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ATI Client Safety
| Question | Answer |
|---|---|
| nurse responsibilities | providing safety & prevent injury |
| factors affecting ability to protect self | -age (young/old) -mobility -cognitive 7 sensory awareness -emotional state -ability to communicate -lifestyle & safety awareness |
| be aware of | -assess clients & their environment for safety using risk assessment tools -encourage pt to speak up & be involved/take active role in health care & preventing errors -create culture of checks & balances to avoid errors working under stress |
| be aware of | -communicate risk factors &plan of care w/ clients, family & other health care providers via dry erase board in room or other protocol -protocols for responding to dangerous situations -quality care priorities |
| be aware of | -use current evidence to promote culture of safety -disaster plan of facility, chain of command & common terminology -documenting incidents & responses per agency policy -location of material safety data sheets & hazardous chemicals in environment |
| provider | -asses, report & document client allergies & provide care that avoids exposure to allergens -equipment should be used only after safety inspection & adequate instruction |
| falls | -older adults inc risk for falls due to dec strength, impaired mobility & balance & endurance limitation combined w/ dec sensory perception -other clients at risk w. dec visual acuity, generalized weakness, urinary frequency, gait/balance problems & cogi |
| falls | -clients at greater risk when more than one risk factor present -prevention of falls is major nursing priority -all pts should be assessed for fall risk at admission & based on assessment preventative measures should be implemented |
| prevention of falls | -complete fall risk assessment upon admission & at regular intervals -plan individually (pt w/ orthostatic hypotension to avoid getting up too fast |
| prevention of falls | -make sure client knows how to use call light & in reach & encourage use -respond to call light in timel manner -use fall risk alerts (wristband, sign) -provide regular toileting & orientation of confused clients as needed |
| prevention of falls | -ensure adequate lighting -orient client to setting & ensure know how to use all assisitive devices & can locate items -place pt at risk near nursing station -ensure bedside tables & frequently used items are w/in reach |
| prevention of falls | -maintain bed in low position -keep bed rails up in low position -avoid use of all 4 bed rails |
| prevention of falls | -provide client w. nonskid footwear & bath mats -use gait belts & additional safety equipment as needed when moving clients -keep floor free of clutter w/ clear path to bathroom -keep asssitive devices near |
| prevention of falls | -educate client & family/caregivers on identified risks & plan of care (more likely to call for assistance) -lock wheels on bed, wheelchairs &carts to prevent rolling dring stops or moving -use chair/bed sensors for clients art risk gettign up unattende |
| falls | report & document all incidents per policy |
| seizure | sudden surge of electrical activity in the brain -partial (one side of brain) -generalized (entire brain) |
| seizure precautions | measures to protect client from injury should a seizure occur w. history or involve entire body or unconsciousness -ensure rescue equip is at bedside including oxygen & oral airway, suction & padding for siderails -saline lock for pt at risk for gener |
| seizure precations | -inspect environment that may cause injury in event of a seizure & remove if not necessary for treatment -asist w/ ambulation & transferring to reduce risk for injury -advise family & caregivers not to put anything in pt mouth |
| seizure precautions | -advise caregivers & family not restrain in event of a seizure -lower bed to floor -protect head -remove nearby furniture -put pt in side w/ head flexed slightly fwd & loosen clothing if possible |
| in event of seizure | -stay w/ client & call for help -administer meds as prescribed -note duration of seizure, sequence & type of movement |
| after seizure | -assess mental status, oxygen saturation & vital signs -explain what happened to client & provide comfort & quiet environment to recover -document seizure in record & description of event & report to provider |
| seclusion & restraints | -nurses must know & follow federal/state/facility policies for use of restraints -seclusion rooms/restraints may be authorized in some cases --seclusion/restraints should be ordered for the shortest duration necessary & only IF restrictive measures aren |
| seclusion & restraints | -client may request temporary seclusion in cases in which environment is disturbing or seems too stimulating -restraints can be physical or chemical |
| seclusion/restraint never used for | -convenience of staff -punishment for client -pt extremely physically/mentally unstable -pt who can't tolerate dec stimulation of seclusion room |
| restraints should | -NEVER INTERFERE W/ TREATMENT -restrict movement as little as necessary to ensure safety -fit properly & be as discreet as possible -be easily removed or changed to dec chance of injury & provide greatest level of dignity |
| restraints | tr all other less restrictive means first -must be prescribed by provider based on face to face assessment -nurse can use in emergency but obtain prescription as soon as possible |
| restraint prescription | include reason, type, location, how long used & types of behaviors demonstrated by client -renewal limited 2 4 hr (adult)/ 2 (children)/1 hr under 9 yr -renew w/in 24 hours if needed -PRN prescriptions for restraints aren't allowed |
| nurse responsibilities | -assess skin integrity & provide skin care every 2 hr -offer food & fluid -provide means for hygiene & elimination -monitor VS -offer ROM of extremities |
| restraints | -always explain need to pt & family & is needed to ensure safety -obtain signed consent from client or guardian if required -remove or replace frequently to ensure good circulation to area & allow full ROM to restricted limbs |
| restraints | -pad bony prominences -use quick release knot to tie to bed frame where it won't tighten when bed is moved -make sure loose enough for ROM & fit two fingers btw -regularly asses need for continued use -never leave unattended w/o restraint |
| document | -events/behavior that led to seclusion/restraint -actions taken to avoid -time restraint were applied/removed -type of restrain used 7 location -behavior while restrained |
| document | -type & frequency of care -condition of body part restrained -response when removed -med administered |
| fires | usually due to problems related to electrical or anesthetic equipment |
| fire safety staff be aware of | -location of exits, alarms, fire extinguishers & oxygen turn off valves -ensuring fire doors aren't blocked -knowing evacuation plan for unit & facility |
| fire response RACE | Rescue: protect clients in close proximity to fire by evacuating them to a safer location -ambulatory clients can walk unattended -Alarm:activate alarm system & report fire details & location per policy |
| fire response RACE | -Contain: close doors & windows, turn off sources of devices -clients on life support ventilate w/ bag mask -Extinguish: if possible using appropriate extinguisher |
| class A extinguisher | paper, wood, upholstery, rags & other types of trash fires |
| class B extinguisher | flammable liquids & gas fires |
| class C | electrical fires |
| PASS | Pull pin Aim at base of fire Squeeze levers Sweep from side to side covering fire |
Created by:
dbishop23