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:
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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
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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
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Normal floras
Body system defenses
Inflammation
Health care–associated infections (HAIs) occur as the result of
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Invasive procedures
Antibiotic administration
Multidrug-resistant organisms (MDROs)
Breaks in infection prevention and control activities
Impacts of Health Care-Associated Infections (HAI)
HAI can:
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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!
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Problem exists because of overuse and inappropriate use
Resistant to multiple antibiotics
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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:
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Where pathogens live and multiply
May be living
Humans, animals, insects
May be nonliving
Food, floors, equipment, contaminated water
Portal of Exit/Entry:
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Skin and Mucous Membranes- seeping wound
Respiratory Tract- sneezing, Coughing
Urinary Tract
Gastrointestinal tract- Diarrhea
Reproductive Tract
Blood
Modes of Transmission:
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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:
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Age
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Nutritional status
Chronic disease history
Trauma
Smoking
Nursing Process: Assessment
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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
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WBC Count
Sedimentation Rate
Cultures of sputum, urine, blood
Differential Count
Nursing Process: Nursing Diagnosis - Nursing diagnoses for infection:
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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:
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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
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Establish priorities for each diagnosis and for related goals of care.
Teamwork and collaboration
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Collaborate with patients and interprofessional team
Nursing Process: Implementation
Health Promotion
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Nutrition
Hygiene
Immunization
Adequate rest and regular exercise
Acute Care
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Eliminate the infectious organism
Support the patient's defenses
Medical Asepsis
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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
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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
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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
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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?
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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:
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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
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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)
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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
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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
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If wearing gown, then extend to cover wrist of gown
Removing gloves
Remember: outside of gloves are contaminated.
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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:
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Put on before gloves.
Fasten at back of neck and waist.
Removing gown:
Remember: outside of gown is contaminated.
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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
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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;
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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:
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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
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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
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“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:
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negative air pressure isolation room
door remains closed
fit-tested N95 respirator
yes… HANDWASHING!
How to Don a Particulate Respirator
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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
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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”
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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
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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
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Discard in appropriate receptacle
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Never wash or reuse disposable gloves
Face Protection
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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
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Face shields – protect face, nose, mouth, and eyes
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Should cover forehead, extend below chin and wrap around side of face
“Contaminated” and “Clean” Areas of PPE
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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
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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
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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
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Promotes personal growth
Helps patients reach their health-related goals
Communication and Interpersonal Relationships
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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
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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
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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
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Verbal communication
– Vocabulary
– Denotative and connotative meaning
7.B
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– 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
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Nurse-patient caring relationships
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Phases of the helping relationship
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Encourages patients to share their thoughts, beliefs, fears, and concerns with the aim of
changing their behavior
Nurse-family relationships
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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
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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
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Affects patient safety and the work environment
– Hand-off reports
– SACCIA/SBAR
SBAR
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*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
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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.
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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
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Courtesy
Use of names
Trustworthiness
Autonomy and responsibility
Assertiveness
Nursing Process: Assessment
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Physical and emotional factors
Developmental factors
Sociocultural factors
Gender
Nursing Diagnosis
Nursing diagnoses for communication
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Communication barrier
Difficult coping
Powerlessness
Impaired socialization
Planning
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Involve the family
Allow adequate time for practice
Goals and outcomes: Specific and measurable
Setting priorities
Teamwork and collaboration
Implementation
Therapeutic communication techniques
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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
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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
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Adapting communication techniques for the patient with special needs
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Use thought and sensitivity
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Adapt to unique circumstances, developmental level, or cognitive and sensory deficits
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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
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Purpose of ethical principles
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Autonomy
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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
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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
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Veracity
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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
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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
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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
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Individuals need to be responsible for their own actions
Nurses are accountable to themselves and to their colleagues
Cultural Awareness and Knowledge
Cultural awareness
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Self-examination of one’s biases toward other cultures and an in-depth exploration of one’s
own cultural and professional background
Stereotypes
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Cultural knowledge: Learning or becoming educated about the beliefs and values of other cultures and
diverse ethnic groups
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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:
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Risk for fall
Impaired home maintenance
Risk for injury
Impaired cognition: confusion
Lack of knowledge
Risk for poisoning
Risk for trauma
Implementation
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Environmental interventions
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Basic needs
Fall safety in the home
General preventive measures
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Lighting
Changing the environment
Falls
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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.
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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?
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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
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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
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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
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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
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Call light within reach
Set the bed alarm
Fall Precautions and Nursing Interventions:
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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
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Use of Hand rails
Door is open
Adequate lighting
Call light
Restraints
Acute and Restorative Care
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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
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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
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Injuries from improperly positioned restraints
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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:
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Poor circulation
Incontinence
Constipation
Weak muscles and bones
Pressure Sores
Mental and Emotional Problems:
Restrained patients often feel humiliated or imprisoned and become
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Depressed
Agitated
Uninterested in eating, sleeping, and socializing
Use Restraints as A Last Resort
Use Restraints only when:
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You have exhausted all alternative interventions
Vital treatments depend on their use
There is a clear and present danger
If Restraints Must Be Used
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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
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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
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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
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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?
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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
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Soft Hand Mitt
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Quick-Release Limb Holders 4.
Vest
On-going Monitoring
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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
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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 …
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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 …
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Writing
Reading
Cooking
Cleaning
Shopping
Doing laundry
Going up stairs
Using the telephone
Outside activities
Managing medications
Managing money
Transportation