Nursing Management of Clients with Nursing Management of Clients with

Stressors that AffectStressors that Affect Safety Safety

NUR101NUR101

Fall 2010Fall 2010

LECTURE # 3LECTURE # 3K. Burger, MSEd, MSN, RN, CNEK. Burger, MSEd, MSN, RN, CNEPPP By: Sharon Niggemeier RN MSNPPP By: Sharon Niggemeier RN MSN

Revised kburger806,707Revised kburger806,707

Therapeutic EnvironmentTherapeutic Environment

Safe environment = where one is Safe environment = where one is protected from physical and psychological protected from physical and psychological harm – harm – A basic human need according to A basic human need according to ____________?____________?

Place where participants can feel safe to Place where participants can feel safe to move toward common goalsmove toward common goals

Nurses need to identify potential risks Nurses need to identify potential risks and unsafe situations.and unsafe situations.

Client Factors that Affect SafetyClient Factors that Affect Safety

DevelopmentalDevelopmental MobilityMobility Sensory Sensory

PerceptionPerception KnowledgeKnowledge CommunicationCommunication Physical HealthPhysical Health Mental stateMental state LifestyleLifestyle

Common Safety Hazards in Common Safety Hazards in Health Care FacilitiesHealth Care Facilities

FallsFalls- accidental injury from pt. falls- accidental injury from pt. falls Equipment misuseEquipment misuse - - injury from injury from

improper use of equipment: Hoyer improper use of equipment: Hoyer lifts/IV pumps etc.lifts/IV pumps etc.

Procedural errorsProcedural errors – – medication medication errors, nosocomialerrors, nosocomial infections, infections, misidentificationmisidentification

Client-inherent accidentsClient-inherent accidents – – seizures, seizures, smoking, self-inflicted injuriessmoking, self-inflicted injuries

Safety @ the BedsideSafety @ the Bedside

Bed lowest position; wheels lockedBed lowest position; wheels lockedNo spillsNo spillsClutter-freeClutter-freeGood lightingGood lightingNecessary articles within reachNecessary articles within reachCall bell within reachCall bell within reachSide-rails up as appropriateSide-rails up as appropriate

Fall Prevention MeasuresFall Prevention Measures

Every client MUST be assessed for their Every client MUST be assessed for their RISK for FALLS upon admission and RISK for FALLS upon admission and dailydaily

Utilize a Utilize a Fall Risk Assessment ToolFall Risk Assessment Tool Fall Risks= history of falls, certain Fall Risks= history of falls, certain

medications, urinary/bowel urgency, in medications, urinary/bowel urgency, in addition to factors listed above.addition to factors listed above.

JCAHO National Patient Safety Goals

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What is the first step in preventing falls and What is the first step in preventing falls and injury?injury?

• Determine who is a greatest riskDetermine who is a greatest risk

Who are the people @ greatest risk?Who are the people @ greatest risk?• Hx of fallsHx of falls• Impaired vision / hearingImpaired vision / hearing• Impaired gaitImpaired gait• Hx of CVAHx of CVA• CV disease ( postural hypotension )CV disease ( postural hypotension )

Fall Prevention MeasuresFall Prevention Measures

Assist with transferring and Assist with transferring and ambulatingambulating

Reduce visual/hearing impairmentsReduce visual/hearing impairmentsOrient client frequentlyOrient client frequentlyMaintain adequate lighting Maintain adequate lighting Use assistive devices and staff prnUse assistive devices and staff prnProper footwear and clothingProper footwear and clothing

Fall Prevention MeasuresFall Prevention Measures

Anticipate needs – Anticipate needs – toileting/bathingtoileting/bathing

Educate client and familyEducate client and familyExercise to strengthen musclesExercise to strengthen musclesChange client position slowlyChange client position slowly

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Identify OTHER fall prevention measuresIdentify OTHER fall prevention measures

• Check medication schedules (diuretics?)Check medication schedules (diuretics?)• Clutter free environmentClutter free environment• Keep needed items in reachKeep needed items in reach• Staff should move slowly around Staff should move slowly around

ambulatory patientsambulatory patients• Frequent reassessmentFrequent reassessment

Protective DevicesProtective Devices(Physical Restraints)(Physical Restraints)

Last resortLast resort Used when client Used when client

may cause harm to may cause harm to self or othersself or others

Used when Used when alternative alternative methods have methods have failed failed

MD order neededMD order needed

Must check 15min Must check 15min after applyingafter applying

Must check every Must check every 30 min30 min

Must REMOVE every Must REMOVE every 2 hours2 hours

Must DOCUMENT Must DOCUMENT behavior justifying behavior justifying restraint & failure of restraint & failure of alternative methods alternative methods

Types of Protective DevicesTypes of Protective Devices Posey vestPosey vest Limb immobilizerLimb immobilizer BeltBelt MittsMitts ElbowElbow Mummy wrapMummy wrap Geri chairGeri chair Side railsSide rails ChemicalsChemicals

AnyAny device device that prevents that prevents the pt. from the pt. from freely moving freely moving is considered a is considered a restraint or restraint or protective protective device !!device !!

Alternatives to RestraintsAlternatives to Restraints

Move client closer to nurse’s stationMove client closer to nurse’s station One-to-one monitoringOne-to-one monitoring Re-orient frequentlyRe-orient frequently Change/eliminate bothersome Change/eliminate bothersome

treatmentstreatments Make environment safe for exercise Make environment safe for exercise

and ambulationand ambulation Electronic alarm devicesElectronic alarm devices

Fall Risk AssessmentFall Risk AssessmentThink-Pair-ShareThink-Pair-Share

Complete Fall Risk Assessments on Complete Fall Risk Assessments on Case-Study Handout.Case-Study Handout.

Pair with a partnerPair with a partner

Share and discuss your assessmentsShare and discuss your assessments

Oxygen Safety Oxygen Safety

Avoid open flamesAvoid open flames

Post no smoking signsPost no smoking signs

Advise client and visitors of O2 safety Advise client and visitors of O2 safety measuresmeasures

Avoid oil based petroleum and synthetic Avoid oil based petroleum and synthetic fabricsfabrics

Check electrical equipment doesn’t emit Check electrical equipment doesn’t emit sparkssparks

Fire SafetyFire Safety A fire requires 3 A fire requires 3

elementselements

OxygenOxygen FuelFuel SparkSpark

Fire SafetyFire Safety

Greatest danger in a fire is Greatest danger in a fire is PANICPANIC so so stay calm!!!!!stay calm!!!!!

Your ability/knowledge to think and Your ability/knowledge to think and act quickly will save livesact quickly will save lives

Don’t yell FIREDon’t yell FIRE

Remember : Remember : R A C ER A C E

Fire Safety-RACEFire Safety-RACE

RR- Remove patients, visitors and staff - Remove patients, visitors and staff from immediate areafrom immediate area

AA- Alarm. Pull the fire alarm - Alarm. Pull the fire alarm

CC –Contain the fire. Close doors and –Contain the fire. Close doors and windowswindows

EE- Extinguish the fire only if it is safe - Extinguish the fire only if it is safe and practicaland practical

Fire SafetyFire SafetyOperating a Fire ExtinquisherOperating a Fire Extinquisher

PP- Pull the pin- Pull the pin

AA- Aim at base- Aim at base

SS- Squeeze - Squeeze triggertrigger

SS- Sweep from - Sweep from side to sideside to side

Fire safetyFire safety

Type Type ABC ABC fire extinguishers (common fire extinguishers (common in health facilities) used on any type of in health facilities) used on any type of firefire

Know how to Know how to reportreport a fire; each facility a fire; each facility differsdiffers

Be Be aware aware of fire alarms/fire exits/ fire of fire alarms/fire exits/ fire extinguishers extinguishers

Listen Listen to the sound of the alarm bells; to the sound of the alarm bells; this tells the location of the firethis tells the location of the fire

Don’t use elevators- use Don’t use elevators- use stairsstairs

Fire SafetyFire SafetyWhen the Fire Alarm SoundsWhen the Fire Alarm Sounds

Close all doorsClose all doors Clear hallwaysClear hallways Avoid unnecessary talking Avoid unnecessary talking

so instructions can be heardso instructions can be heard Place wet towels /sheets Place wet towels /sheets

at the bottom of closed doors at the bottom of closed doors

to contain fire/smoketo contain fire/smoke Turn on all lightsTurn on all lights

Fire Safety-EvacuationFire Safety-Evacuation

Horizontal Horizontal evacuation- move across evacuation- move across from one area to anotherfrom one area to another

VerticalVertical evacuation is moving down evacuation is moving down from one floor to anotherfrom one floor to another

Have Have ambulatory clientsambulatory clients hold hands hold hands and form a chain evacuating using and form a chain evacuating using stairs. stairs. Always escorted by staffAlways escorted by staff

Nonambulatory pt.Nonambulatory pt. need to be need to be carried or dragged using sheetscarried or dragged using sheets

Chemical SafetyChemical SafetyExposure to hazardous Exposure to hazardous chemicalschemicalsMaterial Safety Data Sheets Material Safety Data Sheets

(MSDS)(MSDS)You have the right to know what You have the right to know what

chemicals you could be exposed chemicals you could be exposed to and how to be treated if to and how to be treated if exposedexposed

Radiation SafetyRadiation SafetyPrivate lead-lined roomPrivate lead-lined roomStaff and visitors are Staff and visitors are

restricted in amount of time restricted in amount of time spent in roomspent in room

Distance is also maintained Distance is also maintained between client & staff/visitorsbetween client & staff/visitors

Use of dosimeters Use of dosimeters

Safety Precautions Safety Precautions Latex AllergyLatex Allergy

Health care workers at riskHealth care workers at risk Frequently hospitalized clients at riskFrequently hospitalized clients at risk Clients with hx of allergy to banana Clients with hx of allergy to banana

higher riskhigher risk Types of reaction – Types of reaction – immediate versus immediate versus

delayed hypersensitivitydelayed hypersensitivity Latex alert labeling Latex alert labeling Awareness of latex contentAwareness of latex content

Bioterrorism PreparednessBioterrorism Preparedness

Emergency Management PlanEmergency Management PlanA JCAHO mandateA JCAHO mandate

Epidemiologic Awareness:Epidemiologic Awareness:AnthraxAnthraxSmallpoxSmallpoxPlaguePlagueBotulismBotulism

NYS DOH NYS DOH FACT SHEETS

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What are the (4) major components of What are the (4) major components of an Emergency Management Plan?an Emergency Management Plan?

• Mitigation – vulnerability, types of Mitigation – vulnerability, types of emergencies that might occuremergencies that might occur

• Preparedness – resource stockpilePreparedness – resource stockpile• Response – triage, reportingResponse – triage, reporting• Recovery – restoring essential svcsRecovery – restoring essential svcs

Seizure PrecautionsSeizure Precautions

Airway and suction at bedside of all Airway and suction at bedside of all clients with history and/or potential clients with history and/or potential for seizuresfor seizures

If seizure occurs; Protect Client!If seizure occurs; Protect Client!Lower to floor if necessaryLower to floor if necessaryClear surroundingsClear surroundingsProtect headProtect headAirway inAirway in

Bacteriologic SafetyBacteriologic Safety Preventing the spread of Preventing the spread of

microorganisms from person to microorganisms from person to personperson

The most effective way to prevent The most effective way to prevent the transmission of microbes is by:the transmission of microbes is by:

HAND HYGIENEHAND HYGIENE

HAND HYGIENEHAND HYGIENE

HAND HYGIENEHAND HYGIENE

Chain of Infection Chain of Infection

Process through which infection Process through which infection occurs:occurs:

Infectious agentInfectious agent ReservoirReservoir Exit from reservoirExit from reservoir Means of transmissionMeans of transmission Portals of entryPortals of entry Susceptible hostSusceptible host

Nursing Interventions to Break the Nursing Interventions to Break the Chain of InfectionChain of Infection

Control/Elimination of Infectious AgentsControl/Elimination of Infectious Agents Control/Elimination of ReservoirsControl/Elimination of Reservoirs Control portals of exit and entryControl portals of exit and entry Controlling/Preventing transmissionControlling/Preventing transmission Protecting susceptible hostProtecting susceptible host Promoting normal defense mechanisms Promoting normal defense mechanisms

with personal hygiene and good nutritionwith personal hygiene and good nutrition Encouraging proper immunizationsEncouraging proper immunizations

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What immunizations are routinely What immunizations are routinely recommended for the elderly?recommended for the elderly?

• PneumococcalPneumococcal• FluFlu

What immunizations are routinely What immunizations are routinely recommended for HCWs?recommended for HCWs?

• Hepatitis BHepatitis B• FluFlu

Stages of Infection Stages of Infection

IncubationIncubationPro-dromal (latent)Pro-dromal (latent)Full stage of illnessFull stage of illnessConvalescent PeriodConvalescent Period

AsepsisAsepsis

AsepsisAsepsis -All activities to prevent infection -All activities to prevent infection or break the chain of infectionor break the chain of infection

Medical AsepsisMedical Asepsis – “Clean Technique” – “Clean Technique” practices that decrease the number and practices that decrease the number and transfer of pathogenstransfer of pathogens

Surgical Asepsis Surgical Asepsis - “Sterile Technique” - “Sterile Technique” practices that keep objects free from practices that keep objects free from microbes microbes

Medical Asepsis Medical Asepsis HAND HYGIENEHAND HYGIENE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Personal groomingPersonal groomingCleanest to dirtiestCleanest to dirtiestDisposal practicesDisposal practicesConscientiously follow barrier Conscientiously follow barrier

precautionsprecautions

Surgical Asepsis Surgical Asepsis Object is sterile when all Object is sterile when all

microbes and spores have been microbes and spores have been destroyeddestroyed

Contamination occurs when a Contamination occurs when a non-sterile object touches a non-sterile object touches a sterile objectsterile object

Objects brought into contact with Objects brought into contact with broken skin should be sterilebroken skin should be sterile

Nosocomial InfectionsNosocomial InfectionsExogenousExogenousEndogenousEndogenous IatrogenicIatrogenic

Infection Control Infection Control Standard precautionsStandard precautions

Transmission Based precautionsTransmission Based precautions– ContactContact– AirborneAirborne– DropletDroplet

Standard PrecautionsStandard PrecautionsPractices used when Practices used when caring for caring for ALLALL patients patients when coming in contact when coming in contact with body fluids or with body fluids or secretionssecretions(except sweat), non-(except sweat), non-intact skin or mucous intact skin or mucous membranesmembranes

HandwashingHandwashing PPEPPE SharpsSharps Disposal PracticesDisposal Practices Safe injection Safe injection

practicespractices Respiratory Respiratory

Hygiene/Cough Hygiene/Cough EtiquetteEtiquette(CDC 2007 update)(CDC 2007 update)

Transmission Based Transmission Based PrecautionsPrecautions

In addition to using Standard PrecautionsIn addition to using Standard Precautions AirborneAirborne- used for client with infection - used for client with infection

spread through the air. spread through the air. (measles, varicella,TB, SARS)(measles, varicella,TB, SARS)

DropletDroplet-used for client with infection -used for client with infection spread thru large particles/droplets spread thru large particles/droplets (Influenza, pertussis, Group A strep)(Influenza, pertussis, Group A strep)

ContactContact used for client with infection used for client with infection spread by direct or indirect contact spread by direct or indirect contact (VRE, (VRE, MRSA, C-dificile)MRSA, C-dificile)

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What PPE is required for:What PPE is required for:Airborne?Airborne?Droplet ?Droplet ?Contact ?Contact ?

What type of room is required for:What type of room is required for:Airborne?Airborne?Droplet ?Droplet ?Contact ?Contact ?

Isolation PrecautionsIsolation Precautions

MD orders isolationMD orders isolationBased on how pathogen is Based on how pathogen is

transmittedtransmittedRemain in isolation till 3 Remain in isolation till 3

negative C&Snegative C&SMeet the client’s psychological Meet the client’s psychological

needs due to isolationneeds due to isolationRole of Infection Control NurseRole of Infection Control Nurse

Isolation-Nursing ResponsibilitiesIsolation-Nursing ResponsibilitiesExplain to client why isolation is Explain to client why isolation is

neededneededPost signs outside doorPost signs outside doorGather suppliesGather suppliesTeach family proper donning of Teach family proper donning of

PPEPPE

Critical ThinkingCritical Thinking

Mrs. Niles is 83 years old and lives alone. Mrs. Niles is 83 years old and lives alone. She has difficulty walking and relies on a She has difficulty walking and relies on a church volunteer group to deliver lunches church volunteer group to deliver lunches during the week. Her fixed income limits during the week. Her fixed income limits her ability to buy food. Last week, Mrs. her ability to buy food. Last week, Mrs. Niles’ sister died. The two sisters had Niles’ sister died. The two sisters had been very close. been very close.

As a home care nurse, explain the factors As a home care nurse, explain the factors that might increase Mrs. Niles risk for that might increase Mrs. Niles risk for infectioninfection

Critical ThinkingCritical ThinkingA NOSOCOMIAL STORYA NOSOCOMIAL STORY

Ms Smiley was admitted to the hospital for foot Ms Smiley was admitted to the hospital for foot surgery. Her roommate, Mrs. Sneezy, was in surgery. Her roommate, Mrs. Sneezy, was in the hospital for an appendectomy. No one ever the hospital for an appendectomy. No one ever came to visit Mrs. Sneezy, yet she came down came to visit Mrs. Sneezy, yet she came down with the flu while in the hospital. None of the with the flu while in the hospital. None of the hospital personnel had the flu. Three days hospital personnel had the flu. Three days later, Ms Smiley was recuperating from her foot later, Ms Smiley was recuperating from her foot surgery. The wound on her foot is warm, red, surgery. The wound on her foot is warm, red, and oozing pus. Nurse Sensitive calls the and oozing pus. Nurse Sensitive calls the physician and informs him that the wound looks physician and informs him that the wound looks infected. He tells the nurse that during the infected. He tells the nurse that during the surgery his glove tore, and he orders antibiotics surgery his glove tore, and he orders antibiotics for Ms Smiley. The next day, Nurse Sensitive for Ms Smiley. The next day, Nurse Sensitive calls in sick to work. She has the flu.calls in sick to work. She has the flu.

Critical ThinkingCritical ThinkingA NOSOCOMIAL STORYA NOSOCOMIAL STORY

Fill in the blank with either:Fill in the blank with either:Exogenous OR Endogenous OR IatrogenicExogenous OR Endogenous OR Iatrogenic

Ms Smiley has a ________________nosocomial Ms Smiley has a ________________nosocomial infection.infection.

Mrs. Sneezy has a ______________nosocomial Mrs. Sneezy has a ______________nosocomial infection.infection.

Nurse Sensitive has a ____________nosocomial Nurse Sensitive has a ____________nosocomial infection.infection.