2 JCAHO 2010 National Patient Safety Goals Identify patients correctly – 2 identifiersImprove staff communication – read back, not using certain abbreviations, SBARUses medicines safely – label, look alike/sound alike, blood thinnersPrevent infection – hand hygiene, NO HAIsReconcile medications across the continuum of careID patient safety risks – suicidePrevent fallsHelp patients to be involved in their careWatch patients closely for changes in their health and respond quickly if they need help – Rapid response teamsPrevent errors in surgery
3 Environmental SafetyA 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.
4 Environmental Safety Basic Needs Oxygen Nutrition CO2 poisoningNutritionKeeping perishable foods freshTemperature and HumidityExtreme cold and heat
5 Physical HazardsFractures are the most serious health consequence of fallsAlmost 90% of all fractures among older adults are due to fallsLightingObstaclesBathroom Hazards – burns, poisoning, fallsSecurity – fire safety, lead poisoning, contaminated soil and water
6 Transmission of Pathogens Pathogen = any microorganism capable of producing an illnessHand hygiene most effective method of limiting transmissionImmunization = resistance to an infectious disease is produced or augmented
8 Risks at Developmental Stages Infant, Toddler, Preschool: Injuries are the leading cause of death in children over age 1School aged child: Sports injuriesAdolescent: Risk taking behaviorsAdult: Lifestyle habitsOlder Adult: Physiological changes result in increased risk for falls, burns, MVAs
9 Individual Risk Factors LifestyleImpaired MobilitySensory or communication ImpairmentLack of Safety Awareness9
10 Risks in the Health Care Agency 3 Types of medical errors accounted for almost 60% of the client safety incidentsPost-op infectionsBed soresFailure to diagnose and treat in timeMedication errorsFallsPatient-Inherent Accidents: self-inflictedProcedure-related Accidents: occur during therapyEquipment-related Accidents: malfunction, disrepair, or misuse
11 Safety and the Nursing Process AssessActivity and exerciseMedicationsHistory of fallsHome maintenance and safety
12 Nursing Diagnosis Risk for injury Related to: As evidenced by: General weaknessRight or Left sided weaknessSide effects of medicationPoor eyesightAs evidenced by:Recent fallsNew CVAConfusionMacular degeneration
13 Implementation Nursing Diagnosis Goal Interventions Risk for injury related to (r/t) generalized weakness as evidenced by recent fallsGoalPt. will ask for help to the bathroomPt. will remain free from injury during hospitalizationInterventionsNurse will ensure call light is in reachNurse will work with other care providers to make sure patient is seen every hourNurse will work with other care providers to ensure pt. receives required assistance with ADLs/activities
14 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 restraintUsed only in emergency situations to ensure the patient’s safety.Restraint orders must be specific and time-limited.
15 Other Mechanisms to Prevent Falls Tab AlarmsArm BandsID outside of Patient roomNotice Inside the Patient roomColors of gowns, slippers, blanketsBed AlarmsChair Alarms
16 Restraint Use Must have a physician order Order must be rewritten every 24h.Restraint policies are specific to health care settingNursing documentation must occur at least every two hours
17 Complications from Restraints Skin breakdownConstipationPneumoniaIncontinenceUrinary retentionNerve damageCirculatory damage
26 Patient Hygiene Oral Care Bathing Shaving Hair care Perineal care Foot careBed makingOccupied/unoccupied
27 Goal What is the goal of hygiene in the health care setting? Moving the patient to a higher level of healthCheck the box on the nursing documentation sheetPrevent InfectionAll of the above
28 Self-Assessment Have you ever bathed another adult person? Someone not in your family?
29 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.
30 Factors Influencing Hygiene Physical ConditionAbility to care for selfEnergy levelSensory deficitsIncontinence of urine and/or stoolDexterity and ROMSedation, Pain levelChronic illnessesPsychiatric conditions
31 Factors Cont’d. Social practices Personal preferences Body image Socioeconomic statusHealth beliefs and motivationCultural variables
32 Assessment Skin: wounds, infection Feet and Nails: PVD, diabetic patient with foot issues, foot fungus around toe nailsPatients with poor circulation to the feet and lower legs needs close assessment of those areasOral Cavity: condition of the mouth and teethHair: tangles, liceEyes, Ears, and Nose: Does the patient have any sensory deficits?Foot & Nail Care – p. 880Prevents infection, odors, and injury of soft tissueAssess 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,SensationAbility to perform self careType of footwear – cleanliness, fit, restrictive garters, knee-highs etcFoot problems p. 883CallusesCornsPlantar WartsAthlete’s footIngrown nailsPeripheral NeuropathyMuscle wasting of lower extremitiesAbsence of deep tendon reflexesFoot deformities, infections, abnormal gait,Absent vibratory sensationVascular InsufficiencyDecreased hair growth on legs and feetAbsent or decreased pulsesInfection in footPoor wound healingThickened nailsShiny appearance of skinBlanching of skin on elevation
33 Critical EvaluationWhat is the ability of the person to care for themselves?Physical disabilitiesMental disabilitiesOrganize the dayEarly Morning care – Night shift for those having tests, surgery, (offer bedpan, washing hands and face, oral care)Routine Morning care – After breakfastBedpan, 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 roomAfternoon care – (many tests, rehab, etc) washing hands and face, assisting with oral care, offering bedpan, urinal, straightening bedsEvening care – personal hygiene care promotes sleep, changing soiled linens, gowns, wash hands and face, oral hygiene, back massages, offer beverage33
34 Specific Issues Needing to be Addressed at Bath Time Foot careNormal vs DiabeticDo not soak feet of patients with DM and/or vascular insufficiencySensitive skinInfestationsInfectionsIncontinence
35 Types of Baths Complete bed bath Partial bed bath Sponge at the sink Tub bathShowerBath in a bagComplete 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 bathBath in a gag or travel bath – contains several soft cloths, pre-moistened in solution that does not have to be rinsed
36 Critical EvaluationAre 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, ElderlyHow does that affect their hygiene needs and attitudes?What do you do with this information about the patient?Care Plan
37 Critical EvaluationInvolve patient as much as possible in bathing decisionsWhenWhereTypeTubShowerBed bath
38 Nursing DiagnosisBATHING/HYGIENE SELF-CARE DEFICIT: R/T CONFUSION: AEB POOR PERSONAL HYGIENEBATHING/HYGIENE SELF-CARE DEFICIT: R/T DECREASED CEREBRAL CIRCULATION (RECENT CVA) AEB RIGHT SIDED WEAKNESSRisk of impaired skin integrity related to bathing hygiene self-care deficitInterventions – review with client how to observe feet for breaks, in skin and friction from shoes using a mirrorRationale – injuries to foot increases client’s risk for infection, impaired mobility and amputationIntervention – Instruct client to observe feet for reddened areas, abrasions, blisters, and swollen areas immediately after removing shoesRationale – improperly fitting shoes produce friction, redness and swelling. Observation for these conditions immediately after removing shoes promotes timely identification of early foot problems
39 Oral Care Oral care for the patient who is not conscious Oral care is an essential nursing interventionAssess for decreased saliva, infection, coated tongue, cracked lipsBrush all tooth surfaces using a soft bristle brushObserve for complications such as bleeding gumsOral care for the patient who is not consciousOral care for the patient with partial paralysis of the mouthOral care for the patient who has had mouth surgery or injury1. Oral cavity lined with mucous membranes, light pink and moistFloor 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 productionTeeth are organs of chewing or mastication, surrounded by periodontal membranes which lie just below gum margins (gingivitis – gum inflammation)Oral Care – p. 888Position on side with bed flatRemove dentures (wash with warm water in sink/emesis basin with towel in bottom) pg 145Separate teeth with padded tongue bladeHave suction ready to minimize risk of aspirationGentle brush teeth and gums, roof of mouth, tongue,Bulb syringe to rinse or moistened brushSuction YankauerWater soluble jelly to lipsToothettes – moisten in water or normal saline to clear oral cavity, rinse with mouth wash diluted
40 OtherHair Care: Gather supplies (plastic trough, towels, shampoo, drainage wash basin)Shaving: Check doctor’s ordersAnticoagulantsPerineal Care (see page 877)IndependentNeeds assistDependentFoot Care (see page 880)Do not soak feet of patients with DM and/or vascular insufficiencyFoot & Nail CarePrevents infection, odors, and injury of soft tissueAssess 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,SensationAbility to perform self careType of footwear – cleanliness, fit, restrictive garters, knee-highs etcFoot problems p. 883CallusesCornsPlantar WartsAthlete’s footIngrown nailsPeripheral NeuropathyMuscle wasting of lower extremitiesAbsence of deep tendon reflexesFoot deformities, infections, abnormal gait,Absent vibratory sensationVascular InsufficiencyDecreased hair growth on legs and feetAbsent or decreased pulsesInfection in footPoor wound healingThickened nailsShiny appearance of skinBlanching of skin on elevation
41 Care of Patient with Sensory Aids Glasses/Contacts (pg. 894)Dentures (pg. 891)Hearing Aids (pg. 895)Prosthetic Eyes
42 Basic Principles Remember body mechanics Raise the bed to a comfortable heightFollow medical asepsis when making a bedWear gloves if linen is soiledKeep linen away from uniformDo not place soiled linen on the floor
43 Bed Making – Occupied/Unoccupied LinenUse appropriate linen for the patientChucks and linen saversDraw sheetsTherapy bedsLearn to place a bottom flat sheet when there are no fitted sheets