Fundamentals of nursing | Summaries Nursing

Fundamentals of Nursing - LEC

SAFETY, SECURITY AND EMERGENCY

• Safety is the fundamental concern of the

nurses

• Causes of injury: calamities, firearm,

floods, and etc.,

• Safety should be at the bedside and home

FACTORS AFFECTING SAFETY

• Age and development

- In adult; sensory neurological

deficiency or diminished sensory

neurological activity

• Lifestyle

- Neighborhood or community

- environment

- Insufficient funding for safety equipment

- Risk takers who are prone to injury

• Mobility and health status

• Sensory – perceptual alterations

• Cognitive awareness

- Awareness; is the ability to perceived

environmental stimuli.

- Usually, people who are lacks in sleep,

people who are semi-conscious and

conscious, and disoriented who are

prone to accidents/ injury.

- Ability to perceive environmental

stimuli

• Emotional state

- Stressful situation can reduce perception

- People who are depress are mostly prone

to injuries

• Ability to communicate

- Aphasic individual; leaves a person

unable to communicate effectively with

others.

- Illiterate individual; inability to read

and write.

- Language barrier between two people

• Safety awareness

- Pertains on how to use an equipment

- Ways on not to use drugs

- Preventive measures

• environmental factors

- natural factors

- bio terrorism; deliberately risk of

bacteria and germs that can cause illness

or death

METHODS IN ASSESSING SAFETY

• Nursing health history

- Age and developmental level

- General health status

- Mobility status

- Physiologic or perceptual deficits

- Altered thought processes

• Physical examination

• Risk assessment tools

• Home hazard appraisal

COMMON POTENTIAL HAZARDS

DEVELOPING FETUS

• Exposure to maternal smoking – the mother

itself is smoking

• Alcohol consumption

• Addictive drugs

• X- rays (first trimester) – radiation can

cause congenital defect

• Pesticides - can cause detoriation

NEWBORNS AND INFANTS

• Falling

• Suffocation in crib

• Choking from aspirated milk or objects

• Burns from hot water or other spilled hot

liquids

• Automobile accidents

• Crib or playpen injuries

• Electric shock or poisoning

Nursing responsibilities:

a. Approved car seat – should be placed at the

back of the car, facing rear part of the car.

b. Never leave an infant unattended

c. Use a good rail at the stairs

d. Screen doors

e. Provide large toys with no small detachable

object or parts

f. When feeding, position the client upright and

cut the food into a small piece and never

offer any nuts or popcorn. (slice the food in

lengthwise and cut it into small pieces.)

g. Check the temperature in bathing

h. Use playpen that has small netting

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Fundamentals of Nursing - LEC

SAFETY, SECURITY AND EMERGENCY

Safety is the fundamental concern of the nurses
Causes of injury: calamities, firearm, floods, and etc.,
Safety should be at the bedside and home FACTORS AFFECTING SAFETY
Age and development
- In adult; sensory neurological deficiency or diminished sensory neurological activity
Lifestyle
- Neighborhood or community
- environment
- Insufficient funding for safety equipment
- Risk takers who are prone to injury
Mobility and health status
Sensory – perceptual alterations
Cognitive awareness
- Awareness; is the ability to perceived environmental stimuli.
- Usually, people who are lacks in sleep, people who are semi-conscious and conscious, and disoriented who are prone to accidents/ injury.
- Ability to perceive environmental stimuli
Emotional state
- Stressful situation can reduce perception
- People who are depress are mostly prone to injuries
Ability to communicate
- Aphasic individual; leaves a person unable to communicate effectively with others.
- Illiterate individual; inability to read and write.
- Language barrier between two people
Safety awareness
- Pertains on how to use an equipment
- Ways on not to use drugs
- Preventive measures
environmental factors
- natural factors
  - bio terrorism; deliberately risk of bacteria and germs that can cause illness or death METHODS IN ASSESSING SAFETY
Nursing health history
Age and developmental level
General health status
Mobility status
Physiologic or perceptual deficits
Altered thought processes
Physical examination
Risk assessment tools
Home hazard appraisal COMMON POTENTIAL HAZARDS DEVELOPING FETUS
Exposure to maternal smoking – the mother itself is smoking
Alcohol consumption
Addictive drugs
X- rays (first trimester) – radiation can cause congenital defect
Pesticides - can cause detoriation NEWBORNS AND INFANTS
Falling
Suffocation in crib
Choking from aspirated milk or objects
Burns from hot water or other spilled hot liquids
Automobile accidents
Crib or playpen injuries
Electric shock or poisoning Nursing responsibilities: a. Approved car seat – should be placed at the back of the car, facing rear part of the car. b. Never leave an infant unattended c. Use a good rail at the stairs d. Screen doors e. Provide large toys with no small detachable object or parts f. When feeding, position the client upright and cut the food into a small piece and never offer any nuts or popcorn. (slice the food in lengthwise and cut it into small pieces.) g. Check the temperature in bathing h. Use playpen that has small netting

i. Place hazards out of reach and store it on the cabinets j. Once the diaper is soaked you have to change it to avoid rashes TODDLERS

Physical trauma from falling
Banging into objects
Getting cut by sharp objects
Automobile accidents
Burns
Poisoning
Drowning
Electric shock Nursing responsibilities: a) Keep the windows, balcony, and screen closed, if you have means change the bed in low position. b) Facing forward car seat. c) Keep any plastic bag away d) Teach the child not to run and ride a tricycle without a guardian or a parent. e) The handle pots should be facing inward f) Watch the kids in the tub and fence the pool to prevent drowning g) Cover any electric socket PRE SCHOOLERS
Injury from traffic
Playground equipment
Choking, suffocation
Poisoning
Drowning
Fire and burns
Harm from other people or animals Nursing responsibility: a. Instruct your pre – schooler not to walk in front of the b. Not to insert any small object in mouth or nose c. Teach them to check the treats or candies before eating d. Not to talk to stranger e. Instruct how to cross roads ADOLESCENTS
Vehicular accidenyts
Recreational accidents
Firearms
Substance abuse Nursing responsibilities: a. Complete driver’s lecture b. Never drive when drinking, ask assistance, and restrict the number of passengers c. Teach the individual to wear helmet d. Before entering any sports secure a medical assistance e. Proper use of sunblock f. Proper use of firearms g. Practice safe sex h. Prevent date – rape i. Open communication is the key to prevent injuries OLDER ADULTS
Falling
Burns
Pedestrian
Automobile accidents Nursing responsibilities: a. Instruct the patient to not wear skittled shoes or fitted shoes b. Encourage to exercise to maintain joint flexibility c. Make the area clean and tidy, avoid clutter d. If you have elderly you have to install safety grabs in the kitchen and in the bathroom. bedside commode and attach side rails to prevent falls e. Annual check up f. Make sure that all prescribed medication is being taken MEASURES TO PREVENT FALLS IN HOSPITAL
1in 4 older adults reported a fall
29 million older adult falls
24% of those falls required medical treatment or restricted activity for at least a day.

With or without aura.
Loud cry – unconscious – fall – tonic – clonic – sleep – stops after 3 to 5 minutes. PETIT MAL OR ABSENCE (DAYDREAMING)
Common in children
Blinking eyes – blank stare – twitching mouth – 5 to 10 seconds TRIGGERS SEIZURE
Drug reactions – mercury, lead or carbon monoxide
Epilepsy
Extreme fever
Infections – meningitis, encephalitis
Brain tumors SEIZURE PRECAUTION
Safety measures to protect clients from injury while having seizures.
EEG- EQUIPMENT NEEDED
Blankets or other linens to pad side rails
Oral suction equipment - collects excess saliva
Oral airway or padded tongue depressor
prevent biting his or her tongue, should not be placed when the jaw is clenched.
Oxygen equipment INTERVENTIONS PRIOR TO SEIZURE 1. Provide privacy – away from the nurse’s station 2. Avoid highly stimulating environment 3. Pad the side rails, headboard or foot part of the bed 4. Put oral suction equipment in place 5. Remove blunt or sharp objects 6. Loosen clothing – for easier breathing INTERVENTIONS DURING SEIZURE 1. Remain with the client and call assistance 2. If not in bed, assist to floor and protect head with your lap or pillow 3. Turn the client to side if possible – side lying to prevent aspiration 4. Insert airway between upper and lower teeth (never force if teeth are clenched) 5. Time the onset and duration of the seizure 6. Avoid restraints – never tie just be with the patients INTERVENTIONS AFTER SEIZURE

Apply oxygen by mask – so that it could not affect the patient’s brain
Administer ordered anticonvulsant e.g. Dilantin (phenytoin)
Suction as necessary RESTRAINTS

Device used to limit the physical activity of client or part of the body
Usually given to ensure immediate physical safety of the patient and the staff, and S.O
Make sure it is not easily removable and it should restrict the client LEGAL IMPLICATION OF RESTRAINTS BEHAVIOR MANAGEMENT STANDARD
Nurses may apply restraint but primary care provider must see the patient 1 hour after evaluation
A written order is only valid for 4 hours ( always check the doctor’s order once you give a medication)
Continual monitoring is needed when client is restrained ACUTE MEDICAL AND SURGICAL CARE STANDARD
Nurse may restrain the patient but needs to obtain written order withing 12 hours
All orders must be renewed daily GENERAL GUIDELINES
Reason and time period must be written in the order
PRN orders are prohibited; rationale – because only the convenience of the nurse is being cater
Restraints should only be used ONLY after all means of ensuring safety have been unsuccessful

Restraints cannot be used for staff convenience or client punishment THREE TYPES OF RESTRAINTS A. Intervention or device that hinders patient from moving or restricting the individual from contact of his / her body. e.g. hand mitten, belt, vest, bed restrain B. Use of medication to control or restrict behavior of the client (usually not included in standard treatment) C. Involuntary confinement of client alone in the room e.g., psychiatric ward CRITERIAS IN SELECTING RESTRAINTS 1. Restricts movement as little as possible – restraint only one part of the body 2. Does not interfere with treatment or health problem 3. Readily changeable – if the restraint got soiled must change it immediately 4. Safe – make sure that it is safe for the client and the placement of the restraints is on the bed 5. Least obvious to others DIFFERENT KINDS OF RESTRAINTS RESTRAINTS FOR ADULTS
Jacket restraints – used for confused or sedated clients
Belt restraints – used for clients being moved on stretchers or wheelchairs (to prevent fall during transfer)
Mitt or hand restraints – used to prevent confused clients using their hands or fingers
Limb restraints – for immobilization of limbs RESTRAINTS FOR INFANTS AND CHILDREN
Elbow restraints – used to prevent flexing their elbows to touch or reach their head or face
Mummy restraints – used to prevent movement during procedure
Crib nets – to prevent children from climbing out of the crib

ALTERNATIVES TO RESTRAINTS

1. Buddy nurses 2. Place unstable clients in a closely supervised area 3. Limit sedatives or psycho tropics 4. Stay with the client if the client is confused 5. Position beds at their lowest level 6. Rails should be ¾ length 7. Use rocking chairs 8. Try warm beverages, soft lights, back rub to relax client 9. Use environmental restraints GUIDELINES IN USING RESTRAINTS

Obtain consent
Ensure that order has been obtained within 24 hours
Assure client it is temporary and protective
Ensure that client can move as freely as possible
Ensure that restraint will not impede blood circulation
Pad bony prominences
Always tie a limb restraint with a knot (clove hitch)
Tie the ends of the body restraint to the part of the bed that moves to elevate the head
Assess skin integrity per agency protocol
Provide ROM exercises and skin care once restraint is removed
Assess and assist with basic needs
Reassess continued need for restraint
When restraint in temporarily removed, do not leave client unattended
Immediately report and record pertinent findings
Loosen restraint and exercise limb once cyanosis, pallor, coldness, tingling sensation, pain or numbness is noted or reported
Apply restraint in a normal anatomic position
Provide emotional support through touch and verbal means

Fundamentals of nursing, Summaries of Nursing

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Download Fundamentals of nursing and more Summaries Nursing in PDF only on Docsity!

Fundamentals of Nursing - LEC

SAFETY, SECURITY AND EMERGENCY

ALTERNATIVES TO RESTRAINTS