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38
Client Safety
O B J EC T IVES
Mastery of the content in this chapter will enable the student to:
• Define the key terms listed.
• Identify nursing diagnoses associated with risks to safety.
• Describe how unmet basic physiological needs of oxygen, nu- • Develop care plans for clients whose safety is threatened.
trition, temperature, and humidity threaten clients’ safety.
• Describe nursing interventions specific to clients’ age for re• Discuss the purpose of the National Patient Safety Goals.
ducing risk of falls, fires, poisonings, and electrical hazards.
• Discuss the specific risks to safety related to developmental age. • Describe methods to evaluate interventions designed to main• Identify factors to assess when it becomes necessary to physitain or promote safety.
cally restrain a client.
• Describe the four categories of risks in a health care agency.
• Describe assessment activities designed to identify clients’
physical, psychosocial, and cognitive status as it pertains to
their safety status.
MEDIA RESOURCES
Companion CD
• Review Questions
• Glossary
Website
• Review Questions
• Glossary
KEY TERMS
Air pollution, p. 1004
Ambularm, p. 1028
Aura, p. 1007
Bed-Check, p. 1028
Bioterrorism, p. 1004
Carbon monoxide, p. 1002
Environment, p. 1002
Food and Drug Administration
(FDA), p. 1002
Food poisoning, p. 1002
Hypothermia, p. 1002
Immunization, p. 1003
Land pollution, p. 1004
Noise pollution, p. 1004
Pathogen, p. 1003
Poison, p. 1030
Pollutant, p. 1004
Relative humidity, p. 1002
Restraint, p. 1019
Seizure, p. 1007
Seizure precautions, p. 1032
Status epilepticus, p. 1035
Water pollution, p. 1004
1001
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1002 Unit 7 Basic Human Needs
S
afety, often defined as freedom from psychological and
physical injury, is a basic human need that must be met.
Health care, provided in a safe manner, and a safe community
environment are essential for a client’s survival and well-being.
The nurse, incorporating critical thinking skills when using the
nursing process, is responsible for assessing the client and the
environment for hazards that threaten safety, as well as planning
and intervening appropriately to maintain a safe environment.
By doing this, the nurse is not only a provider of safe acute, restorative, and continuing care, but also an active participant in
health promotion.
Scientific Knowledge Base
Environmental Safety
A client’s environment includes all of the many physical and
psychosocial factors that influence or affect the life and survival of
that client. This broad definition of environment crosses the continuum of care for settings in which the nurse and client interact
(e.g., the home, community center, school, clinic, hospital, and
long-term care facility). Safety in health care settings reduces the
incidence of illness and injury, prevents extended length of treatment and/or hospitalization, improves or maintains a client’s
functional status, and increases the client’s sense of well-being. A
safe environment gives protection to the staff as well, allowing
them to function at an optimal level. A safe environment includes
meeting basic needs, reducing physical hazards, reducing the
transmission of pathogens, maintaining sanitation, and controlling pollution. In addition, a safe environment is one where the
threat of attack from biological, chemical, or nuclear weapons is
prevented or minimized.
Basic Needs. Physiological needs, including the need for sufficient oxygen, nutrition, and optimum temperature and humidity, influence a person’s safety.
Oxygen. Be aware of factors in a client’s environment that
decrease the amount of available oxygen. A common environmental hazard in the home is an improperly functioning heating system. A furnace that is not properly vented or a car left running
inside a closed garage introduces carbon monoxide into the environment. Carbon monoxide is a colorless, odorless, poisonous
gas produced by the combustion of carbon or organic fuels. Carbon monoxide binds strongly with hemoglobin, preventing the
formation of oxyhemoglobin and thus reducing the supply of
oxygen delivered to tissues (see Chapter 40). Low concentrations
cause nausea, dizziness, headache, and fatigue. Very high concentrations cause death after 1 to 3 minutes of exposure (National
Fire Protection Association, 2006a). It is necessary to have annual
inspections of heating systems, chimneys, and appliances in private homes, as well as in institutions. Carbon monoxide detectors
are available for home or institutional use at a reasonable cost but
are not a replacement for proper use and maintenance of fuelburning appliances.
Nutrition. Meeting nutritional needs adequately and safely
requires environmental controls and knowledge. In the home the
client needs a refrigerator with a freezer compartment to keep
perishable foods fresh. An adequate, clean water supply is neces-
sary for drinking and washing fresh produce and dishes. Provisions for garbage collection are necessary to maintain sanitary
conditions.
Foods that are inadequately prepared or stored, or that are
subject to unsanitary conditions, increase the client’s risk for infections and food poisoning (see Chapter 44). Bacterial food infections result from eating food contaminated by bacteria such as
Escherichia coli or Salmonella, Shigella, or Listeria organisms. The
ingestion of bacterial toxins produced in food causes food poisoning; staphylococcal and clostridial bacteria are the most common types. Although most food-borne diseases are bacterial, the
hepatitis A virus is spread by fecal contamination of food, water,
or milk (Nix, 2005).
For illnesses caused by bacterial contamination, the onset of
symptoms is either very rapid or takes a week or longer. Clients
infected with hepatitis A are most contagious during the 2-week
period before onset of jaundice (Fiore, 2004). Preventive measures
include thorough hand washing before handling food, adequate
cooking, and proper storage and refrigeration of perishable
foods.
To protect consumers, commercially processed and packaged
foods are subject to Food and Drug Administration (FDA)
regulations. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect
consumers against the sale of impure or dangerous substances.
Temperature and Humidity. The comfort zone for environmental temperature varies among individuals, but the usual comfort range is between 18.3° and 23.9° C (65° and 75° F). Temperature extremes that frequently occur during the winter and
summer affect not only comfort and productivity, but also
safety.
Exposure to severe cold for prolonged periods causes frostbite
and accidental hypothermia. Frostbite occurs when a surface area
of the skin freezes as a result of exposure to extremely cold temperatures. Hypothermia occurs when the core body temperature
is 35° C (95° F) or below (see Chapter 32). Older adults, the
young, clients with cardiovascular conditions, clients who have
ingested drugs or alcohol in excess, and the homeless are at high
risk for hypothermia (see Chapter 32).
Exposure to extreme heat raises the core body temperature,
resulting in heatstroke or heat exhaustion. Chronically ill clients,
older adults, and infants are at greatest risk for injury from extreme heat. These clients need to avoid extremely hot, humid
environments.
The relative humidity of the air in the environment sometimes
affects the client’s health and safety. Relative humidity is the
amount of water vapor in the air compared with the maximum
amount of water vapor that the air could contain at the same
temperature. The comfort zone varies from person to person, but
most people are comfortable when the humidity is between 60%
and 70%. Increasing the environmental humidity by using a
home humidifier has therapeutic benefits for clients with upper
respiratory tract infections because humidity helps to liquefy pulmonary secretions and improve breathing. It is important to follow the manufacturer’s directions regarding the cleaning and
maintenance of home humidifiers to reduce the contamination of
the water.
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Chapter 38 Client Safety 1003
Physical Hazards. Physical hazards in the environment place
clients at risk for accidental injury and death. According to the
Centers for Disease Control and Prevention (CDC) (2006a),
unintentional injures are the fifth leading cause of death for
Americans of all ages. Motor vehicle accidents are the leading
cause, followed by poisonings and falls. Among older adults 65
years and above, falls are the leading cause of unintentional death.
Falls are the most common cause of hospital admissions for
trauma for older clients. Fractures are the most serious health
consequence of falls. Almost 90% of all fractures among older
adults are due to falls (CDC, 2006a). You can minimize many
physical hazards, especially those contributing to falls, through
adequate lighting, reduction of obstacles, control of bathroom
hazards, and security measures.
Lighting. Adequate lighting reduces physical hazards by illuminating areas in which a person moves and works. Outside the
home, there needs to be adequate lighting on all walkways. Outdoor lighting also helps protect the home and its inhabitants from
crime. Well-lighted garages, walkways, and doorways discourage
intruders from entering homes or hiding in shadows.
Inside the house, halls, staircases, and individual rooms need
to be adequately lighted so that residents are able to safely carry
out activities of daily living. Night-lights in dark halls, bathrooms,
and the rooms of children and older adults help maintain safety
by reducing the risk of falls. A night-light in a guest room will
help orient an overnight guest who needs to get up in the middle
of the night. Make sure artificial lighting is soft and nonglaring,
because glare is a major problem for older adults (Ebersole, Hess,
and Luggen, 2004).
Obstacles. Injuries in the home frequently result from tripping over or coming into contact with common household objects, including doormats, small rugs on the stairs and floor, wet
spots on the floor, and clutter on bedside tables, closet shelves, the
top of the refrigerator, and bookshelves. The risk of falls from
obstacles is present for all age-groups; however, it is greatest for
older adults. Falls are usually a result of a combination of intrinsic
risk factors (e.g., illness, drug therapy, or alcohol use) and extrinsic or environmental factors. In some cases an obstacle or extrinsic
factor is the only cause of a fall. Intrinsic factors are difficult to
modify or eliminate, but extrinsic ones are usually not.
Bathroom Hazards. Accidents such as falls, burns, and poisoning frequently occur in the bathroom. Handheld shower heads
and secure, easily seen grab bars and nonslip, colored adhesive
tape on the bottom of the tub are useful in reducing falls in the
bathtub. An elevated toilet seat with armrests and nonslip strips
on the floor in front of the toilet are also helpful (McCullagh,
2006). Lowering the thermostat setting on the water heater reduces the risk of scalding. In the medicine cabinet, medications
need to be clearly marked and out of the reach of children. Childresistant caps should be on all medication containers when there
are children living in the home or visiting the home. Medication
not in use or out-of-date should be flushed down the toilet.
Security. Death from fires and burns is the third leading cause
of fatal home injury (Runyan and Casteel, 2004). According to the
National Fire Protection Association (2006b), there were 388,500
reported home fires in the United States in 2003, resulting in
3,145 deaths and 13,650 injuries. The leading cause of fire-related
death is careless smoking (Ahrens, 2003). Cooking equipment and
Figure 38-1 Smoke and fire detector.
appliances, particularly stoves, are the main sources for in-home
fires and fire injuries. Clients should have smoke detectors (Figure
38-1), along with carbon monoxide detectors, placed strategically
throughout the home. Multipurpose fire extinguishers need to be
near the kitchen and any workshop areas.
Although lead has not been used in house paint or plumbing
materials since the U.S. Consumer Product Safety Commission
banned it in 1978, older homes continue to contain high lead
levels. Soil and water systems are sometimes contaminated. Poisoning occurs from swallowing or inhaling lead. Fetuses, infants,
and children are more vulnerable to lead poisoning than adults
because their bodies absorb lead more easily and small children
are more sensitive to the damaging effects of lead. Exposure to
excessive levels of lead affects a child’s growth or causes brain and
kidney damage. Other health effects include impaired hearing,
vomiting, headaches, appetite loss, and learning and behavioral
problems (National Center for Environmental Health, 2005).
An insecure home places the client at risk for injury or burglary. Inadequate locks on doors and windows make the home
susceptible to intruders. Clients need to take precautions to secure
their homes. When you assess the home for safety, guide the client
to evaluate doors and windows for the presence and quality of
locks. Encourage clients to join block associations and work
closely with law enforcement personnel to reduce crime in their
neighborhoods.
Transmission of Pathogens. A pathogen is any microorganism capable of producing an illness. One of the most effective
methods for limiting the transmission of pathogens is the medical
aseptic practice of hand hygiene (see Chapter 34). Instruct clients
in proper hand-hygiene techniques and to use them frequently in
the home and hospital.
Immunization can also reduce, and in some cases prevent, the
transmission of disease from person to person. Immunization is
the process by which resistance to an infectious disease is produced or augmented. Individuals acquire active immunity by an
injection of a small amount of attenuated (weakened) or dead
organisms or modified toxins from the organism (toxoids) into
the body. Passive immunity occurs when antibodies produced by
other persons or animals are introduced into a person’s bloodstream for protection against a pathogen.
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The human immunodeficiency virus (HIV)—the pathogen
that causes acquired immunodeficiency syndrome (AIDS)—and
the hepatitis B virus are transmitted through blood and other
body fluids. Drug abusers frequently share syringes and needles,
which increases the risk of acquiring these viruses. Safe sexual
practices, including the correct use of condoms and engaging in
monogamous relationships, reduce the risk for both of these diseases, as well as for other sexually transmitted diseases (STDs).
Nurses use standard precautions when caring for all clients to
protect themselves from contact with blood and body fluids (see
Chapter 34).
At the community level, adequate disposal of human waste
through proper construction and repair of sewers and drains controls the transmission of disease. Insect and rodent control (e.g.,
spraying for mosquitoes) is also necessary to reduce the transmission of disease.
Pollution. A healthy environment is free of pollution. A pollutant is a harmful chemical or waste material discharged into
the water, soil, or air. People commonly think of pollution only
in terms of air, land, or water pollution, but excessive noise is also
a form of pollution that presents health risks. Air pollution is
the contamination of the atmosphere with a harmful chemical.
Prolonged exposure to air pollution increases the risk of pulmonary disease. In urban areas, industrial waste and vehicle exhaust
are common contributors to air pollution. In the home, school,
or workplace, cigarette smoke is the primary cause of air pollution. Improper disposal of radioactive and bioactive waste products (e.g., dioxin) can cause land pollution.
Water pollution is the contamination of lakes, rivers, and
streams, usually by industrial pollutants. Water treatment facilities
filter harmful contaminants from the water, but these systems
sometimes contain flaws. If water becomes contaminated, the
public should use bottled or boiled water for drinking and cooking. Flooding frequently causes damage to water treatment stations and also requires the use of bottled or boiled water.
Noise pollution occurs when the noise level in an environment
becomes uncomfortable to the inhabitants of the environment.
Noise levels are measured in units of sound intensity called decibels.
Tolerance for noise varies from individual to individual, and an
individual’s health status influences tolerance. Irreversible hearing
loss possibly results from constant exposure to high sound intensity.
Clients working in environments with high noise levels need to
wear protective devices to reduce hearing loss (Figure 38-2). Adolescents need to limit their exposure to intense noise such as that
found at rock concerts.
Noise can also pollute a health care facility. The sounds of
machines, people talking, intercoms, and paging systems create
increased noise levels. Even when the noise level is not high
enough to affect hearing acuity, it sometimes produces a syndrome called sensory overload. Sensory overload is a marked increase in the intensity of auditory and visual stimuli. It disrupts
processing of information, and the client no longer perceives the
environment in a meaningful way (see Chapter 49).
Terrorism. A potential environmental health threat is the possibility of a bioterrorist attack. Before 1990 and the Gulf War, the
possibility of the United States coming under attack from terror-
Figure 38-2 Protective device to reduce hearing loss.
ists groups using biological, chemical, or nuclear weapons seemed
unlikely. Today, however, we are concerned about an attack by an
individual or small group on one of our cities, a large sporting
event, or a unit of our military forces (Jones and others, 2002).
Bioterrorism, or the use of biological agents to create fear and
threat, is the most likely form of terrorist attack to occur. Although terrorists could use any agent, health officials are most
concerned with biological agents such as anthrax, smallpox, pneumonic plague, and botulism (American Medical Association,
2004). The Federal Emergency Management Agency (FEMA)
and the American Red Cross provide nationwide efforts to help
community members prepare for disasters of all types (FEMA,
2004). Health care facilities need to be prepared to treat mass
casualties from an attack. The answer lies in the facility’s emergency management plan. Such a plan details how to respond to a
terrorist attack; for example, determining the agent used, determining the time and location of the attack and the affected population, obtaining and delivering supplies, and providing treatment. Nurses need to be prepared through education and training
to be able to respond to an attack by taking the necessary steps to
initiate an agency’s emergency management plan.
Nursing Knowledge Base
In addition to being knowledgeable about the environment, nurses
need to be familiar with a client’s developmental level; mobility,
sensory, and cognitive status; lifestyle choices; and knowledge of
common safety precautions. They also need to be aware of the
special risks to safety that are found in agency settings.
Risks at Developmental Stages
A client’s developmental stage creates threats to safety as a result
of lifestyle, mobility status, sensory impairments, and safety
awareness.
Infant, Toddler, and Preschooler. Injuries are the leading
cause of death in children over age 1 and cause more death and
disabilities than do all diseases combined (Hockenberry and
Wilson, 2007). The nature of the injury sustained is closely related to normal growth and development. For example, the inci-
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dence of lead poisoning is highest in late infancy and toddlerhood
because of a child’s increased level of oral activity and the growing
ability to explore the environment. Accidents involving children
are largely preventable, but parents need to be aware of specific
dangers at each stage of growth and development. Accident prevention thus requires health education for parents and the removal of dangers whenever possible.
School-Age Child. When a child enters school, the environment expands to include the school, transportation to and from
school, school friends, and after-school activities. Parents, teachers, and nurses need to instruct the child in safe practices to follow
at school or play. When discussing safe practices, an effective way
to teach the school-age child is by using examples.
Because school-age children are participating in more activities
outside their home and neighborhood environments, they are at
greater risk of injury from strangers. A child needs to be warned
repeatedly not to accept candy, food, gifts, or rides from strangers.
In addition, a child needs to know what to do if a stranger approaches. Frequently neighborhoods have a “block home” or “safe
house.” In these homes the owner ensures that an adult is home
during the times when children are walking to and from school.
If a stranger approaches a child, the child can run to that home,
and the adult will protect the child and call the proper authorities.
As a nurse, you will work with school systems or neighborhoods
to initiate such a system to protect children.
Sports safety is stressed in school sports, but parents and health
professionals can reinforce these safety tips by insisting that children wear protective gear while participating in sports such as
skateboarding and snowboarding. For example, schools provide
hard batting helmets for baseball games, and parents also need to
provide this equipment when children are playing baseball in
their own backyards.
Bicycle-related injuries, including scooters, are a major cause
of death and disability among children. Children 5 to 14 years of
age account for nearly one third of bicyclists killed in traffic accidents (National Center for Injury Prevention and Control,
2002). Bikes need to be in good working order and be the proper
size for the child. The child needs to learn the rules of the road
and be cautioned not to engage in dangerous stunts or activities
while bike riding. Children also need to wear a properly fitted
helmet. Because most fatalities from bicycle accidents are related
to head injuries, many states have implemented laws requiring
bicycle helmets (Figure 38-3).
Adolescent. As children enter adolescence, they develop greater
independence and begin to develop a sense of identity and their
own values. In addition, adolescents begin to separate emotionally
from their families, and peers generally have a stronger influence.
The struggle toward identity causes the teenager to experience shyness, fear, and anxiety, with resulting dysfunction at home or
school. In an attempt to relieve the tensions associated with physical and psychosocial changes, as well as peer pressures, some adolescents begin to act impulsively and engage in risk-taking behaviors such as smoking and using drugs. In addition to the health
risks posed by nicotine and other drugs, the ingestion of drugs,
including alcohol, increases the incidence of accidents such as
drowning and motor vehicle accidents.
Figure 38-3 Proper bicycle safety equipment for school-age
child.
When adolescents learn to drive, their environment expands
and so does their potential for injury. The risk of motor vehicle
accidents is higher among 16- to 19-year-old drivers than any
other age-group. Teens are more likely to speed, run red lights,
ride with intoxicated drivers, and drive after using alcohol and
drugs. Teens also have the lowest rate of seat belt use (CDC,
2006b). The young driver needs to learn to comply with rules and
regulations regarding use of a car.
S A F E T Y A L E R T Reinforce to new drivers and parents of new drivers
the need to consistently wear safety belts and to never ride in a car with
a driver who has been drinking. Assist parents and teen in developing a
plan of action if teen is with a driver who drinks at an outing.
Because adolescence is a time when mature sexual physical
characteristics develop, some adolescents begin to have physical
relationships with others. They need prompt, accurate instruction
about abstinence and/or safe sexual practices and birth control.
Adult. The threats to an adult’s safety are frequently related to
lifestyle habits. For example, the client who uses alcohol excessively is at greater risk for motor vehicle accidents. The long-term
smoker has a greater risk of cardiovascular or pulmonary disease
as a result of the inhalation of smoke into the lungs and the effect
of nicotine on the circulatory system. Likewise, the adult experiencing a high level of stress is more likely to have an accident or
illness such as headaches, gastrointestinal (GI) disorders, and infections (see Chapter 31).
Older Adult. The physiological changes that occur during the
aging process increase the client’s risk for falls and other types of
accidents such as burns and car accidents (Box 38-1).
Older clients are more likely to fall in the bedroom, bathroom,
and kitchen, and outside as a result of ice on walkways or obstacles in the garden. Inside falls most often occur while transferring
from beds, chairs, and toilets; getting into or out of bathtubs;
tripping over items, such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and
descending stairs.
• • •
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BO X 3 8 - 1 Physical Assessment Findings in the
Older Adult That Increase the Risk of Accidents
Musculoskeletal Changes
Muscle strength and function decrease, joints become less mobile, bones are brittle due to osteoporosis, postural changes
(e.g., kyphosis) are common, and range of motion is limited.
Nervous System Changes
All voluntary or automatic reflexes slow to some extent, ability to
respond to multiple stimuli decreases, and sensitivity to touch
is decreased.
Sensory Changes
Peripheral vision and lens accommodation decrease, lens develops opacity (cataracts), stimuli threshold for light touch and
pain increases, transmission of hot and cold impulses is delayed, and hearing is impaired as high-frequency tones become
less perceptible.
Genitourinary Changes
Nocturia and occurrences of incontinence increase.
Modified from Ebersole P, Hess P, Luggen A: Toward healthy aging, ed 6,
St. Louis, 2004, Mosby.
Unfortunately, clients throughout all developmental stages are
subject to abuse. Child abuse, domestic violence, and abuse of
older adults are serious threats to safety. Chapters 12 through 14
discuss these topics.
Individual Risk Factors
Other risk factors posing threats to safety include lifestyle, impaired mobility, sensory or communication impairment, and lack
of safety awareness.
Lifestyle. Some lifestyles increase safety risks. People who drive
or operate machinery while under the influence of chemical substances (drugs or alcohol), who work at inherently dangerous
jobs, or who are risk takers are at greater risk of injury. In addition, people experiencing stress, anxiety, fatigue, or alcohol or
drug withdrawal, or those taking prescribed medications are
sometimes more accident-prone. Because of these factors, some
clients are too preoccupied to notice the source of potential accidents, such as cluttered stairs or a stop sign.
Impaired Mobility. Impaired mobility due to muscle weakness, paralysis, or poor coordination or balance is a major factor
in client falls. Immobilization predisposes the client to additional
physiological and emotional hazards, which in turn further restricts mobility and independence (see Chapter 37).
Sensory or Communication Impairment. Clients with
visual, hearing, tactile, or communication impairment, such as
aphasia or a language barrier, are at greater risk for injury. Such
clients are not always able to perceive a potential danger or express
their need for assistance (see Chapter 49).
Lack of Safety Awareness. Some clients are unaware of
safety precautions, such as keeping medicine or poisons away
from children or reading the expiration date on food products. A
complete nursing assessment, including a home inspection, will
BOX 38-2 Nine Life-Saving Patient Safety
Solutions
• Be aware of look-alike, sound-alike medication names. Carefully review medication orders of these drugs and use the six
rights of medication safety.
• Use patient identification. Use two forms of patient identification, such as a hospital arm band and medical record number.
• Communication during patient handover. Communicate critical information, provide time for health care personnel to
ask and resolve questions, and involve the patient and family during the handover process.
• Perform correct procedure at correct body site. Mark the operative site and take a “time out” to verify correct patient,
operative site, and procedure before initiating procedure.
• Control concentrated electrolyte solutions. Use the six rights
of medication administration and follow agency protocols for
these solutions.
• Ensure medication accuracy at transitions in care. Perform
medication reconciliation at each care transition. Compare
all medications a patient is taking against medical order and
the patient’s “home” medication list during admission,
transfer, and discharge.
• Avoid catheter and tubing misconnections. Be meticulous in
verification of catheter and tubing connections, right catheter, and right connection tubing. Label tubing and connections when patient has multiple catheters. • Do not reuse single-use injection devices. Never reuse needles, injection devices, or intravenous catheters.
• Improve hand hygiene to prevent health care–associated infections. Perform hand hygiene before and after each patient
encounter and after contact with contaminated objects (even
when gloves are worn). Encourage family and visitors to perform hand hygiene before and after visits.
Courtesy WHO Collaborating Centre for Patient Safety Releases: Nine LifeSaving Patient Safety Solutions http://www.jointcommissioninternational.
org/solutions, last accessed May 12, 2007.
help you identify the client’s level of knowledge regarding home
safety so that you can correct deficiencies with an individualized
nursing care plan.
Risks in the Health Care Agency
Environmental safety pertains to the health care agency, as well as
to the client’s home and community. However, there are specific
risks in health care agencies that also need to be addressed.
A landmark report published by the Institute of Medicine
(IOM) in 1999 brought national attention to the serious problem
of in-hospital medical errors (Kohn, Corrigan, and Donaldson,
1999). A HealthGrades report indicates that an average of 195,000
hospitalized Americans died annually in 2000, 2001, and 2002
because of potentially preventable medical errors (HealthGrades,
2004). Three types of medical errors accounted for almost 60% of
the client safety incidents: infection following surgery, bed sores,
and failure to diagnose and treat in time. Medication errors, also
cited in these reports, can occur at any point in the medication
administration process, during ordering, transcription, dispensing,
and administering. The majority of errors occur during the ordering and administration stages (Agency for Healthcare Research and
Quality [AHRQ], 2006). The World Health Organization and
The Joint Commission (TJC) work together to enhance client
safety (Box 38-2). It is essential that nurses and health care facilities
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build safety into processes of care and take a systems approach
when taking on efforts to reduce medical errors.
Various forms of chemicals used in health care settings are a
source of an environmental risk. Chemicals such as mercury (see
Chapter 32) and those found in some medications, anesthetic
gases, cleaning solutions, and disinfectants are potentially toxic if
ingested or inhaled. Material safety data sheets (MSDSs) are available to provide detailed information about the chemical, any
health hazards imposed, and precautions for safe handling and
use. MSDSs all give information on the steps to take in case the
material is released or spilled.
Specific risks to a client’s safety within the health care environment also include falls, client-inherent accidents, procedure-
related accidents, and equipment-related accidents. The nurse
assesses for these four potential problem areas and, considering
the developmental level of the client, takes steps to prevent or
minimize accidents.
An accident necessitates the filing of an incident report, a confidential document that completely describes any client accident
occurring on the premises of a health care agency (see Chapter
23). The report documents the accident, client assessment, and
interventions carried out for the client. In addition to completing
the incident report, you objectively document the incident in the
client’s medical record. Because this is a confidential document,
do not mention the incident report in the medical record because
this eliminates the health care agency’s protective clause.
Falls. In 2003 more than 1.8 million seniors age 65 and older
were treated in emergency departments for fall-related injuries,
and more than 421,000 were hospitalized (CDC, 2006a). The
risk for falling is significantly higher in older clients. In addition
to age, a history of previous falls, gait disturbance, balance and
mobility problems, postural hypotension, sensory impairment,
urinary and bladder dysfunction, and certain medical diagnostic
categories (e.g., cancer and cardiovascular, neurological, and cerebrovascular diseases) increase the risk. One of the more common
factors precipitating a fall is a client’s attempt to get out of bed to
toilet. Drug use and drug interactions are also implicated in falls.
Hip fractures are among the most serious fall-related injuries.
Half of older adults who suffer a hip fracture never regain their
previous level of functioning, and many are unable to live independently after the injury (National Center for Injury Prevention
and Control, 2002). Falls that result in injuries will possibly extend a client’s length of stay in the health care environment, placing them at an even greater risk for other complications.
Client-Inherent Accidents. Client-inherent accidents are
accidents (other than falls) where the client is the primary reason
for the accident. Examples of client-inherent accidents are selfinflicted cuts, injuries, and burns; ingestion or injection of foreign
substances; self-mutilation or fire setting; and pinching fingers in
drawers or doors.
A client-inherent accident sometimes occurs as a result of a seizure. A seizure is hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of
muscle contractions that is paroxysmal and episodic, as in a seizure
disorder, or transient and acute, such as following a head injury. A
generalized tonic-clonic, or grand mal, seizure lasts approximately 2
minutes (no longer than 5) and is characterized by a cry, loss of
consciousness with falling, tonicity (rigidity), clonicity (jerking),
and incontinence. During a fall, or as a result of muscle jerking,
musculoskeletal injuries can occur. Before a convulsive episode, a
few clients report an aura, which serves as a warning or sense that a
seizure is about to occur. An aura is a bright light, smell, or taste.
During the seizure activity the client will possibly have shallow
breathing, cyanosis, and loss of bladder and bowel control. Following the seizure there is a postictal phase during which the client
often has amnesia or confusion and falls into a deep sleep.
If repeated seizures occur or if a single seizure lasts longer than 5
minutes, the person needs to be taken to a medical facility immediately. Prolonged or repeated seizures indicate status epilepticus. This
condition is a medical emergency and requires intensive monitoring
and treatment (Epilepsy Foundation, 2006). It is important that
you observe the client carefully before, during, and after the seizure
so that you are able to document the episode accurately.
Procedure-Related Accidents. Procedure-related accidents
occur during therapy. They include medication and fluid administration errors, improper application of external devices, and accidents related to improper performance of procedures (e.g., Foley
catheter insertion).
Nurses are able to prevent many procedure-related accidents.
For example, strictly following the procedure for administering
medications will prevent medication errors (see Chapter 35).
Proper administration of intravenous (IV) fluids prevents fluid
overload or deficit (see Chapter 41). The potential for infection is
reduced when surgical asepsis is used for sterile dressing changes or
any invasive procedure, such as insertion of a Foley catheter. Finally,
correct use of body mechanics and transfer techniques reduces the
risk of injuries when moving and lifting clients (see Chapter 47).
Equipment-Related Accidents. Equipment-related accidents result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV
fluids, all general use and client-controlled analgesic pumps need
to have free-flow protection devices. To avoid accidents, do not
operate monitoring or therapy equipment without instruction.
Use a checklist to assess potential electrical hazards to reduce the
risk of electrical fires, electrocution, or injury from faulty equipment. In health care settings, the clinical engineering staff makes
regular safety checks of equipment.
Critical Thinking
Successful critical thinking requires a synthesis of knowledge, experience, information gathered from clients, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require the nurse to anticipate necessary information,
analyze the data, and make decisions regarding client care. Critical
thinking is an ongoing process. During assessment (Figure 38-4)
you consider all critical thinking elements, as well as information
about the specific client, to make appropriate nursing diagnoses.
In the case of safety the nurse integrates knowledge from nursing and other scientific disciplines, previous experiences in caring
for clients who had an injury or were at risk, critical thinking at-
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Knowledge
• Basic human needs
• Potential risks to client
safety from physical
hazards, lifestyle, risks
associated with health
care environment,
environmental risks, and
biohazards
• Influence of developmental
stage on safety needs
• Influence of illness/medications on client safety
Experience
• Caring for clients whose
mobility or sensory
impairments increase
threats to safety
• Personal experience in
caring for younger siblings
or children
ASSESSMENT
• Identify actual potential threats to the
client’s safety
• Determine impact of the underlying illness
on the client’s safety
• Identify the presence of risks for the client’s
developmental stage and client’s environment
• Determine impact of environmental
influence of the client’s safety
Standards
• Apply intellectual standards such as accuracy,
significance, and completeness when assessing
for threats to the client’s
safety
• Apply ANA standards for
nursing practice
• Apply agency practice standards (e.g., fall prevention
or restraint protocols)
• Review and apply the most
joint commission patient
safety goals
Attitudes
• Demonstrate perserverance
when necessary to identify
all safety threats
• Be responsible for collecting unbiased, accurate data
regarding threats to the
client’s safety
• Show discipline in conducting a thorough review
of the client’s home environment
Figure 38-4 Critical thinking model for safety assessment.
titudes such as perseverance, and any standards of practice that are
applicable. For example, the American Nurses Association (ANA)
standards for nursing practice address the nurse’s responsibility in
maintaining client safety. TJC (2006) also provides standards for
safety (e.g., in the administration of medications, use of restraints,
and use of medical devices). You refer to all of this information
and experience as you conduct a detailed assessment of a specific
client. For example, while assessing a specific client’s home environment, the nurse will consider knowledge regarding typical locations within the home where dangers commonly exist. If a client has a visual impairment, you will apply previous experiences
in caring for clients with visual changes to anticipate how to thoroughly assess the client’s needs. Critical thinking directs you to
anticipate what needs to be assessed and how to make conclusions
about available data.
T Box 38-3 F
Nursing Assessment Questions
Activity and Exercise
• Do you use any assistive devices such as a wheelchair,
walker, or cane to help you move or get around? Did someone show you how to use them safely?
• Do you have any difficulty bathing? Dressing? Eating? Using
the bathroom? Transferring out of the bed or chair?
• What type of exercise or physical activity do you get? How often?
• How many meals do you eat in a typical day? How do you
handle meal preparation?
• Do you do your own laundry? How do you do this, and where
are these appliances located?
• Do you drive an automobile? When do you normally drive?
How far?
• How often do you wear a safety belt when in the car?
• Have you recently been involved in a motor vehicle accident?
Medication History
• What medications do you take?
• Has your doctor or pharmacist reviewed your medicines with
you?
• Do any medications make your dizzy or light-headed?
History of Falls
• Have you ever fallen or tripped over anything in your home?
• Have you ever suffered an injury from a fall? What was it, and
how did it happen?
• Did you have any symptoms right before you fell? What were
they?
• What activity were you performing before the fall?
Home Maintenance and Safety
• Who does your simple home maintenance or minor home repairs?
• Who shovels your snow? Tends to your lawn?
• Do you feel safe in your home? What things in your environment make you feel unsafe?
• Do you have someone to call in case of an emergency?
• How do you feel about making modifications to your home to
make it safer? Do you need help finding resources to help
you do this?
Safety and the Nursing Process
FAssessment
To conduct a thorough client assessment, consider possible threats
to the client’s safety, including the client’s immediate environment, as well as any individual risk factors. Ask the client specific
questions related to safety (Box 38-3).
Nursing History. A nursing history includes data about the
client’s level of wellness to determine if any underlying conditions
exist that pose threats to safety. For example, give special attention
to assessing the client’s gait, muscle strength and coordination,
balance, and vision. Consider a review of the client’s developmental status as you analyze assessment information. Also review if the
client is taking any medications or undergoing any procedures
that pose risks. For example, use of diuretics increases the frequency of voiding and results in the client’s having to use toilet
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B O X 3 8 - 4 Home Hazard Assessment
Home Exterior
Are sidewalks uneven?
Are steps in good repair?
Is ice and snow removal adequate?
Do steps have securely fastened handrails?
Is there adequate lighting?
Is outdoor furniture sturdy?
Home Interior
Do all rooms, stairways, and halls have adequate, nonglare lighting?
Are night-lights available?
Are area rugs secured?
Does home have wooden floors?
Do nonslip floor mats cover floors where water accumulates?
Is furniture placed appropriately to permit mobility?
Is furniture sturdy enough to provide support for getting up and
down?
Are temperature and humidity within normal range?
Are there any steps or thresholds that pose a hazard?
Are step edges clearly marked with colored tape?
Are handrails available and secure?
In homes with young children, are window guards and electrical
outlet covers installed?
Is the poison control center number easily accessible?
Can all doors and windows with security gates and locks be
opened from the inside without a key?
Kitchen
Are hand-washing facilities available?
Is the pilot light on for the gas stove?
Are the stovetop and oven clean?
Are the dials on the stove readable?
Are storage areas within easy reach?
Are fluids such as cleaners and bleach in original containers and
stored properly?
In homes with young children, are safety locks on cabinets and
corner counter protectors installed?
Is the water temperature within normal range (no greater than
120° F)?
Are there clean areas for food storage and preparation?
Is refrigeration adequate? Are the refrigerator and freezer temperatures correct?
facilities more often. Falls often occur with clients who have to get
out of bed quickly because of urinary urgency.
Client’s Home Environment. When caring for a client in
the home, a home hazard assessment is necessary (Box 38-4).
Walk through the home with the client, and discuss how the client normally conducts daily activities. Key areas to inspect are the
bathroom, kitchen, and areas with stairs. For example, when you
assess adequacy of lighting, inspect the areas where the client
moves and works, such as outside walkways, steps, interior halls,
and doorways. Getting a sense of the client’s routines helps you
recognize hazards that are not as obvious.
Assessment for risk of food infection or poisoning includes
obtaining a detailed dietary assessment for the past week; conducting an examination of GI and central nervous system (CNS)
function; observing for a fever; and analyzing the results of cultures of feces and vomitus. Inspect suspected food and water
Bathroom
Are hand-washing facilities available?
Are there skid-proof strips or surfaces in the tub or shower?
Are bath mats secured?
Does the client need grab bars near the bathtub and toilet?
Does the client need an elevated toilet seat?
Is the medicine cabinet well lighted?
Are medications in their original containers?
Are medication containers child resistant if children live in the
home or visit?
Has the client discarded outdated medications?
Bedroom
Are beds of adequate height to allow getting on and off easily?
Is day and night lighting adequate?
Are floor coverings nonskid?
Does the client have a telephone nearby?
Are emergency numbers visible near the telephone?
Electrical and Fire Hazards
Are smoke and carbon monoxide detectors installed?
Are the batteries for all detectors tested every month and
changed twice a year?
Have furnaces, chimneys, and stoves been checked for proper
ventilation?
Are extension cords in good condition and used appropriately?
Are appliances in good working order?
Are electrical appliances located away from water sources?
Is there a multipurpose fire extinguisher near the cooking area,
and does client understand how to use it?
Are combustible items such as oil-based paints, gasoline, and
oily rags being stored in a garage and/or basement?
Are electrical outlets overloaded?
Are flashlights available?
Is there a first aid kit available to the adult members of the
household?
Does everyone in the family have easy access to emergency
phone numbers?
Modified from Ebersole P, Hess P, Luggen A: Toward healthy aging, ed 6, St.
Louis, 2004, Mosby; and McCullagh MC: Home modification: how to help
patients make their homes safer and more accessible as their abilities
change, Am J Nurs 106:54, 2006.
sources, and assess the client’s hand-washing practices. It is useful
for the nurse to ask clients when they routinely wash their hands.
This will then prompt a helpful discussion about the purpose and
importance of hand washing.
Assessment of the environmental comfort of a client’s home
includes a review of when the client normally has heating and
cooling systems serviced. Does the client have a functional furnace or space heater? Does the home have air conditioning or
fans? You need to inform clients who use space heaters of the risk
for fires.
When clients live in older homes, encourage clients to have
inspections for the presence of lead in paint, dust, or soil. Because
lead also comes from the solder or plumbing fixtures in a home,
clients should have water from each faucet tested. Local health
offices can assist a homeowner in locating a trained lead inspector
who will take samples from various locations and have them analyzed at a laboratory for content of lead.
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TA B L E 3 8 - 1 Fall Assessment Tool
Directions: Circle the score for the risk factor that corresponds to the client. The tool should be administered on admission, at
specified intervals, and when warranted by changes in health status. Scores of 15 and higher indicate high risk, and preventive measures should be implemented.
Client Factors
Date Admit
History of falls
Confusion
Age (over 65)
Impaired judgment
Sensory deficit
Unable to ambulate independently
Decreased level of cooperation
Increased anxiety/emotional liability
Incontinence/urgency
Cardiovascular/respiratory disease
Medications affecting blood pressure or level of
consciousness
Postural hypotension with dizziness
Environmental Factors
Attached equipment (e.g., IV pole, chest tubes)
Initial Score
Date
Reassessed Score
15
5
5
5
5
5
5
5
5
5
5
15
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Modified from Farmer B: Try this: best practices in nursing care to older adults, New York, 2000, The Hartford Institute for Geriatric Nursing, New York University.
Health Care Environment. When the client is cared for
within a health care facility, you need to determine if any hazards
exist in the immediate care environment. Does the placement of
equipment or furniture pose barriers when the client attempts to
ambulate? Does positioning of the client’s bed allow the client to
reach items on a bedside table or stand? Does the client need assistance with ambulation? The nurse also collaborates with clinical engineering staff to make sure that equipment has been assessed to ensure proper function and condition.
Risk for Falls. Assessment of a client’s fall risk factors is essential in determining specific needs and developing targeted interventions to prevent falls. The nurse begins by asking clients if they
have had a history of falls. A fall assessment tool (Table 38-1)
helps the nurse assess for potential risks before accidents and injuries result (Farmer, 2000). The illustrated tool has weighted risk
factors. A client’s risk of falling increases dramatically as the number of risk factors increases. Initial and daily assessment of fall risk
is important in identifying clients who are at risk of falling. In
many cases family members are important resources in assessing a
client’s fall risk. Families often are able to report on the client’s
level of confusion and ability to ambulate.
Risk for Medical Errors. Be alert to factors within your own
environment that create conditions in which medical errors are
more likely to occur. Studies have shown that overwork and fatigue cause a significant decrease in alertness and concentration,
leading to errors (Trinkoff and others, 2006). It is important for
nurses to be aware of these factors and to include checks and balances when working under stressful conditions. For example, to
reduce the potential for a medical error, it is essential for the nurse
to check the client’s identification bracelet before beginning any
procedure or administering a medication (see Chapter 35).
In January 2003 TJC established National Patient Safety Goals
in an effort to reduce the risk of medical errors. These evidencebased recommendations require health care facilities to focus their
attention on a series of specific actions. Data on the achievement
of the goals will be made public each year. TJC announces new
goals each year in July. The National Patient Safety Goals for
2007 include the following:
• Improve the accuracy of client identification.
• Improve the effectiveness of communication among caregivers.
• Improve the safety of using medications.
• Accurately and completely reconcile medications across the
continuum of care.
• Reduce the risk of harm resulting from falls.
• Reduce the risk of health care–associated infections.
• Encourage clients’ active involvement in their own care as a
client safety strategy.
• In psychiatric hospitals and hospitals that treat clients for
emotional or behavioral disorders, the organization identifies
safety risks inherent in its client population.
Bioterrorist Attacks. Although the occurrence of a bioterrorist attack has been limited to the anthrax deaths following September 11, 2001, the threat is very real. Be prepared to make accurate and timely assessments in any type of setting. If an attack
occurs, it will most likely involve the use of biological agents such
as anthrax, botulism, smallpox, or bubonic plague. A bioterrorist
attack would likely resemble a natural outbreak initially, but you
will need to recognize that the microorganisms used may have
been modified for increased virulence or may have resistance to
antibiotics or vaccines (Jones and others, 2002). Biological attacks
are either overt (announced) or covert (unannounced). Overt attacks require rapid assessment of their true occurrence, followed
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B O X 3 8 - 5 Biological Agent Syndromes
1. Anthrax (acute infectious disease caused by Bacillus anthracis, a spore-forming, gram-positive bacillus). Humans become
infected through skin contact, ingestion, or inhalation. Person-to-person transmission of inhalational disease does not
occur. Direct exposure to vesicle secretions of skin anthrax
will possibly result in secondary cutaneous infection.
Clinical Features: Pulmonary: Flulike symptoms, possible brief
interim improvement, within 2 to 4 days, abrupt onset of respiratory failure, shock, hemodynamic collapse and death within 24 to
36 hours. Gram-positive bacilli on blood culture tests. Cutaneous:
Local skin involvement, common on the head, forearms, or hands;
localized itching followed by a papular lesion that turns vesicular
and within 2 to 6 days become a depressed black eschar. Gastrointestinal: Abdominal pain, nausea, vomiting, and fever after eating contaminated food (usually meat); bloody diarrhea, hematemesis; gram-positive bacilli on blood culture. Symptoms
begin within 1 day to 8 weeks (average 5 days) depending on exposure route and amount of agent.
2. Botulism (caused by Clostridium botulinum, an anaerobic
gram-positive bacillus that produces a potent neurotoxin).
Food-borne botulism is the most common form. An airborne
form of botulism is also possible.
Clinical Features: Food-borne botulism causes abdominal
cramping, diarrhea, and other gastrointestinal symptoms. Both
food-borne and inhalation botulism cause responsive client with
absence of fever; drooping eyelids, weakened jaw clench, difficulty swallowing or speaking; blurred vision and double vision;
symmetric paralysis of arms first, followed by respiratory muscles,
then legs; respiratory dysfunction from respiratory muscle paraly-
by an appropriate response. Covert attacks become obvious only
after victims present for medical care, after the incubation period
has passed and clinical signs begin to appear (Jones and others,
2002). In both cases it is essential for nurses to recognize and
know high-risk syndromes (Box 38-5). Acutely ill clients representing the earliest cases after a covert attack will seek care in
emergency departments. Less-ill clients at the onset of an illness
will possibly seek care in primary care settings.
There are basic epidemiological principles to assess whether a
client’s presentation of symptoms is typical of an endemic disease
or is an unusual event that should raise concern. Features that
alert nurses to the possibility of a bioterrorism-related outbreak
include the following (Dire, 2006):
• A rapidly increasing incidence of a disease (e.g., within hours
or days) in a normally healthy population
• An unusual increase in the number of people seeking care, especially with fever, respiratory, or gastrointestinal complaints
• An endemic disease rapidly emerging at an uncharacteristic
time or location or in an unusual pattern
• Lower attack rates among clients who are primarily indoors,
in areas with filtered or closed ventilation, compared with
people who had been outdoors
• Clusters of clients arriving from a single locale
• Large numbers of rapidly fatal cases
• Any client presenting with a disease that is relatively uncommon to the geographical area and has bioterrorism potential
• Atypical clinical presentation
sis; no sensory deficits. Neurological symptoms of food-borne
botulism begin 12 to 36 hours after ingestion and 24 to 72 hours
after inhalation. The disease is not transmitted from person to
person.
3. Plague (an acute bacterial disease caused by the gram-negative
bacillus Yersinia pestis). A bioterrorism-related outbreak may be
expected to be airborne.
Clinical Features: Fever, cough, chest pain, hemoptysis within
24 hours of symptom onset, mucopurulent or watery sputum with
gram-negative rods in a Gram stain test. X-ray film shows bronchopneumonia. Person-to-person transmission is possible via large
aerosol droplets. Symptoms usually appear within 1 to 3 days.
4. Smallpox (an acute viral illness caused by the variola virus).
Disease has the potential to cause severe morbidity in a nonimmune population, and it can be transmitted via the airborne route. A single case of smallpox is a public health
emergency.
Clinical Features: Symptoms similar to other acute viral illnesses, such as the flu. Skin lesions appear, quickly progressing
from macules to papules to vesicles. Other symptoms include 2 to
4 days of fever and myalgia; rash most prominent on face and
extremities (including palms and soles); rash scabs over in 1 to 2
weeks. Smallpox is transmitted by large and small respiratory
droplets. Client-to-client transmission is likely from airborne and
droplet exposure and by contact with skin lesions or secretions.
Symptoms begin in 7 to 17 days (average 12 days).
Modified from Dire DJ: CBRNE—Biological warfare agents, http://www.
emedicine.com/emerg/byname/cbrne—biological-warfare-agents.htm, accessed April 5, 2006.
Nurses need to be able to recognize a biological casualty and
to carry out their roles and responsibilities quickly and efficiently. Timely communication is critical for alerting both the
medical and general community at large to a bioterrorist attack.
Health care agencies’ emergency plans will outline the predetermined departments and locations to contact in the event of an
attack.
Client Expectations. Clients generally expect to be safe in
their homes and health care settings. However, there are times
when a client’s view of what is safe does not agree with that of the
nurse. For this reason, any assessment needs to include the client’s
understanding of his or her perception of risk factors. This is
important if the nurse needs to make changes in the client’s environment. Clients usually do not purposefully put themselves in
jeopardy. When clients are uninformed or inexperienced, threats
to their safety will occur. You will always need to consult clients
on ways to reduce hazards in their environment.
FNursing Diagnosis
After completing an assessment of the client’s safety status, review
any clusters of data to determine if there are patterns suggesting
that safety is threatened. Identification of defining characteristics
from the data guides you in identifying appropriate nursing diagnoses. The diagnostic process requires accurate recognition of
defining characteristics, as well as the related factors (Box 38-6).
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T Box 38-6 F
Nursing Diagnostic Process
Risk for Injury
Assessment Activities
Observe client’s mobility
and body alignment.
Defining Characteristics
Uncoordinated gait
Poor posture
Ask client about visual acuity.
Reports difficulty seeing at night
Reports “tripping” over rugs and
furniture
Complete a home hazard
appraisal.
Poorly lighted home
Rooms filled with small items
Excessive amount of furniture for
size of room
Rugs not secure
The related factor becomes the basis for selecting nursing
therapies. For example, Risk for injury related to impaired mobility
and Risk for injury related to barriers in the home environment require different nursing interventions. The client with altered
mobility requires ambulatory aids and physical therapy. When the
related factor is barriers in the home, the nurse intervenes to recommend changes that will create a safer environment. At times,
multiple related factors apply. Examples of nursing diagnoses that
possibly apply for clients whose safety is threatened include the
following:
• Risk for imbalanced body temperature
• Impaired home maintenance
• Risk for injury
• Deficient knowledge
• Risk for poisoning
• Disturbed sensory perception
• Risk for suffocation
• Disturbed thought processes
• Risk for trauma
Knowledge
• Role of community
resources in safety
promotion
• Safety risks posed in use of
home care therapies (e.g.,
home oxygenation, IV
therapy)
• Safety interventions suited
to client’s risks and
condition
Experience
• Previous client responses
to planned nursing
therapies to improve safety
(e.g., what worked and
what did not work)
PLANNING
• Select nursing interventions to promote
safety according to the client’s developmental and health care needs
• Consult with occupational and physical
therapists for assistive devices
• Select interventions that will improve the
safety of the client’s home environment
Standards
• Establish interventions
individualized to the
client’s safety needs
• Apply ANA and TJC standards of providing interventions in a safe and
appropriate manner
• Apply ANA code of ethics to
safeguard the client from
incompetent or unethical
care
Attitudes
• Use creativity to assist in
designing interventions
suited to client needs and
available resources
• Take risks to implement
interventions that explore
new resources or use
current resources in new
ways
Figure 38-5 Critical thinking model for safety planning.
FPlanning
During planning, critically synthesize information from multiple
sources (Figure 38-5). Critical thinking ensures that the client’s
plan of care integrates all that you learned about the client, as
well as the key critical thinking elements. For example, the nurse
will reflect on knowledge regarding the services other disciplines
(e.g., occupational therapy) provide in helping clients return to
their home environments safely. Also reflect on any previous experience whereby a client benefited from safety interventions.
Such experience helps you adapt approaches with a new client.
Applying critical thinking attitudes such as creativity helps the
nurse and client collaborate in planning interventions that are
relevant and most useful, particularly when making changes in
the home environment.
Goals and Outcomes. You need to plan and set goals in collaboration with the client, family, and other members of the
health care team (see care plan). The client who is an active par-
ticipant in reducing threats to safety becomes more alert to potential hazards. Make sure goals and outcomes are measurable and
realistic, with consideration of the resources available to the client.
The overall goal for a client with a threat to safety is remaining
free from injury. The following are examples of expected outcomes that focus on the client’s need for safety:
• Modifiable hazards will be reduced in the home environment
by 100% within 1 month.
• Client does not suffer a fall or injury.
• Client identifies risks associated with visual impairment.
Setting Priorities. You prioritize nursing interventions to
provide safe and efficient care. For example, the client described
in the concept map (Figure 38-6) has several nursing diagnoses.
The client’s mobility problem is an obvious priority because of its
influence on skin integrity and risk for falls. Plan individualized
interventions based on the severity of risk factors and the client’s
developmental stage, level of health, lifestyle, and culture (Box
38-7). Planning must involve an understanding of the client’s
need to maintain independence within physical and cognitive
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C ONCEPT M AP
Nursing diagnosis: Risk for falls related to left-sided
paralysis
• Imbalanced gait
• Receiving diuretic
• Urinary incontinence
• Fell at home 1 month ago
Nursing diagnosis: Risk for impaired skin integrity
related to decreased sensation
• Sensory impairment left side
• Urinary incontinence
• Difficulty changing positions
Interventions
• Implement fall precautions
• Visit client hourly to determine needs
• Avoid late evening fluids
• Schedule toileting and hygiene activities
Interventions
• Initiate skin care protocol
• Turn client every 11/2 hours
• Offer urinal/toilet every 2 hours
Client’s chief medical diagnosis: 20 pack-year
smoking history, left-sided paralysis from previous
stroke, postoperative abdominal surgery
Nursing diagnosis: Impaired physical mobility related
to left-sided paralysis
• Difficulty turning
• Reduced strength on left side
• Left-sided neglect
Nursing diagnosis: Ineffective airway clearance
related to retained thick pulmonary secretions
• Abnormal lung sounds in both lobes
• Dyspnea
• Coughs with difficulty
Interventions
• Range of joint motion
• Schedule short walks
• Occupational therapy for bathing, dressing, and
other ADLs
Interventions
• Teach cascade cough
• Increase fluids
• Assist client with coughing and deep breathing
every hour
Link between medical diagnosis and nursing diagnosis
Link between nursing diagnosis
Figure 38-6 Concept map for a client with a cerebrovascular accident 3 months ago with left-sided paralysis, 2 days postoperative after right femoral-popliteal bypass.
capabilities. Collaborate to establish ways of maintaining the client’s active involvement within the home and health care environment. Education of the client and family is also an important
intervention to reduce safety risks over the long term.
Collaborative Care. Clients need to learn how to identify and
select resources within their community that enhance safety (e.g.,
neighborhood block homes, local police departments, and neighbors willing to check on a client’s well-being). Collaboration with
the client and family and other disciplines such as social work and
occupational and physical therapy become an important part of
the nurse’s plan of care. For example, a hospitalized client needs
to go to a rehabilitation facility to gain strength and endurance
before being discharged home. Make sure the client and family
understand the need for resources and are willing to make changes
that will promote their safety.
FImplementation
You direct nursing interventions toward maintaining the client’s
safety in all types of settings. Nursing measures for providing a
safe environment include health promotion, developmental interventions, and environmental interventions.
Health Promotion. To promote an individual’s health, it is
necessary for the individual to be in a safe environment and to
practice a lifestyle that minimizes risk of injury. Edelman and
Mandle (2006) describe passive and active strategies aimed at
health promotion. Passive strategies include public health and
government legislative interventions (e.g., sanitation and clean
water laws) (see Chapter 3). Active strategies are those in which
the individual is actively involved through changes in lifestyle
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T Box 38-7
Cultural Aspects of Care
Environment of Care
Cultural phenomena affecting health and safety include personal
space, social organizations, communication, and environmental
control. While conducting a home assessment for risks to safety,
nurses need to realize that they have entered the client’s territory
and that the client’s attitude toward his or her residence and belongings must be appreciated. For example, clients from Western
Europe and the British Isles may be considered aloof and distant
in terms of space. It is sometimes very difficult for them to have an
outsider in their home who is suggesting changes with regard to
their personal belongings to reduce physical hazards. It is particularly difficult to determine a client’s attitude toward his or her
home environment when the client speaks another language.
Another culturally sensitive issue is the client’s sense of environmental control. Be aware of health beliefs and practices that
will affect the outcome of interventions. For example, reliance on
family and religious organizations, as opposed to community resources, will possibly affect the client’s compliance with nursing
interventions and referrals.
Nurses and health care providers need to learn to be sensitive
when asking questions and showing respect for different cultural
beliefs. Adapting to different cultural beliefs and practices requires flexibility and a respect for others’ viewpoints. Respect for
the belief systems of others and the effects of those beliefs on
the client’s well-being are critically important to competent care.
Nurses need to have the ability and knowledge to communicate
and to understand health behaviors influenced by culture.
(e.g., wearing seat belts or installing outdoor lighting) and participation in wellness programs.
Nurses participate by supporting legislation and working in
community-based settings. Because environmental and community
values have the greatest influence on health promotion, community
and home health nurses are able to assess and recommend safety
measures in the home, school, neighborhood, and workplace.
Developmental Interventions
Infant, Toddler, and Preschooler Infants, toddlers, and preschoolers depend on adults to protect them from injury. Growing
children are curious and completely trusting of their environment
and do not perceive themselves to be in danger. Nurses are frequently in a position to educate parents or guardians about reducing risks of injuries for young children (see Chapter 12). Nurses
working in prenatal and postpartum settings can easily incorporate safety into the care plan of the childbearing family. Community health nurses are able to assess the home and show parents
how to promote safety in their homes (Table 38-2). Educate parents that children under 5 years are also more susceptible to diseases such as measles, mumps, and chickenpox. Immunizations,
given before the age of 2 years and at recommended intervals,
protect a child from life-threatening diseases.
School-Age Child School-age children increasingly explore
their environment (see Chapter 12). They have friends outside
their immediate neighborhood, and they become more active in
school, church, and community activities. The school-age child
needs specific teaching regarding safety in school and at play. See
Table 38-2 for nursing interventions to help guide the parent in
providing for the safety of the school-age child.
Implications for Practice
• Resistance to changing long-standing habits interferes with a cultural group’s acceptance of
injury prevention practices. Include family
members who have a strong influence, such as a dominant
male or older woman, when providing safety education.
• Evaluate the use of traditional ethnic remedies or foods that
contain lead because they increase a client’s risk for lead poisoning.
• Living in rural areas and in manufactured housing places the
client at greater risk for fire-related injuries and death. Stress
the importance of having working smoke detectors and a multipurpose fire extinguisher.
• Assess the client’s smoking and drinking habits. Residential
fire deaths are often attributed to the use of cigarettes and alcohol.
• Clients who live in poverty and have low educational levels
are at greater risk for injury and disease. Assist the client and
family in identifying community resources such as the local
health office or clinic.
• Be aware of family patterns and how the client and family interact with each other. Family disruption and weak intergenerational ties increase a client’s risk for injury due to violent behavior.
Modified from Giger JN, Davidhizar R: The Giger and Davidhizar transcultural assessment model, J Transcult Nurs 13:185, 2002.
Adolescent Risks to the safety of adolescents involve many
factors outside the home environment, particularly their almost
constant involvement with members of their peer group (see
Chapter 12). Adults serve as role models for adolescents and,
through providing examples, setting expectations, and providing
education, can help adolescents minimize risks to their safety.
This age-group has a high incidence of suicide because of feelings
of decreased self-worth and hopelessness. Be aware of the risks
posed at this time, and be prepared to teach adolescents and their
parents measures to prevent accidents and injury.
Adult Risks to young and middle-age adults frequently result
from lifestyle factors such as child rearing, high stress levels, inadequate nutrition, use of firearms, excessive alcohol intake, and
substance abuse (see Chapter 13). In this fast-paced society there
also appears to be more expression of anger, which will possibly
quickly precipitate accidents (e.g., “road rage”). Adults need to
have the opportunity to discuss the choices they have made in
their lifestyle and the types of threats to safety that exist. Given
information about threats to their well-being, some adults will
make necessary modifications in lifestyle practices. Useful resources are stress management centers (see Chapter 31), employee
assistance programs, and health promotion activities, which are in
many communities and hospitals. In addition, neighborhood
centers, community clinics, and outpatient clinics are equipped to
assist adults in modifying lifestyle habits (e.g., smoking, overeating, lack of exercise, and alcoholism) that present risks to health.
Older Adult Nursing interventions for older adults reduce
the risk of falls and other accidents and compensate for the
physiological changes of aging (Box 38-8). Most injuries to older
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T
F
Nursing Care Plan
Risk for Injury
Assessment
Mr. Key, a visiting nurse, is seeing Ms. Cohen, an 85-year-old
woman, at her home. The client is recovering from a mild stroke
affecting her left side. Ms. Cohen lives alone but receives regular
assistance from her daughter Peggy and son Michael, who both
live within 10 miles. Mr. Key’s assessment included a discussion
of Ms. Cohen’s health problem and how the stroke has affected
her, as well as a pertinent physical examination.
Assessment Activities*
Ask Ms. Cohen how the stroke has affected her mobility.
Conduct a home hazard assessment.
Findings/Defining Characteristics
She responds, “I bump into things, and I’m afraid I’m going to fall.”
Cabinets in kitchen are disorganized and full of breakable items
that could fall out. Throw rugs are on floors; bathroom lighting is poor (40-watt bulbs); bathtub lacks safety strips or
grab bars; home cluttered with furniture and small objects.
Ms. Cohen has kyphosis and has a hesitant, uncoordinated gait.
She frequently holds walls for support.
Left arm and leg weaker than right.
Ms. Cohen has trouble reading and seeing familiar objects at a
distance while wearing current glasses.
Observe Ms. Cohen’s gait and posture.
Assess Ms. Cohen’s muscle strength.
Assess visual acuity with corrective lenses.
*Defining characteristics are shown in bold type.
Nursing Diagnosis: Risk for injury related to impaired mobility, decreased visual acuity, and physical environmental hazards.
Planning
Goal
Home will be free of hazards within 1 month.
Ms. Cohen and family will be knowledgeable of potential hazards
for Ms. Cohen’s age-group within 1 week.
Ms. Cohen will express greater sense of feeling safe from falls in
1 month.
Ms. Cohen will be free of injury within 2 weeks.
Expected Outcomes (NOC)†
Risk Control
Modifiable hazards in kitchen and hallway will be reduced in
the home within 1 week. Revisions to bathroom completed
in 1 month.
Knowledge: Personal Safety
Ms. Cohen and daughter will identify risks and the steps to avoid
them in the home at the conclusion of a teaching session
next week.
Safety Behavior: Fall Prevention
Ms. Cohen will report improved vision with the aid of new eyeglasses.
Ms. Cohen will be able to safely ambulate throughout the home
and perform personal care activities within 2 weeks.
†Outcome classification labels from Moorhead S, Johnson M, Maas M: Nursing outcomes classification (NOC), ed 3, St. Louis, 2004, Mosby.
Interventions (NIC)†
Rationale
Fall Prevention
• Review findings from home hazard assessment with Ms. Cohen
and daughter.
• Establish a list of priorities to modify, and have Ms. Cohen’s
son assist in installing bathroom safety devices.
• Install lighting (75-watt bulbs, nonglare) throughout the home.
Have son install blinds over kitchen windows.
• Discuss with Ms. Cohen and daughter the normal changes of
aging, effects of recent stroke, associated risks for injury, and
how to reduce risks.
• Encourage daughter to schedule vision testing for new prescription within 2 to 4 weeks.
• Refer to a physical therapist to assess need for assistive devices for kyphosis, left-sided weakness, and gait.
Fall risks for homebound older adults include visual disturbances, unsteady gait, and postural changes (Meiner and
Leuckenotte, 2006). Home hazard evaluation will highlight
extrinsic factors that lead to falls.
Modification of environment reduces fall risk (McCullagh, 2006).
With aging, the pupil loses the ability to adjust to light, causing
sensitivity to glare. Glare makes it difficult to clearly see a
walking path (Meiner and Lueckenotte, 2006).
Education regarding hazards reduces fear of falling (American
Geriatrics Society, 2001).
Improved visual acuity reduces incidence of falls (Edelman and
Mandle, 2006).
Exercise often improves gait, balance, and flexibility. Modifying
gait problems by increasing lower extremity strength reduces
fall risk.
†Intervention classification labels from Dochterman JM, Bulechek GM: Nursing interventions classification (NIC), ed 4, St. Louis, 2004, Mosby.
Continued
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F
Nursing Care Plan
T
Risk for Injury—cont’d
Evaluation
Nursing Actions
Ask Ms. Cohen and family to identify risks.
Observe environment for elimination of
hazards.
Reassess Ms. Cohen’s visual acuity.
Observe Ms. Cohen’s gait and posture.
Client Response/Finding
Ms. Cohen and daughter able to identify
risks during a walk through the home
and expressed a greater sense of safety
as a result of changes made.
Throw rugs have been removed. Lighting
has increased to 75 watts except in bathroom and bedroom.
Ms. Cohen has new glasses and says she is
able to read better, as well as see distant objects more clearly.
Ms. Cohen’s gait remains hesitant and uncoordinated; she reports that her daughter has not had time to take her to the
physical therapist.
Achievement of Outcome
Ms. Cohen and daughter are more knowledgeable of potential hazards.
Environmental hazards have been partially
reduced.
Ms. Cohen’s vision has improved, enabling her to ambulate more safely.
Outcome of safe ambulation has not been
totally achieved; continue to encourage Ms. Cohen and daughter to go to
physical therapy appointment.
TA B L E 3 8 - 2 Interventions to Promote Safety for Children and Adolescents
Intervention
Rationale
Infants and Toddlers
Have infants sleep on their backs or sides. Teach parents the
mnemonic “back to sleep.”
Do not fill cribs with pillows, large stuffed toys, or comforters.
Sheets should fit snugly.
Pacifiers should not be attached to string or ribbon and placed
around a child’s neck.
All instructions for preparing and storing formula must be followed.
Use large, soft toys without small parts, such as buttons.
Playpens with mesh sides should not be left with a side down;
spaces between crib slats should be less than 23⁄8 inches (6 cm) apart.
Never leave crib sides down or leave babies unattended on
changing tables or in infant seats, swings, strollers, or high
chairs.
Discontinue using accessories such as infant seats, and swings
when the child becomes too active, physically too big, and/
or according to the manufacturer’s directions.
Never leave a child alone in the bathroom, tub, or near any water source (e.g., pool).
Baby-proof the home; remove small or sharp objects and toxic
or poisonous substances, including plants; install safety
locks on floor-level cabinets.
Remove plastic bags from the cleaners or grocery store from the
home.
Electrical outlets should have covers (Figure 38-7).
Sleeping on the stomach with the mouth and nose in close
proximity to the mattress is associated with sudden infant
death syndrome (SIDS) (Hauck and others, 2003).
Possibility for infants to become entwined in sheets and other
bedding and suffocate.
Reduces risk for choking.
Proper formula preparation and storage prevents contamination. A formula comes in a concentrated form, or is already
premixed with water and ready to use. Following directions
ensures proper concentration of the formula. Undiluted formula causes fluid and electrolyte disturbances; very diluted
formula will not provide sufficient nutrients.
Small parts become dislodged, and choking and aspiration
will possibly occur.
Possibility for a child’s head becoming wedged in the lowered
mesh side or in between crib slats, and asphyxiation may
occur.
Infants and toddlers roll or move and fall from changing tables
or out of accessories such as infant seats or swings.
When physically active or too big, the child will possibly fall
out of or tip over these accessories and suffer an injury.
Reduces risk for accidental drowning.
Babies explore their world with their hands and mouth. Choking and poisoning will possibly occur.
Reduces risk for suffocation from plastic bags.
Reduces opportunity for crawling babies to insert objects into
outlets and experience an electrical shock.
Modified from Hockenberry M, Wilson D: Wong’s nursing care of infants and children, ed 8, St. Louis, 2007, Mosby.
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TA B L E 3 8 - 2 Interventions to Promote Safety for Children and Adolescents—cont’d
Intervention
Rationale
Infants and Toddlers—cont’d
Window guards should be on all windows.
Install keyless locks (e.g., deadbolts) on doors above a child’s
reach, even when they are standing on a chair.
Children weighing less than 80 pounds or under 8 years of age
should always be in an age/weight-appropriate car seat that
has been installed according to the manufacturer’s instructions (Figure 38-8). This includes car seats and booster seats.
In cars with a passenger air bag, children under 12 should be
in the back seat. All passengers should have seat belts on.
Caregivers should learn cardiopulmonary resuscitation (CPR)
and the Heimlich maneuver.
Preschoolers
Teach children to swim at an early age, but always provide supervision near water.
Teach children how to cross streets and walk in parking lots. Instruct them to never run out after a ball or toy.
Teach children not to talk to, go with, or accept any item from a
stranger.
Teach children basic physical safety rules, such as proper use
of safety scissors, never running with an object in their
mouth or hand, and never attempting to use the stove or
oven unassisted.
Teach children not to eat items found in the street or grass.
Remove doors from unus ed refrigerators and freezers. Instruct
children not to play or hide in a car trunk or unused appliances.
School-Age Children
Teach children the safe use of equipment for play and work.
Teach children proper bicycle safety, including use of helmet
and rules of the road.
Teach children proper techniques for specific sports, as well as
the need to wear proper safety gear (e.g., eyewear, mouth
guards).
Teach children not to operate electrical equipment while unsupervised.
Children should never have access to firearms or other weapons. All firearms should be kept in locked cabinets.
Figure 38-7 Safety covers for electrical outlets.
This prevents children from falling out of windows.
This prevents a toddler from leaving the house and wandering
off. Death from exposure, car accidents, and drowning will
possibly occur. Keyless locks allow for rapid exit in case of fire.
In case of a sudden stop or crash, an unrestrained child will
possibly suffer severe head injuries and death.
Caregivers should be prepared to intervene in acute emergencies, such as choking.
Learning to swim is a useful skill that will possibly someday
save a child’s life. However, all children need constant supervision near water.
Pedestrian accidents involving young children are common.
Reduces the risk of injury and stranger abduction.
Risk of injury is lower if children know basic safety procedures.
Reduces risk for possible poisoning.
If a child cannot freely exit from appliances and car trunks, asphyxiation will possibly occur.
The child needs to learn the safe, appropriate use of implements to avoid injury.
Reduces injuries from falling off a bike or being hit by a car.
Using proper sports techniques, correct equipment, and protective gear prevents injuries.
If an electrical mishap were to occur, no one would be available to help.
Children are often fascinated by firearms and weapons and
sometimes attempt to play with them.
Figure 38-8 Infant car seat.
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TA B L E 3 8 - 2 Interventions to Promote Safety for Children and Adolescents—cont’d
Intervention
Rationale
Adolescents
Encourage enrollment in driver’s education classes.
Provide information about the effects of using alcohol and
drugs.
Provide sex education, emphasizing safe sex practices, including abstinence.
Refer adolescents to community and school-sponsored activities.
Encourage mentoring relationships between adults and adolescents.
Teach them safe use of the Internet.
Many injuries in this age-group are related to motor vehicle accidents.
Adolescents are prone to risk-taking behaviors and are subject
to peer pressures.
Many adolescents begin sexual relationships. Pregnancy and
sexually transmitted diseases sometimes result.
The adolescent needs to socialize with peers, yet needs some
supervision.
Adolescents are in need of role models after whom they can
pattern their behavior.
Avoids overuse and possible exposure to inappropriate websites.
Modified from Hockenberry M, Wilson D: Wong’s nursing care of infants and children, ed 8, St. Louis, 2007, Mosby.
T Box 38-8 Focus on Older Adults
Physiological Changes of Aging and Their Impact
on Client Safety
• Older adults experience alterations in vision and hearing. Encourage yearly vision and hearing examinations and frequent
cleansing of glasses and hearing aids as a means of preventing falls and burns.
• Some older adults have slowed reaction time. Teach clients
safety tips for avoiding automobile accidents. Sometimes
driving needs to be restricted to daylight hours or suspended.
• Range of motion, flexibility, and strength decrease. Encourage supervised exercise classes for older adults, and teach
them to seek assistance with household tasks as needed.
Safety features, such as grab bars in the bathroom, are often
necessary.
• Reflexes are slowed, and the ability to respond to multiple
stimuli is reduced. Provide adequate, meaningful stimuli but
prevent sensory overload.
• Nocturia and incontinence are more frequent in older adults.
Institute a regular toileting schedule for the client. A recommended frequency is every 3 hours. Give diuretics in the
morning. Provide assistance, along with adequate lighting, to
clients who need to go to the bathroom at night.
• Memory is sometimes impaired. Clients need to use medication organizers, which can be purchased at any drugstore at a
adults involve falls, automobile accidents, and those related to
burns or fires (National Center for Injury Prevention and Control, 2002). Advancing age and the concurrent physiological
changes in vision, hearing, mobility, reflexes, circulation, and the
ability to make quick judgments all predispose older adults to falls
(see Chapter 14). When a client is hospitalized, confusion, multiple medical problems, medications, immobility, urinary urgency,
age-related sensory changes, postural instability, and an unfamiliar environment are major contributors to falling (Meiner and
Leuckenotte, 2006). Certain disease states common to older
adults, such as arthritis or cerebrovascular accidents, increase
chances of injury.
very reasonable cost. These dispensers can be
filled once a week with the proper medications
to be taken at a specific time during the day.
• The family plays a significant role in the care of
older adults. One in five caregivers reported providing more
than 40 hours of care per week (National Alliance for Caregiving, Association for the Advancement of Retired Persons,
2004). Encourage the family to allow the older adult to remain as independent as possible and provide help only for
those things that are especially stressful or depleted.
• The high prevalence of chronic conditions in older adults results in the use of a high number of prescription and overthe-counter medications. Coupled with age-related changes
in pharmacokinetics, there is a greater risk of serious adverse
effects. Medications typically prescribed for older adults include anticholinergics, diuretics, anxiolytic and hypnotic
agents, antidepressants, antihypertensives, vasodilators, analgesics, and laxatives, all of which may themselves pose
risks or may interact to increase the risk for falls. Review the
client’s drug profile to ensure that any of the above-noted
drugs are used cautiously, and assess the client regularly for
any adverse effects that increase fall risk.
Drivers age 65 and older have higher crash death rates per mile
driven than all but teen drivers (Insurance Institute for Highway
Safety [IIHS], 2003). Older adults are more likely to have automobile accidents because of age-related physiological changes
such as decreases in vision, hearing, cognitive functions, and
physical impairments (CDC, 2006c). Because of this, an older
adult is not always able to quickly observe situations in which an
accident is likely to occur. Decreased hearing acuity alters the
older client’s ability to hear emergency vehicle sirens or car and
truck horns. Because of decreased nervous system response, older
adults are unable to react as quickly as they once could to avoid
an accident. A decline in these skills accounts for the most com-
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mon types of accidents, including right-of-way and turning accidents. The nurse educates clients regarding safe driving tips (e.g.,
driving shorter distances or only in daylight, using side and rearview mirrors carefully, and looking behind them toward their
“blind spot” before changing lanes). If hearing is a problem, have
the client try to keep a window rolled down while driving or reduce the volume of the radio or CD or cassette player. Eventually,
counseling is necessary to help clients make the decision of when
to stop driving. At that time help locate resources in the community that provide transportation.
Burns and scalds are also more apt to occur with older people
because they sometimes forget and leave hot water running or
become confused when turning the dials on a stove or other heating appliance. Nursing measures for preventing burns minimize
the risk from impaired vision. Hot water faucets and dials can be
color coded to make it easier for the adult to know what has been
turned on. Recommending a reduction in temperature of the hot
water heater is also very beneficial.
Older adults love to walk. You can reduce pedestrian accidents
for older adults and for all other age-groups by persuading people
to wear reflectors on garments when walking at night; to stand on
the sidewalk and not in the street when waiting to cross a street;
to always cross at corners and not in the middle of the block
(particularly if the street is a major one); to cross with the traffic
light and not against it; and to look left, right, and left again before entering the street or crosswalk.
Environmental Interventions. Nursing interventions directed at eliminating environmental threats include general preventive measures such as meeting basic needs, reducing physical
hazards, and reducing pathogen transmission.
General Preventive Measures Nurses contribute to a safer
environment by helping the client meet basic needs related to
oxygen, nutrition, temperature, and humidity. To ensure that
oxygen availability is not threatened, recommend that the client
be sure to periodically have the furnace inspected for proper functioning. To achieve a comfortable level of humidity in the home,
have the client attach a humidifier to the furnace or, in the case of
clients who have upper respiratory tract infections, use a room
humidifier where the client sleeps. Teach basic techniques for food
handling (e.g., hand washing and checking for spoilage) and
preparation (e.g., keeping food refrigerated before serving) so that
nutritional needs are met safely. It is also helpful to have family
members label the date when leftovers are saved. Some older
adults benefit from Meals on Wheels services. These services provide fresh nutritious meals to older adults who have difficulty
preparing their own food. Client education for older adults or
clients who enjoy outdoor activities should include ways to prevent and treat frostbite, hypothermia, heatstroke, and heat exhaustion (see Chapter 32).
Adequate lighting and security measures in and around the
home, including the use of night-lights, exterior lighting, and
locks on windows and doors, enable clients to reduce the risk of
injury from crime. The local police department and community
organizations often have safety classes available for residents to
learn how to take precautions to minimize the chance of becoming involved in a crime. For example, some useful tips include
always parking the car near a bright light or busy public area, carrying a whistle attached to the car keys, keeping car doors locked
while driving, and always paying attention while driving to notice
if anyone starts to follow the car.
To prevent the transmission of pathogens, nurses teach aseptic
practices. Medical asepsis, which includes hand hygiene and environmental cleanliness, reduces the transfer of organisms (see
Chapter 34). Clients and family members need to learn thorough
hand hygiene (hand washing or use of hand rub) and when to use
it (e.g., before and after caring for a family member, before food
preparation, before preparing a medication for a family member,
and after contacting any body fluids). When clients require dressing changes or the use of syringes and needles, show families how
to properly dispose of contaminated items in the home. Most
communities have regulations for the disposal of biohazardous
waste.
Acute Care. There are a number of specific safety measures applicable to clients in the acute care environment. The nurse takes
measures to help clients avoid falls, injuries from use of restraints
and side rails, fires, poisoning, and electrical hazards. Special precautions are necessary to prevent injury in clients susceptible to
having seizures. Radiation injuries are also a specific safety concern. Finally, be prepared to respond to the emergency of a bioterrorist attack.
Falls. Modifications in the home and health care environment will easily reduce the risk of falls (Table 38-3). Make sure a
heavy or debilitated client in a bed or wheelchair or on a toilet is
properly supported and secured. Side rails are necessary unless a
client is able to freely and easily ambulate independently. Safety
bars on toilets, locks on beds and wheelchairs, and call lights are
additional safety features found in health care settings (Figures
38-9 and 38-10). Remove excess furniture and equipment, and
make sure a weakened client wears rubber-soled shoes or slippers
for walking or transferring. When clients use assistive aids such as
canes, crutches, or walkers, it is important to routinely check the
condition of rubber tips and the integrity of the aid.
To reduce the risk of injury in the home, remove all obstacles
from halls and other heavily traveled areas. Necessary objects such
as clocks, glasses, tissues, or medications remain on bedside tables
within reach of the client but out of the reach of children. Take
care to ensure that end tables are secure and have stable, straight
legs. Place nonessential items in drawers to eliminate clutter. If
small area rugs are used, secure them with a nonslip pad or skidresistant adhesive strips. Make sure any carpeting on the stairs is
secured with carpet tacks.
In the health care environment, frequent observations of the
client at risk for falls are important to reduce the potential for
injury (Meade and others, 2006). Hourly rounding by nurses
significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction (Box 38-9).
Restraints. A physical restraint is a human, mechanical,
and/or physical device that is used with or without the client’s
permission to restrict his or her freedom of movement or normal
access to a person’s body and is not a usual part of treatment
plans indicated by the person’s condition or symptoms (TJC,
2006). The optimal goal for all clients is a restraint-free environment; however, clients who are at risk for injury from wandering,
falls, and disruptive or agitated behavior may need restraints
temporarily.
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TA B L E 3 8 - 3 Measures to Prevent Falls by Older Adults
Measure
Rationale
Stairs
Install treads with uniform depth of 9 inches (22.5 cm) and 9-inch risers (vertical face of steps).
Install uniform-textured or plain-colored surfaces on each
tread, and mark edge of tread with contrasting color.
Ensure proper lighting of each tread. Block sun or lightbulb
glare with translucent shades or screen, or use lower- wattage or nonglare bulbs.
Ensure adequate headroom so that users do not have to duck
to negotiate stairs.
Remove protruding objects from staircase walls.
Maintain outdoor walkways and stairs in good condition and
free of holes, cracks, and splinters.
Handrails
Install smooth but slip-resistant handrail at least 2 inches (5 cm) from wall.
Secure handrail firmly so that user’s weight is supported, especially at bottom and top of stairway.
Install grab rails in bathroom near toilet and tub.
Floors
Ensure that clients wear properly fitting shoes or slippers with
nonskid surface.
Secure all carpeting, mats, and tile; place nonskid backing under small rugs.
Place bath mats or nonskid strips on bathtub or shower stall
floors.
Secure electrical cords against baseboards.
Maintain proper illumination in areas both inside and outside
where the client moves and walks.
Health Care Facility
Orientation
Place disoriented clients in room near nurses’ station.
Maintain close supervision of confused clients.
Show the client how to use the call light at the bedside and in
bathroom, and place within easy reach.
Place bedside tables and over-bed tables close to client.
Remove clutter from bedside tables, hallways, bathrooms, and
grooming areas.
Leave one side rail up and one down on the side where the oriented and ambulatory client gets out of bed.
Transport
Lock beds and wheelchairs when transferring a client from a
bed to a wheelchair or back to bed.
Place side rails in the up position, and secure safety straps
around the client on a stretcher.
When stairs are of uniform size, older adults do not have to
continually adjust vision.
Uniform textures or color help to decrease vertigo. Marking
edge of tread provides obvious visual clue to end of stair.
Older adults’ vision is unable to adjust quickly to changes in
lighting.
Sudden changes in head position sometimes result in dizziness.
Decreased peripheral vision prevents client from seeing object.
Decreased visual acuity prevents client from seeing any structural defect.
Two-inch distance allows client to grasp handrail firmly for support.
Older adults have greatest risk of falling at top and bottom of
stairs, because center of gravity is being shifted and balance
is unstable.
This enables client to have support while rising from sitting to
standing position.
Reduces chances of slipping.
Sudden slip causes dizziness and inability to regain balance.
Wet surfaces increase the risk of falling.
Prevents tripping.
Reduces the risk of falling due to eyestrain.
Provides for more frequent observation by nursing staff.
Confused clients often attempt to wander out of bed or room.
Location and use of the call light is essential to client safety.
Prevents client from searching or overreaching for items such
as eyeglasses, dentures, hearing aid, or telephone.
Eliminates potential hazards and promotes client independence.
Client use the side rail for support when getting in and out of
bed and to position self once in bed.
Provides stability and support during transfer.
Prevents the client from rolling off the stretcher.
Modified from Chang JT and others: Interventions for the prevention of falls in older adults: systematic review with meta-analysis of randomized clinical trials, Br Med J 328(7441):680, 2004.
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Figure 38-9 Safety bars around toilets and showers.
TBox 38-8 Figure 38-10 Safety locks on wheelchairs.
Evidence-Based Practice
Effects of Nursing Rounds
Evidence Summary
Hospitalized clients often require assistance with basic activities
of daily living such as eating, toileting, and ambulating. Clients
usually communicate their needs by use of the call light. Not
meeting client needs in a timely fashion decreases client satisfaction and places clients at greater risk for injury. Researchers
wanted to know if ursing rounds every 1 or 2 hours would reduce
call light usage, increase client satisfaction, and reduce frequency of client falls. During rounding the following items were
performed for each client: pain management, toileting, positioning, and items such as call light, telephone, TV remote, bed light
switch, tissue, and water placed within reach and garbage can
next to bed. In addition, before leaving the room, the nurse
asked, “Is there anything else I can do for you before I leave? I
have time while I’m here in the room.” The client was also told
someone would be back in 1 (or 2) hours to round again. A 6-week
nationwide quasi-experimental study was conducted on 27 nurs-
Whenever a client is restrained, there is a natural tendency for
the client to try to remove the restraint. When this occurs, client
injury is common. Restrained clients easily become entangled in
a restraint device in attempts to get out of the device. In some
cases, death has resulted because of strangulation or asphyxiation.
As a result, nursing homes and many health care facilities have
banned the use of the jacket (vest) restraint because of this risk.
The use of any restraint is also associated with serious complications, including pressure ulcers, constipation, pneumonia, urinary
and fecal incontinence, and urinary retention (see Chapter 47).
Contractures, nerve damage, and circulatory impairment are also
potential hazards. In addition, restrained clients experience a loss
of self-esteem, humiliation, fear, and anger.
ing units in 14 hospitals. Researchers took baseline data on call light usage during the initial 2
weeks. Rounding at set intervals, including specific nursing actions, was associated with statistically significant reduced client call light usage, increased client
satisfaction, and in the 1-hour rounding group, client falls.
Application to Nursing Practice
• Nursing rounds performed at set intervals will positively affect client satisfaction and safety and lead to fewer distractions for staff
• The nurse’s ability to meet the client’s needs affects the client’s perception of the quality of nursing care.
• Anticipate client needs by performing rounds, including specific actions, at 1-hour intervals.
Reference
Meade CM and others: Effects of nursing rounds on patients’ call
light use, satisfaction and safety, Am J Nurs 106(9):58, 2006.
S A F E T Y A L E R T Routine assessment of a client in restraints is
critical to prevent injury. Because of the risk of injury from restraints,
regulatory agencies such as TJC and the Centers for Medicaid and
Medicare Services (CMS) enforce standards for the safe use of restraints and define clients’ rights and choices regarding their use.
Under these guidelines, reasons for use of a physical restraint are to
be clearly stated. The use of restraints must be part of the client’s
medical treatment, all less restrictive interventions must be tried first,
other disciplines must be consulted, and supporting documentation
must be provided (CMS, 2006).
The movement is for health care organizations to become
restraint-free environments. Restraints do not prevent falls or injury. In fact, clients incur less severe injuries if left unrestrained
(Capezuti and others, 1998; Strumpf and others, 1998). A multi-
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BO X 3 8 - 1 0 Alternatives to Restraints
• Orient clients and families to environment; explain all procedures and treatments.
• Provide companionship and supervision; use trained sitters
or adjust staffing.
• Offer diversionary activities, such as music or something to
hold; enlist support and input from the family.
• Assign confused or disoriented clients to rooms near the
nurses’ station; observe these clients frequently.
• Use calm, simple statements and physical cues as needed.
• Use de-escalation, time-out, and other verbal intervention
techniques when managing aggressive behaviors.
• Provide appropriate visual and auditory stimuli (e.g., family
pictures, clock, radio).
• Remove cues that promote leaving (e.g., elevators, stairs, or
street clothes).
• Promote relaxation techniques and normal sleep patterns.
• Institute exercise and ambulation schedules as allowed by
the client’s condition; consult physical therapist for mobility
and exercise programs.
• Attend to needs for toileting, food, and liquid.
• Camouflage IV lines with clothing, stockinette, or Kling
dressing.
• Evaluate all medications client is receiving, and ensure effective pain management.
• Reassess physical status, and review laboratory findings.
Modified from Joint Commission Resources: Strategies for avoiding restraint related errors, 2006, http://www.jcrinc.com; and Geriatric nursing
resources for care of older adults: Physical restraints, 2006, http://www.
geronurseonline.org/index.
disciplinary approach that conducts individualized assessments
and develops structured treatment plans reduces the number of
restraints used. It is imperative that nurses try alternative measures
instead of restraints (Box 38-10). The University of Iowa Gerontological Nursing Interventions Research Center has developed a
restraint use algorithm (Figure 38-11). The algorithm provides
evidenced-based guidelines for how to determine if a restraint is
appropriate and what interventions to employ.
The use of restraints involves a psychological adjustment for
the client and family. If restraints are necessary, the nurse assists
family members and clients by explaining their purpose, expected
care while the client is restrained, precautions taken to avoid injury, and that the restraint is temporary and protective. Informed
consent from family members is sometimes required before using
restraints, as is the case in long-term care settings.
For legal purposes, know agency-specific policy and procedures for appropriate use and monitoring of restraints. The use of
a restraint must be clinically justified and be a part of the client’s
prescribed medical treatment and plan of care. A physician’s order
is required, based on a face-to-face assessment of the client. The
order must state the type of restraint, location, and specific client
behaviors for which restraints are to be used and must have a
limited time frame. These orders need to be renewed within a
specific time frame according to the agency’s policy. Restraints are
not to be ordered prn (as needed). You must conduct ongoing
assessment of clients who are restrained. Proper documentation,
including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the
body part restrained (e.g., circulation to hand), and the evaluation
of the client response, is essential. Restraints must be periodically
removed, and the nurse assesses the client to determine if the restraints continue to be necessary.
Skill 38-1 includes guidelines for the proper use and application of restraints. Use of restraints must meet the following objectives:
• Reduce the risk of client injury from falls.
• Prevent interruption of therapy such as traction, IV infusions,
nasogastric (NG) tube feeding, or Foley catheterization.
• Prevent the confused or combative client from removing life
support equipment.
• Reduce the risk of injury to others by the client.
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PATIENT EXHIBITS:
* Wandering
* Fall prone
* Interfering with
medical devices
* Resistive to care
NURSING ASSESSMENT:
Establish reason(s) for
problematic behavior(s).
Assess factors such as:
- Time of day
- Environment
- Pain
- Other activities
Patient behavior
harmful to self
or others?
NO
YES
NURSING INTERVENTIONS:
• Treat/eliminate the cause
• Seek expert consultation
• Try alternatives to restraints:
* Companionship/supervision
* Change/eliminate bothersome treatments
* Change the environment:
- Light
- Bedside commode
- Bed rails down
- A “quiet room”
* Reality orienting:
- Reality links (TV, radio, clock, calendar)
Use interventions
as appropriate to
maintain safe
behavior
Apply Restraints:
DO NOT APPLY
RESTRAINTS
YES
Intervention
effective?
NO
- Physical restraints
- Chemical restraints
DOCUMENT
Figure 38-11 Restraint use algorithm. (Developed from Restraints—a research-based protocol by L. Ledford, MA, ARNP, and J.
Mentals, MS, RNCS, GNP. Copyright 1998, University of Iowa Gerontological Nursing Interventions Research Center.)
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T SKILL 38-1
A p p ly i n g R e s t r a i nt s
Delegation Considerations
The skill of applying restraints can be delegated. However, the
nurse is always responsible for assessment of client’s safety needs,
selection of appropriate alternative interventions, evaluation of effectiveness of restraint, and ongoing assessment to prevent complications of restraint use. The nurse directs personnel to:
• Inform the nurse of any redness, excoriation, or constriction of
circulation under the restraint.
STEPS
1. Assess whether client needs a restraint. Does the client continually try to interrupt needed therapy? Is the client repeatedly trying to ambulate independently, creating a serious
risk of injury?
2. Assess client’s behavior, such as confusion, disorientation,
agitation, restlessness, combativeness, or inability to follow
directions. Consult with gerontological nurse specialist if
available.
3. Review agency policies regarding restraints. Check physician’s order versus licensed independent practitioner’s order for purpose, type, location, and duration of restraint.
Check agency policy to determine if a signed consent is
needed for use of restraint.
• Ask for assistance if the client has any mobility restrictions
that will affect how to remove or reapply a restraint.
• Change client’s position; provide range of motion, skin care,
toileting, and opportunities for socialization.
Equipment
• Proper restraint: mitten, belt, extremity
• Padding (if needed)
RATIONALE
Use restraints only when other measures have failed to prevent
interruption of therapy such as traction, IV infusions, or nasogastric tube feedings; to prevent a confused or combative client from self-injury by falling out of bed or a wheelchair; to
prevent a client from removing a urinary catheter, surgical
drain, or life support equipment; and to reduce risk of injury to
others by the client.
If client’s behavior continues despite attempts to eliminate cause of
behavior, use of physical restraint will possibly be necessary.
An order by a licensed independent practitioner is necessary to
apply restraints. The least restrictive type of restraint should
be ordered.
Critical Decision Point: Because restraints limit the client’s ability to move freely, the nurse must make clinical judgments appropriate to the client’s condition and agency policy. If the nurse restrains a client in an emergency situation because of violent or self- destructive behavior that presents an immediate danger, a face-to-face physician assessment within 1 hour is necessary (CMS, 2006).
4. Review manufacturer’s instructions before entering client’s
room. Determine the most appropriate size restraint.
5. Gather equipment, and perform hand hygiene upon entering room.
6. Introduce self to client and family. Assess their feelings
about restraint use. Explain that restraint is temporary and
designed to protect client from injury.
7. Inspect placement area of restraint. Assess condition of
skin underlying area where restraint will be.
8. Approach client in a calm, confident manner. Explain what
you plan to do.
9. Adjust bed to proper height, and lower side rail on side of
client contact.
10. Provide privacy. Make sure client is comfortable and in
proper body alignment. Drape client as needed.
11. Pad skin and bony prominences (if necessary) before applying restraints.
12. Apply appropriate-size restraint, making sure it is not over
an IV line or other device (e.g., dialysis shunt).
A. Belt restraint: Device that secures client to bed or
stretcher. Apply over clothes or gown. Remove wrinkles
from front and back of restraint while placing it around
client’s waist. Bring ties through slots in belt. Avoid
placing belt across the chest or too tightly across the
abdomen (see illustration).
The nurse should be familiar with all devices used for client care
and protection. Incorrect application of a restraining device will
possibly result in client injury or death.
Promotes organization and reduces transmission of microorganisms.
Helps minimize client anxiety during application of the device and
helps minimize family concern during maintenance of restraint.
Restraints compress and interfere with functioning of devices or
tubes. Provides baseline assessment data regarding skin integrity.
Reduces client anxiety and promotes cooperation.
Allows nurse to use proper body mechanics and prevent injury.
Privacy prevents lowering of self-esteem. Proper body alignment
promotes comfort, prevents contractures and neurovascular
injury.
Padding reduces friction and pressure on skin and underlying tissue.
IV lines and other therapeutic devices sometimes become occluded.
Restrains center of gravity and prevents client from rolling off
stretcher or sitting up while on stretcher or from falling out of
bed. Tight application interferes with ventilation.
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T SKILL 38-1
A p p ly i n g R e s t r a i nt s — co nt ’ d
STEP 12a Belt restraint tied to the bed frame or hook under the bed and to an area that does not cause the restraint to tighten when the side rail
or bed is raised or lowered. (From Sorrentino SA: Mosby’s textbook for nursing assistants, ed 6, St. Louis, 2004, Mosby.)
STEP 12b Extremity restraint being applied to wrist.
STEP 12c Mitten restraint.
STEPS
B. Extremity (ankle or wrist) restraint: Restraint designed
to immobilize one or all extremities. Commercially available limb restraints are composed of sheepskin or foam
padding (see illustration). Wrap limb restraint around
wrist or ankle with soft part toward skin and secured
snugly in place by Velcro straps.
C. Mitten restraint: Thumbless mitten device to restrain client’s hands (see illustration). Place hand in mitten, being sure to bring end all the way up over the wrist.
D. Elbow restraint: Piece of fabric with slots in which
tongue blades are placed so that elbow joint remains
rigid (see illustration).
RATIONALE
Maintains immobilization of extremity to protect client from injury
from fall or accidental removal of therapeutic device (e.g., IV
tube or Foley catheter). Tight application interferes with circulation.
Prevents clients from dislodging invasive equipment, removing
dressings, or scratching, yet allows greater movement than a
wrist restraint.
Commonly used with infants and children to prevent elbow flexion
(e.g., when an IV line is in place).
Continued
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T SKILL 38-1
STEPS
E. Mummy restraint: Open blanket or sheet on bed or crib
with one corner folded toward center. Place child on
blanket with shoulders at fold and feet toward opposite
corner (see illustration for Step 12E-1). With child’s right
arm straight down against body, pull right side of blanket firmly across right shoulder and chest and secure beneath left side of body (see illustration for Step 12E-2).
Place left arm straight against body, and bring left side
of blanket across shoulder and chest and lock it beneath
child’s body on right side (see illustration for Step 12E-3). Fold lower corner and bring it over body, and tuck or fasten it securely with safety pins (see illustration for Step 12E-4).
RATIONALE
Maintains short-term restraint of small child or infant for examination or treatment involving head and neck. Effectively controls
movement of torso and extremities.
STEP 12d Elbow restraint.
1
2
3
4
STEP 12e Mummy restraint.
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T SKILL 38-1
STEPS
13. Attach restraints to movable part of the bed frame, which
moves when the head of bed is raised or lowered (see illustration).
RATIONALE
Client will possibly be injured if restraint is secured to side rail and
it is lowered.
Critical Decision Point: Do not attach end of restraint to side rails.
14. Secure restraints with a quick-release tie (see illustration).
Do not tie in a knot.
15. Insert two fingers under the secured restraint (see illustration).
16. Assess proper placement of restraint, skin integrity, pulses,
temperature, color, and sensation of the restrained body
part at least every 2 hours (TJC, 2006) or according to
agency policy.
STEP 13 Tie restraint strap to bed frame or hook under bed.
Allows for quick release in an emergency.
A tight restraint will possibly cause constriction and impede circulation. Checking for constriction prevents neurovascular injury.
Frequent assessment prevents complications, such as suffocation, skin breakdown, and impaired circulation.
STEP 14 The Posey quick-release tie. (Courtesy JT Posey Co,
Arcadia, Calif.)
STEP 15 Place two fingers under restraint to check tightness.
Continued
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T SKILL 38-1
STEPS
17. Restraints should be removed at least every 2 hours (TJC,
2006). If client is violent and noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Do not leave client unattended at this time.
18. Secure call light or intercom system within reach.
19. Leave bed or chair with wheels locked. Bed should be in
lowest position.
20. Perform hand hygiene before leaving room.
21. While restraints are in use:
A. Inspect client for any injury, including all hazards of immobility.
B. Observe IV catheters, urinary catheters, and drainage
tubes to ensure that they are positioned correctly and
that therapy remains uninterrupted.
C. Frequently reassess client’s need for continued use of
restraint with the intent of discontinuing restraint at the
earliest possible time (TJC, 2006) (see agency-specific
policy).
D. Provide appropriate sensory stimulation, and reorient
client as needed.
Recording and Reporting
RATIONALE
Provides opportunity to change client’s position and perform full
range of motion (ROM), toileting, and exercise and to provide
food or fluids.
Allows client, family, or caregiver to obtain assistance quickly.
Locked wheels prevent bed or chair from moving if client attempts
to get out. If client falls when bed is in lowest position, this will
reduce the chances of injury.
Reduces transmission of microorganisms.
Client should be free of injury and not exhibit any signs of immobility complications.
Reinsertion is uncomfortable and increases risk of infection or interrupt therapy.
Use of restraints is a temporary measure and discontinued as
soon as possible (Strumpf and others, 1998).
Use of restraints further increases disorientation.
• Record behaviors that place client at risk for injury.
• Describe restraint alternatives attempted and client’s response.
• Record client’s and/or family’s understanding of and consent
to restraint application.
• Record type and location of restraint and time applied.
• Record time of assessments and releases.
• Document client’s behavior after application of restraint.
• Document specific assessments related to orientation, oxygenation, skin integrity, circulation, and positioning.
• Describe client’s response when restraints were removed.
3. Client has increased confusion, disorientation, or agitation.
a.Identify reason for change in behavior, and attempt to
eliminate cause.
b.Attempt a restraint alternative.
4. Client escapes from the restraint device and suffers a fall or
injury.
a.Attend to client’s immediate physical needs, and inform
physician.
b.Reassess type of restraint used, correct application, and if
alternatives can be used.
Unexpected Outcomes and Related Interventions
• Plan care with family. If possible, use of an Ambularm will free
client from physical restraints.
• Instruct family (or other caregiver) in use of alternatives to restraints (see Box 38-9).
• A physical restraint is a device that requires a physician order.
It should not be sent home with family unless the device is
needed to protect client from injury. If physical restraints are
necessary, you need to instruct the family (or other caregiver)
in proper application, care needed while in restraints, and
complications to look for. Also inform caregiver whom to contact if any abnormal findings occur.
• A client who needs to be restrained in bed should have a hospital bed and will require constant supervision in the home.
1. Client has signs of impaired skin integrity.
a.Assess skin, and provide appropriate therapy.
b.Notify the physician, and reassess the need for continued
use of the restraint
c.Ensure correct application of restraint. Pad skin under a restraint, and remove restraint more frequently.
2. Client has altered neurovascular status to an extremity (cyanosis, pallor, coldness of the skin, or complaints of tingling,
pain, or numbness).
a.Remove restraint immediately, stay with the client, and notify the physician. Protect extremity from further injury (e.g.,
pressure from tubing or encumbrance, positioning).
In keeping with current trends toward health promotion, improved assessment techniques and modifications of the environment are alternatives to restraints. The client can wear a device
called the Ambularm on the leg. It signals when the leg is in a
dependent position, such as over the side rail or on the floor (Figure 38-12). There are also weight-sensitive sensor mats that you
can place on clients’ mattresses or in the chair such as the BedCheck bed exit alarm system (Figure 38-13). This device sounds
Home Care Considerations
an audible alarm at the bedside when pressure is released off the
sensor mat. The alarm can be designed to signal at the central
nurses’ station so that staff are alerted quickly when a client is up
and out of bed. There are also alarms that you can place on doors
to alert staff or family members when a confused or disoriented
client, prone to wandering, opens a door.
A less-restrictive restraint is the Posey Bed Enclosure (Figure
38-14). The bed is a soft-sided, self-contained enclosed bed that
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Figure 38-12 Client wearing an Ambularm device.
is much less restrictive than chemical or physical restraints. It
allows for freedom of movement and thus reduces the side effects caused by physical restraints such as pressure ulcers and loss
of dignity. A vinyl top covers the padded upper frame of the bed
and the nylon-net canopy surrounds the mattress and completely encloses the client in the bed. Zippers on the four sides
of the enclosure provide access to the client. The Posey Bed
Enclosure works well for clients who are restless and unpredictable, cognitively impaired, and at risk for injury if they were to
fall or get out of bed, such as clients on anticoagulant therapy at
risk for intracranial bleed. The bed is also a safer alternative to
side rails.
Side Rails. Side rails help to increase a client’s mobility and/
or stability when in bed or when moving from bed to chair. Side
rails also help prevent the unconscious client from falling out of
bed or from a stretcher (Figure 38-15). A full set of raised side
rails is considered a restraint if they restrict a client’s freedom of
voluntary movement in and out of bed (CMS, 2006). The use of
side rails alone for a disoriented client will cause more confusion
and further injury. A confused client who is determined to get out
of bed attempts to climb over the side rail or climbs out at the foot
of the bed. Either attempt usually results in a fall or injury. Nursing interventions to reduce a client’s confusion first focus on the
cause of the confusion. Frequently nurses mistake a client’s attempt to explore his or her environment or to self-toilet as confusion. A thorough assessment is essential. Whenever side rails are
used, make sure the bed is in the lowest position possible.
S A F E T Y A L E R T Side rails have the potential to cause entrapment of
the head and body, especially in older adult clients who are frail, confused, and restless or have uncontrollable body movement (FDA, 2006).
Entrapment has resulted in death, due to asphyxiation, and injuries,
such as fractures and lacerations. To prevent this hazard, assess for excessive gaps and openings between the bed frame and mattress and
utilize side rail netting or covers, protective padding, and/or antiskid
mats to prevent the mattress from being pushed to one side.
Fires. A fire is always possible in the home or hospital. Accidental home fires typically result from smoking in bed, placing
cigarettes in trashcans, grease fires, or electrical fires resulting from
faulty wiring or appliances. Institutional fires typically result from
an electrical or anesthetic-related fire. Although smoking is usually
Figure 38-13 The Bed-Check bed exit alarm and sensor mat.
(Courtesy Bed-Check Corp.)
not allowed in the hospital setting, smoking-related fires continue
to pose a significant risk due to unauthorized smoking in bed.
The interventions described here are directed toward fires occurring in health care agencies, but the same principles apply for fires in
the home (Box 38-11). Homes need to be equipped with smoke and
fire alarms. It is important to have a plan of action in the event of
fire, including a route of exit and identification of a location where
family members will meet. All clients, even young children, need to
be familiar with the phrase “stop, drop and roll,” which describes the
actions to follow when clothing and skin are burning.
If a fire occurs in a health care agency, the nurse protects clients
from immediate injury, reports the exact location of the fire, and
contains the fire and extinguishes it if possible. All personnel are
mobilized to evacuate clients. Clients who are close to the fire,
regardless of its size, are at risk of injury and need to be moved to
another area. If a client is receiving oxygen but not life support,
the nurse discontinues the oxygen, which is combustible and will
fuel an existing fire. If the client is on life support, you will need
to maintain the client’s respiratory status manually with a bagvalve-mask device (see Chapter 40) until the client is away from
the fire. You direct ambulatory clients to walk by themselves to a
safe area. In some cases, they will be able to assist in moving clients in wheelchairs. You generally move bedridden clients from
the scene of a fire by a stretcher, their bed, or a wheelchair. If none
of these methods is appropriate, clients need to be carried from
the area. If the nurse has to carry a client, be careful not to overextend physical limits for lifting because injury to the nurse will
result in further injury to the client. If fire department personnel
are on the scene, they will help evacuate the clients.
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Figure 38-14 The Posey Bed Enclosure. (Courtesy JT Posey Co, Arcadia, Calif.)
BOX 38-11 Fire Intervention Guidelines for
Nurses Working in Health Care Agencies
Keep the phone number for reporting fires visible on the telephone at all times.
Know the agency’s fire drill and evacuation plan.
Know the location of all fire alarms, exits, extinguishers, and
oxygen shut-off.
Use the mnemonic RACE to set priorities in case of fire:
R Rescue and remove all clients in immediate danger.
A Activate the alarm. Always do this before attempting to
extinguish even a minor fire.
C Confine the fire by closing doors and windows and turning off oxygen and electrical equipment.
E Extinguish the fire using an extinguisher (see Figure 38-16).
Figure 38-15 Side rails in the up position on a stretcher.
After a fire has been reported and clients are out of danger,
nurses and other personnel take measures to contain or put out the
fire, such as closing doors and windows, placing wet towels along
the base of doors, turning off sources of oxygen and electrical equipment, and using a fire extinguisher. Fire extinguishers are categorized as type A, used for ordinary combustibles (e.g., wood, cloth,
paper, and many plastic items); type B, used for flammable liquids
(e.g., gasoline, grease, paint, and anesthetic gas); and type C, used
for electrical equipment. Box 38-12 discusses the correct use of an
extinguisher, and Figure 38-16 demonstrates the process as well.
The best intervention is to prevent fires. Nursing measures
include complying with the agency’s smoking policies and keeping combustible materials away from heat sources. Some agencies
have fire doors that are held open by magnets and close auto-
matically when a fire alarm sounds. It is important to keep equipment away from these doors.
Poisoning. A poison is any substance that impairs health or
destroys life when ingested, inhaled, or otherwise absorbed by the
body. Specific antidotes or treatments are available for only some
types of poisons. The capacity of body tissue to recover from the
poison determines the reversibility of the effect. Poisons impair
the respiratory, circulatory, central nervous, hepatic, GI, and renal
systems of the body.
The toddler, preschooler, young school-age child, and older
adult need be protected from accidental poisoning. Using childresistant caps, placing medications and cleaning fluids and powders out of the reach of children, leaving potentially poisonous
materials in original containers, and removing poisonous plants
from the home prevent accidental ingestion of poisonous materials. Poisoning also results from swallowing miniature button or
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A
B
C
Figure 38-16 A, Pull the pin. B, Aim at the base of the fire. C, Squeeze the handles. Sweep from side to side to coat the area
evenly.
TBox 38-12 Client Teaching
Correct Use of a Fire Extinguisher in the Home
Objectives
• Client will correctly place the extinguisher in the home.
• Client will describe when it is appropriate to use a home fire
extinguisher.
• Client will demonstrate the correct technique when using a
fire extinguisher.
• Client will state when fire extinguishers need to be replaced.
Teaching Strategies
• Discuss correct location of the extinguisher. It is recommended that one be placed on each level of the home, near
an exit, in clear view, away from stoves and heating appliances, and above the reach of small children. Keep a fire extinguisher in the kitchen, near the furnace, and in the garage.
Make sure clients read instructions after purchasing the extinguisher and keep them for periodic review.
• Describe the steps to take before using the extinguisher. Attempt to fight the fire only when all occupants have left the
disk batteries commonly found in games, cameras, calculators,
and watches. In older adults, diminished eyesight and impaired
memory results in accidental ingestion of poisonous substances or
in accidental overdose of prescribed medications. To prevent
medication errors on the part of clients in the home, recommend
the use of medication organizers that are filled once a week by the
home, the fire department has been called, the
fire is confined to a small area, there is an exit
route readily available, the extinguisher is the
right type for the fire (see discussion in text for
a description of the types of extinguishers), and the client
knows how to use the extinguisher.
• Instruct the client to memorize the mnemonic PASS: Pull the
pin to unlock handle, Aim low at the base of the fire, Squeeze
the handles, and Sweep the unit from side to side (see Figure
38-16).
Evaluation
• Client is able to correctly place an extinguisher in the home.
• Client correctly lists the steps to take before attempting to
use an extinguisher.
• Client demonstrates correct use of the extinguisher while reciting the instructions with the mnemonic PASS.
Modified from National Safety Council: Home fire prevention and preparedness fact sheet, Itasca, Ill, 2002, The Council.
client and/or family. These organizers have the day and time on
each box, so the client knows when and what to take at any given
time (Figure 38-17). This is particularly useful for clients who
forget whether they have taken their medications.
Also, adhere to guidelines for intervening in accidental poisoning. The poison control center phone number needs to be visible
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TBox 38-13 Client Teaching
Prevention of Electrical Hazards
Objective
• Client will recognize electrical hazards in the
home and eliminate them.
Figure 38-17 One-Day-At-A-Time medicine organizer. (Courtesy Apothecary Products, Inc, Burnsville, Minn.)
TBox 38-13
Procedural Guidelines
Interventions for Accidental Poisoning
in the Home Setting
1. Assess for airway patency, breathing, and circulation (ABCs)
in all clients in whom accidental poisoning is suspected.
2. Remove any visible materials from areas such as the mouth
and eyes to terminate exposure.
3. Identify the type and amount of substance ingested, if possible. This helps to determine the antidote.
4. Call the poison control center before attempting any interventions. The universal phone number for poison control is
(800) 222-1222.
5. If directed by a physician, give oral fluids to assist vomiting.
6. If directed, save vomitus for laboratory analysis, which will
assist with further treatment.
7. Position the victim with the head to the side to prevent aspiration of vomitus, and assist in keeping the airway open.
8. Never induce vomiting in an unconscious victim or in a client experiencing convulsions, because aspiration will occur.
9. Never induce vomiting if any of the following substances
have been ingested: lye, household cleaners, hair care
products, grease or petroleum products, or furniture polish.
Vomiting increases internal burns.
10. If instructed to take the victim to the emergency department, call an ambulance. Emergency equipment is sometimes en route.
11. In the case of convulsions, cessation of breathing, or unconsciousness, call 911.
12. Do not administer syrup of ipecac to induce vomiting. It has
not been proven effective in preventing poisoning.
American Academy of Pediatrics: News release—don’t treat swallowed
poison with syrup of ipecac, 2004, www.aap.org/advocacy/releases/
novpoison.htm.
on the telephone in homes with young children. In all cases of
suspected poisoning, clients should call this number immediately
(Box 38-13).
Electrical Hazards. Electrical equipment needs to be in
good working order and grounded. The third (longer) prong in
an electrical plug is the ground. Theoretically, the ground prong
Teaching Strategies
• Discuss grounding appliances and other equipment.
• Provide examples of common hazards: frayed cords, damaged equipment, and overloaded outlets.
• Discuss guidelines to prevent electrical shocks:
• Use extension cords only when necessary, and use electrical tape to secure the cord to the floor where it will
not be stepped on.
• Do not run wires under carpeting.
• Grasp the plug, not the cord, when unplugging items.
• Keep electrical items away from water.
• Do not operate unfamiliar equipment.
• Disconnect items before cleaning.
Evaluation
• Have client list electrical hazards existing in the home.
• Review steps the client will take to eliminate these hazards.
• Check the home after the client has had an opportunity to
eliminate hazards.
carries any stray electrical current back to the ground, hence its
name. The other two prongs carry the power to the piece of electrical equipment. Improperly grounded or malfunctioning electrical equipment increases the risk of electrical injury and fire. Educating both the client and the family reduces the risk for electrical
hazards in the home environment (Box 38-14).
If a client receives an electrical shock in a health care setting,
immediately determine whether the client has a pulse. If the client
has no pulse, initiate cardiopulmonary resuscitation (CPR) and
notify emergency personnel (see Chapter 40). If the client has a
pulse and remains alert and oriented, quickly obtain vital signs
and assess the skin for signs of thermal injury. Make sure to notify
the client’s physician. If an electrical shock occurs in the home,
follow the same procedure but have the client go to the emergency
department and then notify the client’s physician.
Seizures. Clients who have experienced some form of neurological injury or metabolic disturbance are at risk for a seizure. A
seizure involves a hyperexcitation of neurons in the brain leading
to a sudden, violent, involuntary series of contractions of a group
of muscles. The client often loses consciousness. Seizure precautions encompass all nursing interventions to protect the client
from traumatic injury, positioning for adequate ventilation and
drainage of oral secretions, and providing privacy and support
following the seizure (Skill 38-2).
During a seizure a client’s jaw muscles become tense. Research
has found that significant injury to the client’s oral cavity is rare,
even during the most violent seizures. Injury instead occurs from
a caregiver forcing an object into the client’s mouth and from the
teeth biting down on a hard object. Soft objects will possibly break
in the mouth during a seizure and be aspirated. The Epilepsy
Foundation (2006), in its recommendations for seizure first aid,
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T SKILL 38-2
SEIZURE PRECAUTIONS
Delegation Considerations
The skill of seizure precautions cannot be delegated. If a seizure
occurs, the nurse must constantly assess the client’s airway patency, adequacy of breathing, and circulatory status. You must
make clinical judgments quickly. Setting up seizure precautions
and protecting clients at risk for seizures can be delegated. The
nurse instructs personnel to:
• Notify the nurse when any seizure activity occurs.
• Protect at-risk clients from falls by assisting with ambulation
and transfer.
• Never attempt to restrain a client’s extremities during an actual seizure.
Equipment
• Oral airway
• Padding for side rails and headboard
• Suction machine, oral suction equipment
• Clean disposable gloves
STEPS
RATIONALE
1. Assess seizure history, noting frequency of seizures, presence of aura, and sequence of events, if known. Assess for
medical and surgical conditions that will lead to seizures or
exacerbate existing seizure condition. Assess medication
history.
2. Inspect client’s environment for potential safety hazards if
risk for seizure exists: bedside stand or table, IV pole or
other medical equipment.
3. Perform hand hygiene, and prepare bed with padded side
rails and headboard, bed in low position, and client positioned in side-lying position when possible (see illustration).
4. For clients with a history of seizures, an airway, suction apparatus, clean gloves, and pillows need to be visible in the
hospital setting for immediate use.
5. When a seizure begins, position client safely. If client is
standing or sitting, guide client to floor and protect head by
cradling in nurse’s lap or placing a pillow under head. Clear
surrounding area of furniture. If client is in bed, raise side
rails, add padding, and put bed in low position.
6. Provide privacy.
Enables the nurse to anticipate onset of seizure activity. Seizure
medications must be taken as prescribed and not stopped
suddenly, because this will precipitate seizure activity.
Prevents client from sustaining injury by striking head or body on
furniture or equipment.
Minimizes risks associated with seizure activity.
Ensures prompt, organized intervention.
Protects client from traumatic injury, especially head injury.
Embarrassment is common after a seizure, especially if others
witnessed the seizure.
Privacy provided
Side rails up and padded
Pillow
under head
Loosened
clothing
Bed in lowest
position
Client in side-lying position
(immediately postseizure)
STEP 3 Provide client privacy. Put bed in lowest position with side rails
up and padded. Position client in side-lying position, with pillow under
head and loosened clothing.
Continued
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T SKILL 38-2
S E I Z U R E P R E C A U T I O N S — co nt ’ d
STEPS
RATIONALE
7. If possible, turn client on side, with head flexed slightly forward.
8. Do not restrain client. Loosen clothing.
9. Do not put anything into the client’s mouth such as fingers,
tongue depressor, or medicine.
Prevents tongue and dentures from blocking the airway and promotes drainage of secretions, thus reducing risk of aspiration.
Prevents musculoskeletal injury.
Critical Decision Point: Putting something in the client’s mouth will possibly result in injury to the jaw, tongue, or teeth and cause
stimulation of the gag reflex, causing vomiting, aspiration, and respiratory distress.
10. Stay with client, observing the sequence and timing of seizure activity.
11. After the seizure is over, explain what happened and answer
client’s questions. Foster an atmosphere of acceptance and
respect.
12. Following seizure, perform hand hygiene and assist client to
position of comfort in bed with padded side rails up and
bed in low position. Place call light within reach, and provide a quiet, nonstimulating environment.
Status Epilepticus
Continued observation is necessary to ensure adequate ventilation during and following seizure activity. Accurate, specific
observations will assist in documentation, diagnosis, and
treatment of the seizure disorder.
Informing clients of the type of seizure activity experienced will
assist them in participating knowledgeably in their care.
Provides for continued safety. Clients are often confused and
sleepy following a seizure.
13. For a client experiencing status epilepticus, put on clean
gloves and insert an oral airway when the jaw is relaxed between seizure activity. Hold airway with curved side up, insert downward until airway reaches back of throat, then rotate and follow natural curve of the tongue. Do not place
fingers near or in client’s mouth.
14. Access oxygen and suction equipment. Prepare for IV insertion.
15. Use pillows/pads to protect client from injuring self.
Prevents transmission of infection. Client is in continual seizure
state and requires oral airway to ensure airway patency. Client
will possibly inadvertently bite nurse’s fingers during a seizure
if nurse does not use caution.
Recording and Reporting
Home Care Considerations
• Record the timing of seizure activity and sequence of events.
Record presence of aura (if any), level of consciousness, posture, color, movements of extremities, incontinence, and patterns of sleep following the seizure.
• Document client’s response and expected or unexpected outcomes.
• Report to physician immediately as seizure begins. Status epilepticus is an emergency situation requiring immediate medical management.
Unexpected Outcomes and Related Interventions
1. Client suffers traumatic injury.
a.Continue to protect client from further injury.
b.Notify the physician immediately.
c.Ensure environment is free of safety hazards.
2. Client verbalizes feelings of embarrassment and humiliation.
a.Offer support, and allow client to verbalize feelings.
b.Encourage client and family to participate in decision making and planning care.
Intensive monitoring and treatment are required for this medical
emergency.
Helps avoid traumatic injury.
• Communicate with client and family to identify precipitating
factors.
• Teach family to care for the client during a seizure.
• Assess client’s home for environmental hazards in light of seizure condition.
• Provide family with guidelines to detect status epilepticus.
• Until a seizure condition is well controlled (usually for at least
1 year), the client should not take a tub bath or engage in activities such as swimming unless a knowledgeable family
member is present. Driving may also be restricted during this
time.
• Client needs to wear a medical alert bracelet or tag and have
an ID card noting the presence of a seizure disorder and listing the medications taken.
• Referral to a support group or the Epilepsy Foundation will
help to improve client’s self-esteem and coping ability.
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TA B L E 3 8 - 4 Postexposure Management of Bioterrorist-Related Illnesses
Illness
Decontamination/Exposure Management
Anthrax
In settings where threat of gross exposure exists, instruct clients to remove contaminated clothing and store in labeled, plastic bags. Handle clothing minimally to avoid agitation. Instruct clients to shower thoroughly with soap
and water. Use standard precautions, and wear appropriate protective barriers when handling contaminated
clothing or other items. Recommended postexposure prophylaxis includes the administration of IV or oral fluoroquinolones (e.g., ciprofloxacin, levofloxacin, and ofloxacin).
Even a single case of botulism immediately raises concerns of an outbreak associated with contaminated food. The
aim is to locate contaminated food and identify other persons who may have been exposed. Decontamination is
not required because clients are not at risk for skin exposure or reaerosolization.
Risk for reaerosolization from contaminated clothing of exposed persons is low. In the case of gross exposure, instruct clients to remove contaminated clothing and store in labeled, plastic bags. Handle clothing minimally to
avoid agitation. Instruct clients to shower thoroughly with soap and water. Use standard precautions, and wear
appropriate protective barriers when handling contaminated clothing or other items. Postexposure prophylaxis is
recommended for clients and health care workers. The antimicrobial agent of choice is streptomycin.
Client decontamination after exposure to smallpox is not indicated. Handle items potentially contaminated by infectious lesions using contact isolation precautions. Postexposure immunization with smallpox vaccine is available
and effective.
Botulism
Plague
Smallpox
Modified from Dire DJ: CBRNE—Biological warfare agents, 2006, http://www.emedicine.com/emerg/byname/cbrne—-biological-warfare-agents.htm.
includes avoiding the insertion of objects into the mouth. The
exception is in the case of status epilepticus, a medical emergency
whereby a person has continual seizures without interruption. An
adequate airway is maintained with an oral airway. Never restrain
clients experiencing a seizure. Instead, place them on seizure precautions and adequately protect them from traumatic injury.
Radiation. Radiation is a health hazard in the health care
setting and the community. Radiation and radioactive materials
are used in the diagnosis and treatment of clients. Hospitals have
strict guidelines on the care of clients who are receiving radiation
and radioactive materials. Be familiar with established agency
protocols. To reduce the nurse’s exposure to radiation, limit the
time spent near the source, make the distance from the source as
great as possible, and use shielding devices such as lead aprons.
Staff working near radiation will wear devices that track the accumulative exposure to radiation.
Some communities are at risk for radiation exposure because of
incorrect disposal and transportation of radioactive waste products. Community health agencies and the Environmental Protection Agency (EPA) have established specific, strict guidelines for
the disposal of radioactive waste. If a radioactive leak occurs, these
agencies institute measures to prevent exposure of surrounding
neighborhoods, to clean up radioactive leaks as quickly as possible,
and to ensure that injured parties receive prompt medical care.
Bioterrorist Attack. If a bioterrorist attack occurs, nurses
working in hospital settings need to be prepared to respond and
care for a sudden influx of clients. TJC (2006) requires hospitals
to have an emergency management plan that addresses four
phases:
• Mitigation—Assessment process to determine hazard vulnerability for the hospital’s service area. This includes an identification of the kinds of emergency situations that are most
likely to occur and their probable impact.
• Preparedness—Steps taken to increase a hospital’s ability to
manage the effects of an attack. Hospital preparedness in-
cludes creating an inventory of resources (staff to supplies)
that are necessary. This includes establishing agreements with
product vendors and other health care facilities to provide increased resources in the event of an attack. In addition, preparedness includes establishing primary and backup communications systems, training staff, and conducting
organization-wide drills.
• Response—Steps taken by staff in the event of an attack. A formal response includes reporting to predetermined locations,
using specific triage strategies to identify the most acutely ill,
and management activities such as issuing warnings and notifications to the community. Decontamination procedures and
disease reporting are also part of a hospital’s response plan.
• Recovery—Steps taken to restore essential services and resume
normal agency operations. This phase begins almost as soon as
the response phase.
All hospitals must test their emergency plans twice a year. This
includes implementation of planned drills. Communication is a
key to any emergency management plan. If a bioterrorist attack
occurs, nursing staff must know what happened, how many clients
to expect, and when clients will begin to arrive so they can prepare
both themselves and their facility (Steinhauer and Bauer, 2002).
Infection control practices are critical in the event of a biological attack. You need to manage all clients symptomatic with
suspected or confirmed bioterrorism-related illnesses using standard precautions (see Chapter 34). For certain diseases, such as
smallpox or pneumonic plague, additional precautions are necessary, such as airborne or contact isolation precautions. Although
most infections associated with biological agents cannot be transmitted from client to client, in general you limit the transport
and movement of clients to movement that is essential for treatment and care. An important aspect of care for clients who have
a bioterrorism-related illness is postexposure management. Table
38-4 summarizes the steps to take to manage exposure to anthrax, botulism, plague, and smallpox.
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FEvaluation
Knowledge
You apply the components of critical thinking to the evaluation
step of the nursing process (Figure 38-18). You evaluate the actual
care delivered by the health care team based on the expected outcomes. If you have met the client’s goals, you consider the nursing
interventions effective and appropriate. If not, you determine
whether new risks to the client have developed or whether previous risks remain. The client and family need to participate to find
permanent ways to reduce risks to safety. The nurse continually
assesses the client’s and family’s need for additional support services such as home care, physical therapy, counseling, and further
teaching.
When you have developed a good relationship with a client
and the client feels safe and secure in the relationship, as well as
in the environment, the client will most likely demonstrate less
anxiety and verbalize satisfaction with the surroundings. You need
to determine, however, if client expectations have been met. If
outcomes are not met, these are questions to ask: Are you satisfied
with changes made to the environment? Do you believe that your
safety is ensured? If client expectations have not been met, you
reassess not only the client and the environment but also the client’s expressed desires.
• • •
A safe environment is essential to promoting, maintaining, and
restoring health. Incorporating critical thinking skills in the application of the nursing process, the nurse assesses the client and
the environment to determine risk factors for injury; clusters risk
factors; formulates a nursing diagnosis; and plans specific interventions, including client education. The expected outcomes include a safe physical environment, a client whose expectations
have been met, a client who is knowledgeable about safety factors
and precautions, and a client free of injury.
Key Concepts
• In the community a safe environment means basic needs
are achievable, reducing physical hazards and the transmission of pathogens, controlling pollution, and maintaining
sanitation.
• In a health care agency a safe environment is one that minimizes falls, client-inherent accidents, procedure-inherent
accidents, and equipment-related accidents.
• A factor that reduces atmospheric oxygen is the presence of
high carbon monoxide levels, which results from an improperly functioning furnace.
• Prolonged exposure to extreme environmental temperatures causes client injury or even death.
• Reduction of physical hazards in the environment includes
providing adequate lighting, decreasing clutter, and securing the home.
• You reduce the transmission of pathogens through medical
and surgical asepsis, immunization, adequate food sanitation, insect and rodent control, and appropriate disposal of
human waste.
• Effect of new medication
therapies on the client’s
cognitive/motor functioning
• Characteristics of safe and
unsafe client behaviors
• Characteristics of a safe
environment
Experience
• Previous client responses
to planned nursing therapies to improve the client’s
safety (e.g., what worked
and what did not work)
EVALUATION
• Reassess the client for the presence of
physical, social, environmental, or developmental risks
• Determine if changes in the client’s care
resulted in increased threats to safety
• Ask if the client’s expectations are being
met
Standards
• Use established expected
outcomes to evaluate the
client’s response to care
(e.g., reduction in modifiable risk factors)
Attitudes
• Display humility when rethinking unsuccessful interventions designed to promote client safety
• Demonstrate responsibility
for accurately evaluating
nursing interventions
designed to promote the
client’s safety
Figure 38-18 Critical thinking model for safety evaluation.
• Children less than 5 years of age are at greatest risk for
home accidents that result in severe injury and death.
• The school-age child is at risk for injury at home, at school,
and while traveling to and from school.
• Adolescents are at risk for injury from automobile accidents,
suicide, and substance abuse.
• Threats to an adult’s safety are frequently associated with
lifestyle habits.
• Risks of injury for older clients are directly related to the
physiological changes of the aging process.
• Risks to client safety within a health care agency include
falls and other client-inherent, procedure-related, and
equipment-related accidents.
• Nursing interventions for promoting safety are individualized for developmental stage, lifestyle, and environment.
• Nursing interventions are developed to modify the environment for protection from falls, fires, poisonings, and electrical hazards.
• An emergency management plan includes the elements of
mitigation, preparedness, response, and recovery.
• The nurse needs to manage all clients symptomatic with
suspected or confirmed bioterrorism-related illnesses using
standard precautions.
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Critical Thinking Exercises
While making a routine visit, Peggy, Ms. Cohen’s daughter,
finds Ms. Cohen at the bottom of her porch steps. Ms. Cohen
is complaining of hip pain and cannot get up. Peggy calls 911.
A few hours later, Ms. Cohen is hospitalized for repair of her
right hip fracture.
1. What are Ms. Cohen’s intrinsic factors that make her at
higher risk for falls while in the hospital?
2. List three environmental interventions to promote Ms.
Cohen’s safety in her room.
3. Ms. Cohen’s bed has four side rails. What position would
you put the rails in and why?
Ms. Cohen requires IV antibiotics to be delivered postoperatively. Shortly after the first dose, she became restless and
started picking at her IV.
1. What might be precipitating Ms. Cohen’s behavior?
2. List two interventions that can be utilized to prevent the
use of restraints on Ms. Cohen.
3. Why should the nurse avoid using physical restraints on
Ms. Cohen?
Several restraint alternatives were attempted, but due to Ms.
Cohen’s restlessness she was successful at pulling out her IV.
It becomes necessary to restrain Ms. Cohen temporarily during
IV antibiotic therapy.
1. You know that a physician’s order is required for the restraint. What are essential components of the restraint
order?
2. The physician orders bilateral upper limb restraints. Your
assessment of Ms. Cohen reveals that during the day only
her left arm needs to be restrained in order to maintain
her IV. Can you remove the right limb restraint?
3. What assessment is performed on Ms. Cohen’s upper extremity while she is restrained?
Review Questions
1. The physiological changes that occur during the aging
process increase the older client’s risk for:
1. Falls and burns
2. Poisoning
3. Alcoholism
4. Medication errors
2. You discover an electrical fire in a client’s room. Your first
action would be to:
1. Activate the fire alarm
2. Evacuate any clients or visitors in immediate danger
3. Confine the fire by closing all doors and windows
4.Extinguish the fire by using the nearest fire extinguisher
3. A parent calls the pediatrician’s office frantic about the
bottle of cleaner that her 2-year-old son drank. Which of
the following is the most important instruction you can
give to this parent?
1. Give the child milk.
2. Give the child syrup of ipecac.
3. Call the poison control center.
4. Take the child to the emergency department.
4. A couple is with their adolescent daughter for a school
physical. The parents tell you that they are worried about
all the safety risks affecting this age. As you plan to teach
the parents about these risks, you remember that adolescents are at a greater risk for injury from:
1. Poisoning and child abduction
2. Automobile accidents, suicide, and substance abuse
3. Home accidents
4. Physiological changes of aging
5. During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurse’s initial intervention would be to:
1. Insert a urinary catheter
2. Assign a staff member to stay with the client
3. Ask the physician to order a restraint
4. Provide scheduled toileting during the night shift
6. Lisa, a nurse assistant, is working with you during your
shift. One of your clients has upper limb restraints. In
delegating care of this client to the Lisa, you would tell her
to:
1. Call the physician if the client becomes more agitated
with the restraint
2. Report any signs of redness, excoriation, or constriction of circulation under the restraint
3. Move the client to a room closer to the nurses’ station
4. Check to see if the client can have a medication for
sleep
7. The family of your confused, ambulatory client insists that
all four side rails be up when the client is alone. The best
way to handle this situation would be to:
1. Thank them for being conscientious and put the four
rails up
2. Ask them to stay with the client at all times
3. Provide the client a one-to-one sitter while the side
rails are up
4. Inform them of the risks associated with side rail use
8. During your assessment of a 56-year-old man, he reports
increased alcohol consumption due to stress at work.
One of your expected outcomes for this client will be to:
1. Provide the client with resources for stress management classes
2. Decrease his alcohol intake during stress
3. Decrease stress in his life
4. Teach him ways to promote sleep
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9. Health care workers who have direct contact with individuals suspected of being contaminated with anthrax
should (select all that apply):
1. Have the client remove clothing and place in a sealed
biohazard bag
2. Wear an isolation gown, gloves, and high-efficiency
particulate air (HEPA) mask
3. Instruct client to wash hands and exposed areas with
soap and water
4. Prepare the client for transfer to the radiology department for a chest x-ray examination
10. A child you are caring for in the hospital starts to have a
grand mal seizure while playing in the playroom. What is
the most important intervention you can do during this
situation?
1. Restrain the child to prevent injury.
2. Place a tongue blade over the tongue to prevent aspiration.
3. Clear the area around the child to protect the child
from injury.
4. Begin cardiopulmonary respiration.
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Client Safety - coursewareobjects.com

Transcription

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