1. Patient Environment and Safety
Chapter 20
Patient Environment and Safety

2. Chapter 20
Lesson 20.1

3. Learning Objectives Theory
Discuss nursing responsibilities for environmental management
Identify common noises in health care facilities and ways to minimize their effects on patients
Explain the importance of neatness and order in the patient's environment

4. Learning Objectives Clinical Practice
Discuss how the health care facility's environment affects your patient
Using correct technique, make an unoccupied and an occupied bed

5. Factors Affecting the Environment
Florence Nightingale wrote about environmental factors that needed to be controlled more than a century ago
Temperature
Ventilation and humidity
Lighting
Odor
Noise
Neatness
Privacy
How much control do nurses have over each of these environmental factors?
Discuss how HIPAA has changed privacy laws.
Discuss what makes controlling these factors so difficult.

6. Environmental Factors
Temperature
Infants and older adults require warmer rooms
Room temperature should be between 68°and 74°F
Operating rooms and critical care areas slightly cooler
Ventilation—supplying a room with fresh air continually
Fans are discouraged because of infection control concerns
Do not open windows in the hospital
Discuss who is responsible for determining the temperature in the patient’s room.
Why are operating rooms kept cool? When may it be permissible to use a table fan?

7. Environmental Factors
Humidity—amount of moisture in the air
From 30% to 50% is comfortable
Too little humidity will dry respiratory passages
Lighting
Should be adequate to perform tasks and prevent accidents and injury
Should be bright enough to see, but soft enough to prevent sharp shadows
Patient should be able to control lights independently
What other issues should be considered regarding proper lighting in a patient’s room?
Why do most hospitals maintain a low humidity setting?
A sunny, cheerful room can improve a patient's spirits.
Appropriate interior and exterior lighting in the home helps protect it against crime.

8. Environmental Factors
Odor
To control odors:
Empty and rinse bedpans, bedside commodes, and urinals promptly
Dispose of dressings and used equipment
Nothing odorous should be placed in trash in a patient’s room
Avoid the sources of odors
Remove old flowers and stagnant water
Perfumes, scented lotions, or scented cosmetics should not be worn in patient areas
Review proper disposal of urine and feces if a patient uses a bedpan or bedside commode.
What physical responses might occur in a patient due to uncontrolled odor? (nausea, vomiting, loss of appetite)
Discuss strategies to minimize odor if the odor is coming directly from the patient (i.e., wounds).

9. Environmental Factors
Noise
The main source in a hospital is people
Patient may experience sensory overload from noise
Soft, pleasant background music can mask other sounds and promote relaxation
Reduce noise by:
Avoiding long conversations in the hallways
Encouraging staff to speak in lowered voices
Avoiding jokes and laughter at the nurses’ station
Answering alarms on IV pumps and equipment promptly
Ask students to list and describe noises commonly heard in a clinical setting.
Discuss the noisier and quieter areas in a clinic.
What are some areas in a clinic in which the noise factor is a bigger issue?

10. Environmental Factors
Neatness
Straighten the patient’s unit after making the bed and whenever appropriate
Remove trays and dishes promptly after meals
Keep the over-the-bed table clear of unnecessary clutter or equipment
Review proper handling or disposal of the following:
Dirty dishes
Dirty instruments
Discontinued/expired dressing items, splints, Ace wraps, etc.
If the patient is in isolation, how are these items removed from the room?

11. Environmental Factors
Privacy: essential for patient’s well-being
Always knock gently and identify yourself before entering the room
In multiple-patient rooms, close the curtain around the patient for personal tasks such as using a bedpan and bathing
Post a sign on the door informing others of such tasks to discourage them from entering the room
To help maintain the patient’s privacy, treat the patient’s room as if you were entering a person’s home, apartment, dorm room, etc.

12. Patient Units Interior design
Patients' rooms and public areas look more like a hotel now as opposed to the stark white of the past
Rooms have draperies and colorful bedspreads
These changes are to promote comfort by providing a homelike environment for the patient

13. Patient Units
Beds
Usually have a firm mattress covered with a material that allows easy cleaning between patients; side rails should not present a hazard
May use an overlay to prevent pressure ulcer formation
Always lock wheels on a bed when not moving it and leave it in the low position when not performing a procedure on a patient
Review the types of beds used in a clinical setting, including traction, Clinitron, Stryker, and Kin-Aire.
Discuss special beds used for children.
Discuss special beds used for morbidly obese patients.
Newer hospital mattresses are designed to reduce pressure areas.
You need to make sure that the mattress fits snugly to the rails and that the rails are close enough together so that the patient's head is not able to fit through the rails.

14. Patient Units Unoccupied bed Occupied bed
Made when the patient is out of bed in the chair or out of the room for a diagnostic procedure or therapy
Occupied bed
Made only if the patient absolutely cannot be out of bed
Bed linens should be neat, orderly, and free of wrinkles
Discuss situations that require making an occupied bed.
What are good times for making a patient’s bed? (when a patient is at an imaging exam, in the bathroom, etc.)
It is useful for the nurse to have someone help make an occupied bed—it is easier on the patient and nurse.
Raise the occupied bed at the nurse’s waist height to prevent back strain, and place the bed in a low position when finished.

15. Chapter 20
Lesson 20.2

16. Learning Objectives Theory
Describe methods to prevent mechanical and thermal accidents and injury in health care facilities and the home
Discuss the various forms of bioterrorism, safety measures to be taken, signs and symptoms of agents used, and measures to treat or contain the threat
Demonstrate knowledge of the legal implications of using protective devices
Discuss the principles for using protective devices

17. Learning Objectives Clinical Practice
Explain, according to your facility's procedures, how to clean up a biohazard spill
Discuss your clinical facility's response plan to a bioterrorism threat
Given an emergency scenario, practice triaging the victims
Correctly apply a vest protective device

18. Safety A primary concern when caring for your patients
Safety is needed to prevent accidents and possible injuries to patients, visitors, and health care personnel
Review methods to minimize risks.

19. Environmental Factors
Most common patient accidents/incidents:
Falls
Burns
Cuts and bruises
Fights with others
Loss of possessions
Choking
Electrical shock
Review Box 20-3 for ways to promote patient safety
Review fall precautions.
What are common causes for these accidents? (cuts and bruises—usually from falls or procedures; shock—improper use of hospital electrical equipment)

20. Falls Three common factors
Impaired physical mobility
Altered mental status
Sensory and/or motor deficits
Patients at risk for falls may need a leg or bed alarm
Sense a change in position or pressure and sound an alarm to alert health care workers or family members that patients are attempting to get out of bed or a chair
The Joint Commission 2009 safety goals require that every patient be assessed and periodically reassessed for risk for falling, particularly correlating the patient's medications with increased risk for falls.
Discuss use of the following to promote patient safety:
Ambulatory devices.
Assisting the patient to the bathroom, up to the chair, etc.
Keeping the call light in place.
Making sure the patient knows how to or remembers how to use the call light.

21. Burns Prevention includes protecting the patient from thermal injury
Can be caused by hot or cold materials
Diabetic patients, paralyzed patients, or patients with altered mental awareness at risk for burns
The nurse should check the temperature of liquids before giving them to the patient
The nurse should caution the patient about sleeping on a heating pad or a cold pack
Inspect electrical cords for frayed or broken areas that may cause sparks or fires
How can thermal injuries be prevented?
Nurses and patients should never use a heating pad in the clinical setting.
Discuss the use of the aqua K or “K pad” for local heat administration.
Use assessment and appropriate judgment for leaving hot/cold liquids at patient’s bedside.

22. Smoking Banned in most health care facilities
Some long-term care agencies allow smoking in designated areas
Carefully supervise the patient who wants to smoke and is sedated, confused, or irrational
Smoking is never allowed when oxygen is in use because a spark could cause a fire
Any equipment that might cause a spark is also prohibited near oxygen
How would you help a patient who smokes a pack a day and is admitted to your unit?

23. Nursing Actions to Promote Patient Safety in the Hospital
Orient the patient to the unit on admission
Assess patient’s gait and risk for falling on admission
Evaluate patient’s drug regimen for side effects that increase the risk for falling
Keep bed in low position when not giving direct care
Toilet the patient on a regular schedule
Reorient the patient to the unit as needed. Continually assess the patient’s level of consciousness and comprehension.

24. Nursing Actions to Promote Patient Safety in the Hospital
Lock the wheels on the bed
Provide a night-light for going to the bathroom
Encourage the use of nonskid slippers
Answer call lights promptly
Tell the patient when you will next check in
Encourage the use of grab bars
What issues might make it difficult for the nurse to promptly answer a patient’s call light?
Discuss strategies to decrease call light incidence (i.e., checking in with patients, toileting at frequent intervals, etc.).

25. Nursing Actions to Promote Patient Safety in the Hospital
Place high-risk patients in a room close to the nurses’ station
Be sure the patient’s call bell is within reach
Stay with confused or unsteady patients when they are up
Provide diversionary activities for confused patients
Make sure wheelchair brakes are locked
Discuss methods to minimize noise and traffic at the nurses’ station.
Discuss appropriate diversionary strategies for confused patients.
Ask the patient’s family and friends to help provide companionship and diversions for the patient.

26. Nursing Actions to Promote Patient Safety in the Home
Place a nonskid bath mat in the tub or shower
Use night-lights to help patient find the bathroom
Suggest installation of grab bars
Install door buzzers or bed alarms
Maintain the same furniture arrangement
Encourage removal of extension cords
Caution the patient about toys and animals
Provide appropriate community resources
The nurse may assess these actions with the patient’s family members.
What are some specific safety precautions for various places in the home, i.e., kitchen, porch, living room, bedroom, stairs?
Ask students for other suggestions in improving physical safety in the home.

27. Fire Know and be familiar with your institution's fire regulations
Know the location of the fire extinguishers, fire alarms, and escape routes, and how to notify the telephone operator of a fire in your area
Should a fire occur, you must
Rescue any patients in immediate danger by removing them from the area
Activate the fire alarm system
Contain the fire by closing doors and windows
Extinguish flames with an appropriate extinguisher
Where are the fire extinguishers in your home? In your class?
Four types of extinguishers
Type A—Water under pressure; used for paper, wood and cloth fires
Type B—Contains CO2; used for gasoline, oil, paint, and flammable liquids
Type C—Used for electrical fires
Type ABC—Can be used on any type of fire
What are methods for evacuating a patient to prevent injury? (place wet towels across the bottom of closed doors, have patients hold wet cloths over their noses and mouths to prevent smoke inhalation)
What are other important fire safety precautions?

28. Biohazards
A biologic agent, chemical, or condition that can be harmful to a person's health
OSHA publishes specific guidelines for labeling, handling, cleaning spills, and disposing of these materials
MSDS consulted for recommended methods of storage, labeling, handling spills, and disposal
Determine whether the school or clinic has a biohazard policy.
Discuss the location of MSDS information.
Discuss how to prepare one’s home for a bioterrorism event.
Discuss the nurse’s role for a bioterrorism event in the community.
The Occupational Safety and Health Administration (OSHA) classifies materials in the work environment according to the degree of hazard to health that they impose.
There should be a material safety data sheet (MSDS) for each biohazard substance stored or used on the nursing unit.
What is an example of a biohazard?

29. Bioterrorism and Other Terrorism Agents
Bioterrorism: the release of pathogenic microorganisms into a community to achieve political and/or military goals
Chemical terrorism: use of certain compounds to cause destruction to achieve political and/or military goals
Pulmonary agents, cyanide agents, nerve agents, vesicants, and incapacitating agents
Radioactive substances attached to an explosive device (a “dirty bomb”) disperse radiation
Terrorist activities are designed to cause panic, fear, and chaos and disrupt an area's rescue and medical systems.
What are the three basic ways to protect the body from radiation?

30. Common Diseases Spread Through Bioterrorism
Anthrax
Botulism
Ebola virus
Lassa fever
Plague
Smallpox
Tularemia
You must be familiar with your institution’s policies for decontamination, treatment, and triage in the event of a terrorist attack
What are common symptoms for these diseases?
Discuss health care institutions’ disaster drills regarding chemical/biologic agents.

31. Decontamination
Staff must wear masks and protective clothing that are impervious to chemicals and cover all skin surfaces
Military mission-oriented protective posture (MOPP) suits may be used
A chemical mask with filtered respirator must be worn with the suit
When a terrorist attack has occurred, a portable decontamination unit with a specially trained staff is set up outside the emergency room.
There is an emergency protocol from the local health department's disaster response plan that is followed to decontaminate victims before they enter the hospital building.
Thorough scrubbing of the all of the person's skin is often part of the protocol.
What is an example of a terrorist attack with hazardous materials?

32. Triage and Treatment
Assessed and labeled according to the priority of care as “immediate,” “delayed,” “minimal,” or “expectant”
Treatment based on type of agent to which the patient was exposed and degree of exposure
Antibiotics used for some biologic agents
Antidotes used for some of the chemicals and poisonous gases
Otherwise, treatment is directed at supporting organ function while the body tries to recover
Triage priorities are based on the premise that limited medical resources should be used on those patients who will most likely live if they receive treatment.
Why are those with severe life-threatening wounds not always triaged as immediate?

33. Poisons
A substance that when ingested inhaled, absorbed, applied, injected, or developed within the body, may cause functional or structural disturbances
Treatments and antidotes obtained from a poison control center or listed on some containers
In the event of a suspected poisoning:
Contact the poison control center; have the label of the product in front of you and be ready to report:
Name of the product
Patient’s age
Amount you believe is involved
Any symptoms involved
Discuss the appropriate use of syrup of ipecac.
Do not try to induce vomiting until conferring with Poison Control.
Why is it important to include the patient’s height and weight, if possible, when reporting to Poison Control? (height and weight are often calculated as part of body mass to determine toxicity of poison and any antidote amount)

34. Protective Devices Behavioral indications Nonbehavioral indications
Psychiatric setting
Sudden change in mental status/behavior
Nonbehavioral indications
Continuation of medical treatments
It is your responsibility to be aware of and follow the regulations in your facility and area
Discuss strategies to encourage some movement to reduce problems of muscle weakness, atrophy, etc.
Review the alternative use of alarms (bed alarms, wheelchair alarms, door alarms, etc.).
Discuss whether “chemical restraint” is a viable alternative to using physical protective devices.
What problems may be caused by restricting movement on a long-term basis?
Health care workers must check patients in a behavioral health protective device more frequently.

35. Legal Implications of Using Protective Devices
Federal and local laws mandate:
Protect the patient from physical and mental abuse and from physical and chemical restraints
Except those that are authorized by a physician, in writing, for a specified and limited period of time, or that are needed in an emergency situation
The Joint Commission supports the use of protective devices if clinically necessary, but only as a last resort.
Who may apply protective devices?

36. Alternatives to Protective Devices
The goal is to move to a less restrictive environment
Health care workers are encouraged to find alternatives to the use of protective devices
Family and friends of a patient who is confused can be encouraged to sit with the patient to promote safety
Many of the actions described in Box 20-3 involve frequent observations of the patient, which helps prevent patient injury and decrease the use of the devices.

37. Principles Related to the Use of Protective Devices
Protective devices must help the patient or be needed to continue medical therapy
Use the least amount of immobilization needed
For all restrictive devices there must be a written order. As soon as the device is no longer needed, the physician must be notified
Apply the device snugly but not so tightly as to interfere with blood circulation or nerve function
Device must be removed and patient’s position changed every 2 hours. Active or passive exercises for immobilized joints and muscles
Review why the patient needs to be up and mobile.
If the patient is exercised safely and appropriately, the patient will be less restless and more tired at the end of the day, and will rest better during the night.
The patient’s level of consciousness and orientation to surroundings have been shown to improve with increased mobility.