agreements & responsibilities accepted as part of the practice of the profession Justice – – – Principle of truth-telling Belief that truth could at times could be harmful held for many years Consumers expect accurate and precise information revealed in an honest and respectful manner To develop trust between providers and patients, truthful interaction and meaningful communication must occur Fidelity – – – – – Implies a duty not to inflict harm To abstain from injuring others To help others further their own well-being by removing harm Every individual must be treated equally This requires nurses to be nonjudgmental Accountability – – Individuals need to be responsible for their own actions Nurses are accountable to themselves and to their colleagues Cultural Awareness and Knowledge Cultural awareness – Self-examination of one’s biases toward other cultures and an in-depth exploration of one’s own cultural and professional background Stereotypes – Cultural knowledge: Learning or becoming educated about the beliefs and values of other cultures and diverse ethnic groups – – – Health-related beliefs and cultural values Disease incidence and prevalence Treatment efficacy Cultural Skill The summary of the domains of culture is a framework for the information you might choose to include in a nursing history. Collecting a patient history – – – – Provide language assistance resources Inform all of the availability of language assistance Ensure competence of those providing language assistance Provide print/multimedia materials in local languages Assessing health literacy – The degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions Culturally based physical assessment – – Knowledge about a patient directs your physical assessment Learn to anticipate physical findings based on a patient’s cultural health practices Cultural Encounter and Desire – – Cultural encounter goals: – Communicate in a way that generates a wide variety of responses – Interact to validate, refine, or modify existing values, beliefs, and practices about a cultural group Cultural desire: having the motivation to engage patients so that you understand them from a cultural perspective Safety – – Safety is often defined as freedom from psychological and physical injury. Safety refers to the prevention of patient injury caused by health care errors. The QSEN safety competency for a nurse is defined as “Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.” To Err Is Human: Building A Safer Health System – Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. Building A Safer Health System – Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. Introduction – – Health care provided in a safe manner and in a safe community environment is essential for a patient's survival and well-being. Nurses are responsible for incorporating critical thinking skills to promote patient safety. Mistaken Patient Identity: wrong patient – – – – – – Taken to x-ray Given wrong diet Taken to surgery Given the wrong medication Given the wrong blood transfusion Having a procedure (Foley catheterization) Patient Identification – – – – FIRST and best way to identify for the RIGHT patient is to have them STATE their name and birthday. SECOND is to check the name bracelet. BOTH of these should be done prior to any patient contact Bar Scan when giving medications Scientific Knowledge – – – – – – – – – – – Environmental safety: a safe environment protects the staff to function optimally Basic human needs: sufficient oxygen, nutrition, and optimum temperature, influence a person's safety Oxygen: supplemental poses fire risk Nutrition: requires knowledge about healthy food and food safety Temperature: extremes pose safety risks to vulnerable populations Physical hazards: often result in physical or psychological injury or death Motor vehicle accidents: elderly Poison: often impair the function of every major organ system Falls: rank as the second leading cause of accidental or unintentional injury deaths worldwide Fire: the leading cause of fire-related death is careless smoking, especially when people smoke in bed at home. Factors influencing patient safety – Patient’s developmental level – Mobility, sensory, and cognitive status – Lifestyle choices – Knowledge of common safety precautions Nursing Process Assessment – – – Nursing history and examination Health care environment – Risk for falls – Risk for medical errors – Disasters Patient’s home environment Nursing Diagnosis Nursing diagnoses for patients with safety risk: – – – – – – – Risk for fall Impaired home maintenance Risk for injury Impaired cognition: confusion Lack of knowledge Risk for poisoning Risk for trauma Implementation – Environmental interventions – – – Basic needs Fall safety in the home General preventive measures – – Lighting Changing the environment Falls – A patient fall, defined as a sudden, unintentional change in position, coming to rest on the ground or other lower level, is among the most commonly reported adverse hospital events, with more than 1 million occurring annually. – Approximately 30% of falls result in some type of injury, and 10% result in serious injury, such as head trauma and fracture. Among older adults, falls are especially dangerous because of their increased causation of morbidity and mortality. What Factors Increase the Risk for Falls? – – – – – – – – – A history of falls Weakness, being unsteady Drowsiness and slow reaction time Poor vision Confusion, disorientation, memory problems, poor judgment Decreased mobility Foot problems Elimination needs Dizziness and lightheadedness – – – – – – Joint pain and stiffness Low blood pressure Fainting Depression Strange setting Care equipment (IV poles, drainage tubes and bags, wheelchairs, walkers, canes, crutches, etc.) Fall Assessment Tools – Assessment of a patient’s risk factors for falling is essential in determining specific needs and developing targeted interventions to prevent falls. Morse Fall Scale Hendrick II Fall Risk Model Risk Factor (≥ 5 = High Risk) Interventions for Falls – – – – – – – Designate patient as a fall risk Give patient information about fall risks Hourly rounding Bed in low position Use gait belt assist patient using assistive devices Encourage patient to wear rubber-soled shoes or slippers Lock beds and WC – – Call light within reach Set the bed alarm Fall Precautions and Nursing Interventions: – – – – Set bed alarm while patient is in bed Apply yellow non-skid socks on patient when ambulating Place patient with strong side by the hand rails when walking with patient Ensure electronic device is attached to patient when in bed or chair (be patient specific) and is working correctly Do Not Use 4 Side Rails – risk for entrapment / is a physical restraint Bathroom Safety – – – – Use of Hand rails Door is open Adequate lighting Call light Restraints Acute and Restorative Care – – – Restraints- Device used to immobilize a client or an extremity – Physical, Chemical A temporary means to control behavior – Restraints are used to: – Protect from self-injury (pulling out tubes) – Prevent violence toward others Restraints deprive a fundamental right to control your own body. Restraints and Restraint Alternatives Restraint: Any manual method, physical or mechanical device, or material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs or head freely. Restraint Alternative: Devices or techniques employed to avoid the use of restraints. Depending on the intent and how it is used, it can be an alternative or a restraint. Restraint-Free Guidelines – – – – Establish restraint-free standard Least restrictive but safest environment Clinically appropriate situations; not “routine”; evaluate patient Rationale must be documented; orders limited in duration to 24-hours. Restraints Can Also Cause Serious Harm – Injuries from improperly positioned restraints – – – Patients get tangled in straps and choke Patients struggle to get free and end up broken bones, cuts, concussions, or other injuries as a result Medical complications from keeping the body and limbs in the same position for long periods can cause: – – – – – – Poor circulation Incontinence Constipation Weak muscles and bones Pressure Sores Mental and Emotional Problems: Restrained patients often feel humiliated or imprisoned and become – – – Depressed Agitated Uninterested in eating, sleeping, and socializing Use Restraints as A Last Resort Use Restraints only when: – – – You have exhausted all alternative interventions Vital treatments depend on their use There is a clear and present danger If Restraints Must Be Used – – – – – Protect the patient’s rights and dignity Choose the least restrictive method Document each occurrence of restraint use Only properly trained and authorized staff may apply and remove restraints Choose the correct restraint size - if too small, restraints may cause increased agitation and if too large, the patient can slide down in the restraint which could lead to asphyxiation. Initiation of Restraints – – Only a RN may initiate the first-time application of restraints. A UAP or LPN may remove and reapply restraints as needed for safety and hygiene. Restraints Monitoring Behavioral Unit – – – Observe every 15 minutes for behaviors and physical conditions and document on Behavioral Restraint/Seclusion Flowsheet Offer liquid, nutrition, comfort, and bathroom every 2 hours Remove restraints every 2 hour for no less than 5 minutes for range of motion and skin care. Medical/Surgical Unit – – – Observe every 2 hours for behaviors and physical conditions and document Offer liquid, nutrition, comfort, and bathroom every 2 hours Remove restraints every 2 hours for no less than 10 minutes for range of motion and skin care Examples of Restraints: Restraint or Restraint Alternative? – – Ex. Patient one is alert, oriented, and able to remove a lap belt on her own. You and the patient agree the best way to remind her to ask for help to the bathroom is to use a lap belt. Ex. Patient two is an older gentleman with a UTI and some confusion. He’s left handed but his left arm is contracted due to a stroke. He can’t remember to ask for help out of the chair so you used a lap belt and chair alarm. – Patient One: this belt is an alternative – Patient Two: the belt is a restraint; the chair alarm is an alternative. – Same device – different classification – because it is based on each patient’s unique circumstances; nursing judgment and clinical reasoning are the most critical factors in deciding if you’re applying a restraint or an alternative. – Use your resources! Talk with your CNS or educator when you have questions. They will know how to contact the Restraint Team when needed. Examples of Restraint Alternatives: 1. Freedom Splint 2. Soft Hand Mitt 3. Quick-Release Limb Holders 4. Vest On-going Monitoring – – – Patient Comfort – Food – Hydration – Toileting – ROM Continuation/Discontinuation – Mental Status – Cognitive Functioning – Level of Distress/Agitation Patient Safety – Vital Signs – Circulation Checks – Skin Integrity – Correct Application Criteria to Discontinue Restraints – – – – – – Able to follow directions Able to participate in care Able to participate in program Behavior improves/changes Lines tubes discontinued Positive response to medication intervention When implementing the use of restraints on a hospitalized client, the nurse should A. Restrain all confused clients so that they do not sustain a fall injury. B. Tie the restraint to the bottom of the siderail so the client cannot reach it. C. Ensure that the primary care provider renews the order for restraints once every 24 hr. D. Release the restraints and provide skin care at least once every shift. A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: A. raise all four side rails when darkness falls. B. use an electronic bed monitoring device. C. place the patient in a room close to the nursing station. D. use a loose-fitting vest-type jacket restraint. What does assessment of ADLs include? A. Driving a car B. Grocery shopping C. Dressing D. Cooking Assessment of ADLs includes bathing, dressing, eating, elimination, and mobility. Activities of Daily Living Ask if need help with activities done every day, such as … – – – – – – Bathing and grooming Ambulation Transfers Toileting Eating Dressing Instrumental Activities of Daily Living Ask if need help with activities which are more complex, such as … – – – – – – – – – – – – Writing Reading Cooking Cleaning Shopping Doing laundry Going up stairs Using the telephone Outside activities Managing medications Managing money Transportation
0
advertisement
Download
advertisement
Add this document to collection(s)
You can add this document to your study collection(s)
Sign in Available only to authorized usersAdd this document to saved
You can add this document to your saved list
Sign in Available only to authorized users