1. Patient Safety and Positioning Unit 2

2. Patient Safety p.236 Risk factors for injury: Impaired mobility due to injury, disease, or surgery Medications affecting mental status, balance, coordination Disorientation due to change in environment or disease Impaired hearing or vision Possible causes for falls: Misjudged distance Weak, dizzy Rapid change in position – losing balance, getting light headed Hazards on hallways Poor lighting Not calling for help Prevention is key! Study Preventing Patient Falls Figure 15.1 p. 237!!!!!

3. Restraints p. 237 Chemical – medications affecting mood/behavior Physical: any technique or device that restricts movement or normal access to body Remember: The resident has the right to be free from physical and chemical restraints, so document objectively what’s going on Physical restraints are only used when safety of pt or others is at risk and nothing else works, ex. If pt climbs out of bed to go to bathroom – keep urinal in reach Always have to try alternatives first, ex. Pt who gets out of WC gets a chair alarm and WC is placed by the nurse’s station, so everyone can keep an eye on pt If restraints are necessary, start with least restrictive first Need a MD order, often family/pt will sign consent, and follow protocol P. 238 examples of physical restraints Table 15.1: Complications of restraints ! P. 246: Guidelines for The Use of Restraints!! Especially: check q15mins, release q2hrs for at least 10 mins etc

5. Applying Restraints in Bed p. 244 Ex: wrist, vest, poncho, jacket, belt restraints; Always follow manufacturers guidelines Center pt’s hips in middle of bed (where it bends when HOB goes up) Make sure straps are straight, not at an angle Wrap straps around frame deck (movable part of bed frame that supports mattress) Don’t wrap on stationary bed frame part (when you move HOB, it gets pulled), side rails, or on outside of bed, so pt can’t untie it Use bedspring to tie on strap Use side rails when pt is restrained in bed See Figure 15-14

6. Enablers & Side rails p. 241 Enabler: Device that empowers, assists pt to function at highest level possible; if used purely to keep pt from getting up = restraint ex. Wheelchair lap tray Figure 15-9 Postural supports: devices that maintain body position and alignment Side Rails: can be enablers, can be restraints; 4 rails up=always restraint If pt has physical restraints on in bed – side rails must be up Injuries with side rails: falls = hip fractures, entrapment between mattress and rails see Figures 15-10A and B p. 242 Padding for side rails: for seizure disorders, blood thinning medications, pt who wants to climb through side rails Alternatives to side rails: see all figures on p. 243 Keep bed in lowest possible position, wheels locked Padded mats on floors, so no injuries when fall Meet needs = anticipate reasons for getting up: hunger, thirst, bathroom, pain Pressure-sensitive bed and chair alarms: sound when pt gets out of bed or chair Pressure-sensitive mats: sound alarm when someone steps on them

7. Alternatives to Restraints p. 245 Try before using restraints – document what was tried, how it didn’t work 1. Care for pt’s personal needs promptly 2. Know pt’s with fall risks – monitor them more often 3. Make sure pts walk and transfer correctly 4. Report any physical or mental change that could lead to an accident STAT 5. Maintain safe, quiet, calm environment 6. Comfortable chairs, supportive devices 7. Use Security devices: wrist sensors (go off if pt tries to leave building), bed or chair alarms 8. Use clothing wisely, often just covering the IV site with long sleeves etc. keeps pt from pulling on it

8. Preventing other Incidents p. 247 Accidental poisoning: lock all chemicals/cleaning solutions; Pt food belongs in pt refrigerator, labeled with name and date Thermal injuries: heat or cold Follow procedures accurately when administering warm/cold treatments Check water temperature Check food temperature Store flammables safely Skin injuries: lacerations (cuts/breaks in skin) Keep sharps locked up: scissors, knives, razors, needles Dispose of them properly in a _______________ Clean up broken glass immediately

9. Preventing other Incidents p. 248 Choking: Aspiration: accidental entry of food or object into trachea (windpipe) Pt having problems with swallowing (dysphagia): cut food small, feed slowly, fluids between bites, place food in unaffected side (CVA), use thickeners if ordered Place pt upright, good body alignment before eating; sit up for 30 mins after eating If pt pockets food, give oral care after meal

10. Procedures p. 249 - 252 Procedure: practices and processes used when following facility policies in patient care Prioritizes and orders your responsibilities Initial Procedure actions p. 249!! Ending Procedure actions p.251!!

11. Body mechanics for the patient p. 253 Body alignment: position in which body can properly function Maintained by moving, turning, positioning pt so it Helps the pt feel more comfortable Relieves strain Helps body function more efficiently Prevents complications like contractures and PUs (pressure ulcer)

12. Complications of incorrect positioning p. 253 Pressure ulcers (PUs): unrelieved pressure on a bony prominence interferes with blood flow leading to tissue breakdown (wounds) Contractures: Occur when joint is in same position for too long Can begin in as little as 4 days of immobility Pt loses ability of free movement after 15 days Muscles stiffen and shorten, preventing joint from moving fully Painful, permanent, interfere with mobility

13. Supportive devices p. 254 Anything that helps maintain proper body alignment Pillows, folded sheets, blankets Orthotic devices, ex. Splints Special boots or shoes Bed cradles to prevent blanket sitting on feet Footboards to prevent foot drop

14. Body Positions p. 254 Prone (abdomen)/ semiprone (variation Supine (back)/ semisupine (variation) Lateral (side)/ Sims’ (variation) Fowler’s position/ high Fowler’s, semi-Fowler’s, orthopneic position Regardless the position, it always involves: moving pt into proper body alignment, may need to move pt up or to one side of the bed Turning pt on back, side, or abdomen Placing pt’s trunk and extremities in proper position, maintaining alignment with use of supportive devices

15. Moving/ lifting pts p. 255 Responsibility of nursing assistant Follow proper body mechanics and safety rules for you and your pt ALWAYS find out if you need help moving/lifting pt before beginning Ask for help Check care plan for special positioning instructions Turn sheet /draw sheet: Extends from above shoulders to below hips Used to move heavy or helpless pt

16. Procedures 14-17!! P. 255-258 Read/know procedures: Turn pt toward you Turn pt away from you Moving pt to HOB Logrolling pt

17. Positioning pt p. 259 You have to know the positions!! Supine Position p. 259 HOB flat, head 2-3 inches from HOB Pillow extends 2 inches below pts shoulders, head in middle Trochanter roll: from above hip to above knee, for affected hip or weak hips (prevents external rotation) Pillows everywhere, feet at 90 Degree angles Semisupine Position = tilt position (not lateral) Relieves pressure from hip, sacrum, coccyx and buttocks 45 Degree angle between pt back and bed Bottom shoulder slightly forward Legs and spine are straight

18. Positioning pt p. 259 Prone Position p. 260 Pillow under head extends to shoulders and 5-6 inches beyond face Small pillow under abdomen (reduces back pressure) Pillows under arms, lower legs Legs and spine are staight Semiprone Position (not lateral) Starts in prone, then pillow under shoulder and chest, under top leg Lower arm is behind body Legs and spine are straight

19. Positioning pt p. 262 Right Lateral Position p. 262 XXXX Skill check off XXX Start in supine, bring pt more to left side of bed, so he can turn right and have enough space Place pillow under head extending 5-6 inches beyond face and down to shoulders Position right (lower) arm, so shoulder, elbow are flexed, palm facing up Place left (upper) arm in comfortable position, support with pillow; shoulder, elbow wrist at same height Pillow behind pts back to maintain position Pillow between legs from above knee to below ankles; hip, knee and ankle at same height Sims’ position p. 262 (variation of left lateral position) Left (lower arm) extended and behind back Right (upper arm) flexed and forward, supported with pillow Left leg extended Right leg flexed

20. Positioning pt p. 262 Fowler’s Position (to feed pts, for watching TV etc) Start in supine, middle of bed, hip where bed bends HOB at 30 Degrees = semi-Fowler’s, HOB 45-60 Degrees = Fowler’s, HOB 90 Degrees = high Fowler’s Pillow extends 4-5 inches below shoulders Flex elbows, support with pillows to prevent pulling on shoulders Pillow under legs from above knee to ankles to prevent pressure on heels Footboard/folded pillow to prevent foot drop

21. Positioning pt p. 263 Orthopneic Position Variation of high Fowler’s when pt has difficulty breathing Sit pt up as high as possible Lean pt forward, using overbed table in front of pt as support for extended arms Pillow behind back for support Sitting Position In chair or WC Back and buttocks up against chair back Stabilize feet on floor or footrests Feet, knees, thighs at 90 degree angles (90-90-90 position)

22. Step P/F 1Performed beginning standards 2Explains procedure to resident before care 3Provides privacy 4Lowers HOB 5 Raises side rail on side to which body will be turned 6 Slowly rolls resident onto side as one unit towards raised side rail, keeping upper knee bent in front of lower leg 7 Keeps resident positioned a safe distance from the edge of bed 8Ensures resident is not lying on lower arm 9 Places or adjusts pillow under head of bed to support neck and chin 10Supports top arm with supportive device 11 Supports residents back with supportive device 12 Places supportive device between legs so ankles/knees are separated 13Asks resident about comfort during care 14Puts call bell within reach 15Washes hands 16End procedures Skill 3: Positioning pt on side Google video: nursing skills youtube chesapeake

23. Homework Textbook: Read Unit 15 Workbook: Read Unit summary p. 94, Memorize Initial Procedure Actions, Memorize Ending Procedure Actions, True/False questions p. 96, Name the position p. 97