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Chapter 38: Client Safety
Bonnie M. Wivell, MS, RN, CNS
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JCAHO 2010 National Patient Safety Goals
Identify patients correctly – 2 identifiers Improve staff communication – read back, not using certain abbreviations, SBAR Uses medicines safely – label, look alike/sound alike, blood thinners Prevent infection – hand hygiene, NO HAIs Reconcile medications across the continuum of care ID patient safety risks – suicide Prevent falls Help patients to be involved in their care Watch patients closely for changes in their health and respond quickly if they need help – Rapid response teams Prevent errors in surgery
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Environmental Safety A safe environment includes meeting basic needs, reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and controlling pollution. A safe environment also includes one where the threat of attack from biological, chemical, or nuclear weapons is prevented or minimized.
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Environmental Safety Basic Needs Oxygen Nutrition
CO2 poisoning Nutrition Keeping perishable foods fresh Temperature and Humidity Extreme cold and heat
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Physical Hazards Fractures are the most serious health consequence of falls Almost 90% of all fractures among older adults are due to falls Lighting Obstacles Bathroom Hazards – burns, poisoning, falls Security – fire safety, lead poisoning, contaminated soil and water
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Transmission of Pathogens
Pathogen = any microorganism capable of producing an illness Hand hygiene most effective method of limiting transmission Immunization = resistance to an infectious disease is produced or augmented
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Environment Safety Cont’d.
Pollution Air Land Water Noise Terrorism Bioterrorism
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Risks at Developmental Stages
Infant, Toddler, Preschool: Injuries are the leading cause of death in children over age 1 School aged child: Sports injuries Adolescent: Risk taking behaviors Adult: Lifestyle habits Older Adult: Physiological changes result in increased risk for falls, burns, MVAs
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Individual Risk Factors
Lifestyle Impaired Mobility Sensory or communication Impairment Lack of Safety Awareness 9
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Risks in the Health Care Agency
3 Types of medical errors accounted for almost 60% of the client safety incidents Post-op infections Bed sores Failure to diagnose and treat in time Medication errors Falls Patient-Inherent Accidents: self-inflicted Procedure-related Accidents: occur during therapy Equipment-related Accidents: malfunction, disrepair, or misuse
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Safety and the Nursing Process
Assess Activity and exercise Medications History of falls Home maintenance and safety
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Nursing Diagnosis Risk for injury Related to: As evidenced by:
General weakness Right or Left sided weakness Side effects of medication Poor eyesight As evidenced by: Recent falls New CVA Confusion Macular degeneration
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Implementation Nursing Diagnosis Goal Interventions
Risk for injury related to (r/t) generalized weakness as evidenced by recent falls Goal Pt. will ask for help to the bathroom Pt. will remain free from injury during hospitalization Interventions Nurse will ensure call light is in reach Nurse will work with other care providers to make sure patient is seen every hour Nurse will work with other care providers to ensure pt. receives required assistance with ADLs/activities
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Use of Restraints in the Health Care Setting
Physical or chemical means of stopping a patient from being free to move. 4 bedrails up is considered a restraint Used only in emergency situations to ensure the patient’s safety. Restraint orders must be specific and time-limited.
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Other Mechanisms to Prevent Falls
Tab Alarms Arm Bands ID outside of Patient room Notice Inside the Patient room Colors of gowns, slippers, blankets Bed Alarms Chair Alarms
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Restraint Use Must have a physician order
Order must be rewritten every 24h. Restraint policies are specific to health care setting Nursing documentation must occur at least every two hours
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Complications from Restraints
Skin breakdown Constipation Pneumonia Incontinence Urinary retention Nerve damage Circulatory damage
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Other Safety Issues Fires Poisoning Electrical Hazards
Seizure precautions Radiation safety Bioterrorist attack Bomb threats
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Chapter 39: Hygiene
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Patient Hygiene Oral Care Bathing Shaving Hair care Perineal care
Foot care Bed making Occupied/unoccupied
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Goal What is the goal of hygiene in the health care setting?
Moving the patient to a higher level of health Check the box on the nursing documentation sheet Prevent Infection All of the above
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Self-Assessment Have you ever bathed another adult person?
Someone not in your family?
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Why is Hygiene Important?
Personal hygiene affects a patient’s comfort, safety, and sense of well-being. A variety of personal, social, and cultural factors influence hygiene practices.
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Factors Influencing Hygiene
Physical Condition Ability to care for self Energy level Sensory deficits Incontinence of urine and/or stool Dexterity and ROM Sedation, Pain level Chronic illnesses Psychiatric conditions
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Factors Cont’d. Social practices Personal preferences Body image
Socioeconomic status Health beliefs and motivation Cultural variables
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Assessment Skin: wounds, infection
Feet and Nails: PVD, diabetic patient with foot issues, foot fungus around toe nails Patients with poor circulation to the feet and lower legs needs close assessment of those areas Oral Cavity: condition of the mouth and teeth Hair: tangles, lice Eyes, Ears, and Nose: Does the patient have any sensory deficits? Foot & Nail Care – p. 880 Prevents infection, odors, and injury of soft tissue Assess for risk of foot/nail problems – diabetics (neuropathy), cardiacs and kidney for edema which compromises blood flow to neighboring tissues, stroke (muscle weakness increases friction and pressure on affected foot) Palpate dorsalis pedis in both feet simultaneously, color, cap refill, Sensation Ability to perform self care Type of footwear – cleanliness, fit, restrictive garters, knee-highs etc Foot problems p. 883 Calluses Corns Plantar Warts Athlete’s foot Ingrown nails Peripheral Neuropathy Muscle wasting of lower extremities Absence of deep tendon reflexes Foot deformities, infections, abnormal gait, Absent vibratory sensation Vascular Insufficiency Decreased hair growth on legs and feet Absent or decreased pulses Infection in foot Poor wound healing Thickened nails Shiny appearance of skin Blanching of skin on elevation
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Critical Evaluation What is the ability of the person to care for themselves? Physical disabilities Mental disabilities Organize the day Early Morning care – Night shift for those having tests, surgery, (offer bedpan, washing hands and face, oral care) Routine Morning care – After breakfast Bedpan, urinal, providing bath or shower, perineal care, oral care, foot care, nail and hair care, back rubs, changing linens and gown, straightening bedside table, and room Afternoon care – (many tests, rehab, etc) washing hands and face, assisting with oral care, offering bedpan, urinal, straightening beds Evening care – personal hygiene care promotes sleep, changing soiled linens, gowns, wash hands and face, oral hygiene, back massages, offer beverage 33
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Specific Issues Needing to be Addressed at Bath Time
Foot care Normal vs Diabetic Do not soak feet of patients with DM and/or vascular insufficiency Sensitive skin Infestations Infections Incontinence
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Types of Baths Complete bed bath Partial bed bath Sponge at the sink
Tub bath Shower Bath in a bag Complete bed bath administered to person who is totally dependent (unconscious, dementia) Partial bed bath – bathing only body parts that if left unattended would cause discomfort (hands, face, axillae, perineal area) Sponge – bathing from sink or basin while client sitting in chair or in bed. (Help patient with areas hard to reach). Tub – Immersion in water – client may still need assistance, may involve lifting devices, Shower – client sits or stands – client gets thorough cleaning better than bed bath Bath in a gag or travel bath – contains several soft cloths, pre-moistened in solution that does not have to be rinsed
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Critical Evaluation Are there any cultural issues that need to be addressed prior to bathing? What is your patient’s developmental status? Teen, Young adult, Adult, Older Adult, Elderly How does that affect their hygiene needs and attitudes? What do you do with this information about the patient? Care Plan
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Critical Evaluation Involve patient as much as possible in bathing decisions When Where Type Tub Shower Bed bath
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Nursing Diagnosis BATHING/HYGIENE SELF-CARE DEFICIT: R/T CONFUSION: AEB POOR PERSONAL HYGIENE BATHING/HYGIENE SELF-CARE DEFICIT: R/T DECREASED CEREBRAL CIRCULATION (RECENT CVA) AEB RIGHT SIDED WEAKNESS Risk of impaired skin integrity related to bathing hygiene self-care deficit Interventions – review with client how to observe feet for breaks, in skin and friction from shoes using a mirror Rationale – injuries to foot increases client’s risk for infection, impaired mobility and amputation Intervention – Instruct client to observe feet for reddened areas, abrasions, blisters, and swollen areas immediately after removing shoes Rationale – improperly fitting shoes produce friction, redness and swelling. Observation for these conditions immediately after removing shoes promotes timely identification of early foot problems
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Oral Care Oral care for the patient who is not conscious
Oral care is an essential nursing intervention Assess for decreased saliva, infection, coated tongue, cracked lips Brush all tooth surfaces using a soft bristle brush Observe for complications such as bleeding gums Oral care for the patient who is not conscious Oral care for the patient with partial paralysis of the mouth Oral care for the patient who has had mouth surgery or injury 1. Oral cavity lined with mucous membranes, light pink and moist Floor of mouth and undersurface of tongue has rich supply of blood (useful in medication administration, buccal pitocin, nitroglycerin) Three pairs of salivary glands secrete about 1 L of saliva per day – medications, radiation, mouth breathing interfere with this production Teeth are organs of chewing or mastication, surrounded by periodontal membranes which lie just below gum margins (gingivitis – gum inflammation) Oral Care – p. 888 Position on side with bed flat Remove dentures (wash with warm water in sink/emesis basin with towel in bottom) pg 145 Separate teeth with padded tongue blade Have suction ready to minimize risk of aspiration Gentle brush teeth and gums, roof of mouth, tongue, Bulb syringe to rinse or moistened brush Suction Yankauer Water soluble jelly to lips Toothettes – moisten in water or normal saline to clear oral cavity, rinse with mouth wash diluted
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Other Hair Care: Gather supplies (plastic trough, towels, shampoo, drainage wash basin) Shaving: Check doctor’s orders Anticoagulants Perineal Care (see page 877) Independent Needs assist Dependent Foot Care (see page 880) Do not soak feet of patients with DM and/or vascular insufficiency Foot & Nail Care Prevents infection, odors, and injury of soft tissue Assess for risk of foot/nail problems – diabetics (neuropathy), cardiacs and kidney for edema which compromises blood flow to neighboring tissues, stroke (muscle weakness increases friction and pressure on affected foot) Palpate dorsalis pedis in both feet simultaneously, color, cap refill, Sensation Ability to perform self care Type of footwear – cleanliness, fit, restrictive garters, knee-highs etc Foot problems p. 883 Calluses Corns Plantar Warts Athlete’s foot Ingrown nails Peripheral Neuropathy Muscle wasting of lower extremities Absence of deep tendon reflexes Foot deformities, infections, abnormal gait, Absent vibratory sensation Vascular Insufficiency Decreased hair growth on legs and feet Absent or decreased pulses Infection in foot Poor wound healing Thickened nails Shiny appearance of skin Blanching of skin on elevation
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Care of Patient with Sensory Aids
Glasses/Contacts (pg. 894) Dentures (pg. 891) Hearing Aids (pg. 895) Prosthetic Eyes
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Basic Principles Remember body mechanics
Raise the bed to a comfortable height Follow medical asepsis when making a bed Wear gloves if linen is soiled Keep linen away from uniform Do not place soiled linen on the floor
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Bed Making – Occupied/Unoccupied
Linen Use appropriate linen for the patient Chucks and linen savers Draw sheets Therapy beds Learn to place a bottom flat sheet when there are no fitted sheets
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