Fundamentals of Nursing Exam 2: Chapter 28 Client Safety

• developmental considerations (children, adolescents)

• lifestyle (occupation, risk takers)

• environment (high crime areas)

• knowledge (awareness of safety)

• psychological state (stress, depression)

• mobility

• sensory perception alterations

• ability to communicate

• physical health state

• lower body weakness

• poor vision

• gait and/or balance issues

• problems with feet and/or shoes

• use of psychoactive medications

• postural dizziness

• hazards in the home (and community)

• hourly patient rounding

• complete risk assessment and communicate if patient at risk

• keep bed low position and locked

• call bell and needed items within reach

• eliminate physical obstacles

• non-skid footwear

• cognitive assessment-report any changes

• side rails

• locking devices on wheeled equipment

• nonskid slippers

• interfere with physiologic function

• limit physical activity to the point of immobilization

• interfere with respiratory function

• must be able to raise and lower rails

• health care facilities must check them for safety

• know your hospital/agency policy

• use least restrictive option first

• not for staff convenience

• long-term care (involves family before using them)

• require written order from physician/licensed independent practitioner (type of restraint, justification, criteria for removal, never a prn)

• get order immediately

• emergency: order restraints immediately

• monitor and assess pt every hour (know agency guidelines)

• documentation

• type of restraint

• when it was applied

• alternatives attempted

• pt, family & physician notification

• frequency of assessments (and findings)

• regular intervals of release

• nursing interventions

• toileting schedule

• reduce stimulation

• conceal tubing with gauze

• use of pillows

• bed alarm

R- rescue and remove all pt’s from danger
A - activate alarm
C -confine fire by closing doors, turn off O2 and equipment
E - extinguish fire with appropriate extinguisher

• must be completed after any accident/incident

• describes circumstances of accident/incident

• details pt responses to exam and treatment

• primary concern: pt’s well being

• disclosure to pt - check agency policy

• not part of medical record