Chapter 23 Legal Implications in Nursing Practice Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Legal Limits of Nursing Sources of legal guidelines come from: Statutory law (Nurse Practice Act) • Criminal law (felonies or misdemeanors) • Civil law Regulatory law (administrative law) Common law (judicial decisions) Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 2 Legal Limits of Nursing (cont’d) Standards of care Legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care Best known comes from the American Nurses Association (ANA) Set by every state Set by state and federal laws that govern where nurses work Joint Commission requires policies and procedures (P&P). Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 3 Case Study Lynette Donovan, a 15-year-old female African American, was a passenger in a motor vehicle collision and is now admitted to the hospital with a fractured right femur. The emergency department health care provider applied a cast to the affected leg with insufficient padding. Lynnette told the nurses that her right leg felt numb, was swollen, and looked discolored. The nurses recognized that these symptoms indicate impaired circulation in the extremity with the cast. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 4 Proof of Negligence The nurse owed a duty to the patient. The nurse did not carry out the duty or breached it. The patient was injured. The patient’s injury was caused by the nurse’s failure to carry out that duty. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 5 Case Study (cont’d) The nurse was unable to reach Lynette’s health care provider despite several calls. The nurse has not notified the nursing supervisor of the patient’s situation. David Ortiz is a 23-year-old nursing student newly assigned to the nursing division and to Miss Donovan. His initial assessment notes that the patient’s right leg is swollen, slightly blue, and slightly malodorous. Lynette seems very anxious and upset. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 6 Federal Statutory Issues in Nursing Practice Americans With Disabilities Act Emergency Medical Treatment and Active Labor Act Mental Health Parity Act Uniform Anatomical Gift Act Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 7 Federal Statutory Issues in Nursing Practice (cont’d) Living Wills, Durable Power of Attorney Health Insurance Portability and Accountability Act Advance Directives Restraints Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 8 State Statutory Issues in Nursing Practice Licensure Good Samaritan Laws Public Health Laws Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 9 State Statutory Issues in Nursing Practice (cont’d) The Uniform Determination of Death Act Physician-Assisted Suicide Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 10 Quick Quiz! 1. A nurse is caring for a patient who states, “I just want to die.” For the nurse to comply with this request, the nurse should discuss A. Living wills. B. Assisted suicide. C. Passive euthanasia. D. Advance directives. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 11 Civil and Common Law Issues in Nursing Practice Torts Intentional Assault Battery False imprisonment Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 12 Civil and Common Law Issues in Nursing Practice (cont’d) Quasi-intentional Invasion of privacy Malice Slander Libel Unintentional Negligence Malpractice Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 13 Common Negligent Acts Failure to assess and/or monitor, including making a nursing diagnosis Failure to monitor in timely fashion Failure to use proper equipment to monitor the patient Failure to document the monitoring Failure to notify the health care provider of problems Failure to follow orders Failure to follow the six rights of medication administration Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 14 Common Negligent Acts (cont’d) Failure to convey discharge instructions Failure to ensure patient safety, especially for patients who have a history of falling, are heavily sedated, have disequilibrium problems, are frail, are mentally impaired, get up in the night, and are uncooperative Failure to follow policies and procedures Failure to properly delegate and supervise Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 15 Statutory Guidelines for Legal Consent for Medical Treatment Adults A. Any competent individual 18 years of age or older for himself or herself B. Any parent for his or her unemancipated minor C. Any guardian for his or her ward D. Any adult for the treatment of his or her minor brother or sister (if an emergency, and parents are not present) E. Any grandparent for a minor grandchild (if an emergency, and parents are not present) Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 16 Statutory Guidelines for Legal Consent for Medical Treatment (cont’d) Minors A. For his or her child and any child in his or her legal custody B. For himself or herself in the following situations: 1. Lawfully married or a parent (emancipated) 2. Pregnancy (excluding abortions) 3. Venereal disease 4. Drug or substance abuse Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 17 Statutory Guidelines for Legal Consent for Medical Treatment (cont’d) • Minors (cont’d) C. Unemancipated minors may not consent to abortion without one of the following: 1. Consent of one parent 2. Self-consent granted by court order 3. Consent specifically given by a court Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 18 Case Study (cont’d) David remembers that Lynette Donovan is legally a minor. She is hurt and afraid and in an unfamiliar setting. She may not be comfortable speaking with the health care providers who are present, and her expressions of pain may be modified by the circumstances she is in. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 19 Abortion Issues 1973 Roe v. Wade U.S. Supreme Court ruled that there is a fundamental right to privacy, which includes a woman’s right to have an abortion. 1989 Webster v. Reproductive Health Services Some states require viability tests if the fetus is more than 28 weeks’ gestational age. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 20 Nursing Students You are liable if your actions cause harm to patients, as is your instructor, hospital, and college/university. You are expected to perform as a professional when rendering care. You must separate your student nurse role from your work as a certified nursing assistant (CNA). Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 21 Malpractice Insurance A contract between the nurse and the insurance company Provides a defense when a nurse is in a lawsuit involving negligence or malpractice insurance Nurses covered by institution’s insurance while working Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 22 Quick Quiz! 2. A student nurse employed as a nursing assistant may perform care A. As learned in school. B. Expected of a nurse at that level. C. Identified in the hospital’s job description. D. Requiring technical rather than professional skills. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 23 Abandonment and Assignment Issues Short staffing Floating Legal problems occur if inadequate number of nurses will provide care. Based on census load and patient acuities Physician’s orders Nurses follow orders unless they believe an order is given in error or is harmful. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 24 Case Study (cont’d) Lynette Donovan developed gangrene in the right leg. She requires a right below-the-knee amputation. David Ortiz is returning from escorting Miss Donovan to the operating room for her procedure. He gets on the elevator, where several visitors and two nursing supervisors are talking about the health care provider who “made Donovan lose her leg.” Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 25 Quick Quiz! 3. You are about to administer an oral medication and you question the dosage. You should A. Administer the medication. B. Notify the physician. C. Withhold the medication. D. Document that the dosage appears incorrect. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 26 Risk Management A system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs Steps involved: Identify possible risks. Analyze risks. Act to reduce risks. Evaluate steps taken. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 27 Risk Management (cont’d) One tool used in risk management is the incident report or occurrence report. Occurrence reporting Serves as a database for further investigation Alerts risk management to a potential claim situation. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 28 Chapter 26 Documentation and Informatics Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Confidentiality Nurses are legally and ethically obligated to keep all patient information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 30 Quick Quiz! 1. Information regarding a patient’s health status may not be released to non–health care team members because A. Legal and ethical obligations require health care providers to keep information strictly confidential. B. Regulations require health care institutions to document evidence of physical and emotional wellbeing. C. Reimbursement issues related to patient care and procedures may be of concern. D. Fragmentation of nursing and medical care procedures may be identified. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 31 Standards Current documentation standards require that each patient have an assessment: Physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs Nursing documentation standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 32 Interdisciplinary Communication Within the Health Care Team Interdisciplinary communication is essential within the health care team. Records or chart Reports Confidential permanent legal document Oral, written, or audiotaped exchange of information Conferences Team members communicating in a group Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 33 Interdisciplinary Communication Within the Health Care Team (cont’d) Consultations A professional caregiver giving formal advice to another caregiver Referrals Arrangement for services by another care provider Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 34 Purposes of Records Communication Legal documentation Reimbursement Education Research Auditing/monitoring Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 35 Legal Guidelines for Recording • • • • • • • • • Correct all errors promptly, using the correct method. Record all facts; do not enter personal opinions. Do not leave blank spaces in nurses’ notes. Write legibly in permanent blank ink. If an order was questioned, record that clarification was sought. Chart only for yourself, not for others. Avoid generalizations. Begin each entry with the date/time and end with your signature and title. Keep your computer password secure. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 36 Guidelines for Quality Documentation and Reporting Factual Accurate Complete Current Organized Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 37 Case Study Mrs. Smith is a 93-year-old patient with fractures in her lower spine resulting from severe osteoarthritis that can be treated with surgery. She reports her pain as 10 out of 10. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 38 Case Study (cont’d) While completing Mrs. Smith's admission history, you find out that she had a total knee replacement 3 years ago and pain was not well controlled at that time. Mrs. Smith tells you, “I'm dreading surgery. Last time, I had such pain when I got out of bed.” Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 39 Quick Quiz! 2. A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record A. An interpretation of patient behavior. B. Objective data that are observed. C. Lengthy entry using lay terminology. D. Abbreviations familiar to the nurse. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 40 Methods of Recording Paper record Episode-oriented Key information may be lost from one episode of care to the next. Electronic health record (EHR) A digital version of a patient’s medical record Integrates all of a patient’s information in one record Improves continuity of care Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 41 Methods of Recording (cont’d) Narrative The traditional method Problem-oriented medical record (POMR) Database Problem list Care plan Progress notes Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 42 Methods of Recording: Progress Notes SOAP SOAPIE Subjective, objective, assessment, plan, intervention, evaluation PIE Subjective, objective, assessment, plan Problem, intervention, evaluation Focus charting (DAR) Data, action, response Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 43 Methods of Reporting Source records Charting by exception (CBE) A separate section for each discipline Focuses on documenting deviations Case management plan and critical pathways Incorporate a multidisciplinary approach to care Variances Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 44 Quick Quiz! 3. A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 45 Common Record-Keeping Forms Admission nursing history form Flow sheets and graphic records Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems Help team members quickly see patient trends over time and decrease time spent on writing narrative notes Patient care summary or Kardex A portable “flip-over” file or notebook with patient information Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 46 Common Record-Keeping Forms (cont’d) Standardized care plans Preprinted, established guidelines used to care for patients who have similar health problems Discharge summary forms Acuity records Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 47 Case Study (cont’d) Mrs. Smith’s surgery is successful, and she has been discharged by her physician. What are some key points to consider in providing discharge information? Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 48 Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. Medicare guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Nurses need to document all their services for payment. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 49 Long-Term Health Care Documentation Governmental agencies are instrumental in determining standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. The department of health in states governs the frequency of written nursing records. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 50 Reporting Hand-off report Occurs with transfer of patient care Provides continuity and individualized care Reports are quick and efficient. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 51 Reporting (cont’d) Telephone reports and orders Situation-background-assessmentrecommendation (SBAR) Document every call Read back Incident or occurrence reports Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient Follow agency policy Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 52 Quick Quiz! 4. A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to A. Exchange information among health care members. B. Provide information about patients from one unit to another unit. C. Ensure proper care for the patient. D. Aid in the hospital’s quality improvement program. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 53 Health Informatics Application of computer and information science for managing health-related data Focus on the patient and the process of care Goal is to enhance the quality and efficiency of care provided. Driven by the Health Information Technology for Economic and Clinical Health Act (HITECH) Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 54 Nursing Informatics A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice Health care information system (HIS): a group of systems used in a health care organization to support and enhance health care Consists of one or more Computerized clinical information systems (CISs) Administrative information systems Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 55 Nursing Informatics (cont’d) A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice Supports the way that nurses function and work Supports and enhances nursing practice through improved access to information and clinical decision-making tools Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 56 Nursing Information Systems Two designs of NISs Nursing process design Protocol or critical pathway design Clinical decision support systems (CDSSs) Used to support decision making Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 57 Advantages of NISs Increased time to spend with patients Better access to information Enhanced quality of documentation Reduced errors of omission Reduced hospital costs Increased nurse job satisfaction Compliance with accrediting agencies Common clinical database development Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 58 Nursing Information Systems (cont’d) Privacy, confidentiality, and security mechanisms Legal risks Handling and disposal of information Protection of the confidentiality of patients’ health information and the security of computer systems are top priorities that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 59 Clinical Information Systems A hospital information system consists of two major types of information systems: CISs and administrative information systems. CIS = Monitoring systems, order entry, and laboratory, radiology, and pharmacy systems Computerized provider order entry (CPOE) Improves accuracy Speeds implementation Improves productivity Saves money Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 60 Chapter 27 Patient Safety Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Safety in Health Care Organizations Performance improvement Risk management and safety reports Current reliable technology Evidence-based practice Safe work environment Adequate staff education Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 62 Quality and Safety Education for Nurses (QSEN) Future nurses need knowledge, skills, and attitudes to promote safety. Continuous improvement is essential. QSEN minimizes risk of harm to patients and providers by System effectiveness Individual performance Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 63 Critical Thinking In patient safety, critical thinking is an ongoing process. Standards have been developed by American Nurses Association and The Joint Commission. Use of the nursing process when planning care promotes safety. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 64 Safety in Health Care Settings Reduces the incidence of illness and injury Prevents extended length of treatment/stay Improves or maintains functional status Increases patient’s sense of well-being Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 65 A Safe Environment Includes meeting patients’ physical and psychosocial needs Applies to all places where patients receive care Includes patients’ and health care providers’ well-being Reduces risk of injury and transmission of pathogens Maintains sanitation and reduces pollution Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 66 Basic Human Needs Oxygen Temperature Low concentration High concentration Carbon monoxide Normal Hyperthermia Hypothermia Nutrition Proper storage Proper refrigeration Preparation area Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 67 Case Study Mr. Gonzales is a 68-year-old man who has lived alone in a senior apartment building since his wife died 6 months ago. He and his wife were born in Mexico but came to live in the United States shortly after they were married. He is retired from a produce warehouse, where he worked for 37 years. They have raised 3 sons; the closest son, Carlos, is 30 minutes away by car. Carlos visits Mr. Gonzales every week to socialize and take him shopping. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 68 Environmental Hazards Physical hazards: Lighting Obstacles Bathroom hazards Motor vehicle accidents Poison Fires Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 69 Quick Quiz! 1. While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that A. Teenagers need to practice safe sex. B. A 3-year-old can safely sit in the front seat of the car. C. Children need to wear safety equipment when bike riding. D. Children need to learn to swim even if they do not have a pool. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 70 Environmental Hazards Falls Transmission of pathogens Pollution Disasters Natural Man-made Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 71 Case Study (cont’d) Mr. Gonzales is generally healthy but has decreased visual acuity, hearing loss from the noisy warehouse job, and some “arthritis.” He expects to live at least as long as his father, who lived to be 92 years old. Since his wife’s death, Mr. Gonzales has attended Catholic mass every day at his parish church, where his wife had attended daily. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 72 Safety Risks by Developmental Stage Children younger than 5 years of age School-aged child Adolescent Adult Older patient Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 73 Nursing Knowledge Base Factors influencing safety: Developmental stages Individual risk factors • Mobility, sensory, and cognitive status • Impaired mobility • Lifestyle choices • Lack of safety awareness Risks in the health care agency Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 74 Case Study (cont’d) Joani Green, a 25-year-old married mother of two, is currently a nursing student at the local college. As part of the clinical environment, she and her study partner are conducting health screenings and providing health promotion education for the residents of apartments where Mr. Gonzales lives. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 75 National Quality Forum List of serious reportable events (SREs) Surgical events Product or device events Patient protection events Care management events Environmental events Criminal events Procedure to report an event Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 76 CMS list of “Never Events” “Never events” should never occur. The Centers for Medicare and Medicaid Services (CMS) now denies hospitals higher payments resulting from or complicated by a “never event.” Many hospital-acquired conditions are nurse sensitive indicators. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 77 Risks in Health Care Agencies Chemical use (Material Safety Data Sheets [MSDSs]) Medical errors Medication errors Infection Bed sores Failure to diagnose and treat in time Falls Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 78 Risks in Health Care Agency (cont’d) Classification of health care agency accidents: Patient-inherent accidents Procedure-related accidents Equipment-related accidents Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 79 Safety and the Nursing Process Assessment Through the patient’s eyes Patient’s home environment Assessment questions • Activity and exercise • Medication history • History of falls • Home maintenance and safety Nursing history Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 80 Safety and the Nursing Process (cont’d) Assessment (cont’d) Health care environment • Risks in immediate environment • Risk for falls • Risk for medication errors • Disaster preparedness Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 81 Diagnosis Nursing diagnoses for patients with safety risk: Risk for falls Impaired home maintenance Risk for injury Deficient knowledge Risk for poisoning Risk for suffocation Risk for trauma Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 82 Case Study (cont’d) Joani has also discovered through the screening that Mr. Gonzales has decreased visual acuity and has not had a new pair of glasses for 3 years. He fell in his apartment about a month ago but did not have any injuries. Gait assessment reveals that Mr. Gonzales does not pick his feet very high up off the floor, and his movements are stiff. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 83 Safety and the Nursing Process: Planning Goals and outcomes Prevent and minimize safety threats Are measurable and realistic May include active patient participation Setting priorities Teamwork and collaboration Goals for Mr. Gonzales Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 84 Safety and the Nursing Process: Implementation Health promotion Individualization of implementation Developmental stage Lifestyle Environment Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 85 Safety and the Nursing Process: Implementation (cont’d) Basic needs General preventive measures Lighting Changing the environment Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 86 Case Study (cont’d) The son, Carlos, has purchased a medication organizer that Mr. Gonzales has not used because he is concerned he will make a mistake. Mr. Gonzales is unable to read the labels on his medication bottles. What additional interventions are justified as a result of Mr. Gonzales’ safety assessment? Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 87 Implementation in Acute Care Safety Fall risk prevention Restraints as a last resort Restraint alternatives Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 88 Safety and the Nursing Process: Implementation Acute care safety Seizures Poisoning Electrical hazards Radiation Disasters Hospitals must have an emergency management plan. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 89 Implementation Acute care safety Fires: “RACE” and “PASS” • Rescue patients. • Activate alarm. • Confine fire. • Extinguish. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 90 Implementation (cont’d) Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 91 Quick Quiz! 2. 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. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 92 Case Study (cont’d) What additional health behavior can be encouraged for Mr. Gonzales? What effects could this health behavior produce? Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 93 Safety and the Nursing Process: Evaluation Through the patient’s eyes Are the patient’s expectations met? Are the family’s expectations met? Patient outcomes Monitor care by the health care team. Measure outcomes for each diagnosis. Continually assess needs for additional support. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 94 Case Study (cont’d) It has been 2 weeks since Joani implemented the plan of care for Mr. Gonzales. Joani will observe Mr. Gonzales’ environment for elimination of threats to patient safety. She will reassess motor, sensory, and cognitive status for appropriate environmental modifications. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 95 Quick Quiz! 3. A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as A. A poisoning accident. B. An equipment-related accident. C. A procedure-related accident. D. An accident related to time management. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 96 Case Study (cont’d) With regular exercise, Mr. Gonzales has found that his walking has improved, and now he feels safer about leaving the apartment. The new medication labels and organizer have made it easier for him to tell his several medications apart. He reports that his vision is much better with his new glasses. He understands that he is able to make changes in his environment that will keep him safe. Mr. Gonzales has been injury free and plans to live to a “ripe old age.” Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 97 Expected Outcomes A safe physical environment A patient whose expectations have been met A patient who is knowledgeable about safety factors and precautions A patient free of injury Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 98