This chapter reviews four skills and one procedure: fall prevention in health care agencies; designing a restraint-free environment; applying physical restraints; fire, electrical, and chemical safety; and seizure precautions.
Health care provided in a safe environment, in which nurses practice safety-related skills, reduces the risk for illness and injury and contains the costs of health care by preventing extended lengths of treatment and/or hospitalization, improving or maintaining a patient’s functional status, and increasing the patient’s sense of well-being.
As a health care provider it is essential to share information about any patient injury, learn from errors, and participate in the trending and evaluation of those errors.
Being hospitalized places patients at risk for injury in an unfamiliar and confusing environment. The experience is usually at least minimally frightening.
It is a nurse’s responsibility to diligently protect all patients, regardless of their socioeconomic status and cultural background.
Health care providers must be particularly attentive to communication during assessment.
[Ask students: how can being attentive during communication with a patient aid assessment? Discuss: for example, nurses must use approaches that recognize a patient’s cultural background, so appropriate questions can be raised to clearly reveal health behaviors and risks. You enhance a patient’s safety by considering him or her in light of the whole person and seeing each care situation through “the patient’s eyes,” not just from your perspective.]
You enhance a patient’s safety by considering him or her in light of the whole person and seeing each care situation through “the patient’s eyes” and not just your perspective. Here are some specific patient-centered safety guidelines:
Patients should be emotionally supported and empowered to express their values and preferences and ask questions without being inhibited by their nurses.
When restraints are needed, clarify their meaning to the patient and the family. Some patients may view restraining of an older adult as disrespectful. Similarly some survivors of war or persecution view restraints as imprisonment or punishment.
Collaborate with family members in accommodating a patient’s cultural perspectives regarding restraints. Removing restraints when family members are present shows respect and caring for a patient.
Be familiar with agency restraint protocol. Identify potential areas for negotiation with a patient’s and family’s preferences such as using a mitten versus arm restraints.
Inform patients and family members of the reasons a patient is at fall risk. It is important for patients to know their risks, the options that exist to promote safety, and the consequences of not following precautions.
Young neurological patients with impaired gait and balance or medium to severe motor disability are at an increased risk of falling. Patients who are relatively independent and still involved in challenging activities have an increased exposure to fall risk. Improperly fitted canes and walkers, wheelchair characteristics, and environmental hazards are significant environmental risk factors.
Long-term care settings, multifactorial interventions (using multiple fall prevention strategies) significantly reduce falls and the number of recurrent fallers.
Older adults should be routinely screened for relevant risk factors for falling. These individuals will most likely benefit from a fall prevention program targeted to their risk factors (e.g., frailty, polypharmacy, multi-morbidity, vitamin D status, and home hazards. Not all fall prevention strategies are useful for all patients.
Single exercise interventions (e.g., Tai Chi) can significantly reduce numbers of falls among older adults with and without cognitive impairment in institutional or noninstitutional settings. Such programs also reduce the rate of falls that lead to medical care.
Vitamin D and calcium supplementation, home visits, and adjustments within the living environment can reduce the risk of falls among older adults in noninstitutional settings. Including an occupational therapist or physical therapist in a home-hazard assessment may have added benefit.
Exercise programs designed to prevent falls in older adults, including planned group exercise, also seem to prevent injuries caused by falls, including the most severe ones. Such programs also reduce the rate of falls leading to medical care.
The Agency for Healthcare Research and Quality (2013c) cites factors for health care organizations to consider when implementing best practices for fall prevention. Some factors that make fall prevention challenging include:
Fall prevention must be balanced with other priorities for a patient. A patient is usually not in the hospital because of falls, so attention is naturally directed elsewhere. Yet a fall in a sick patient can be disastrous and prolong the recovery process.
Fall prevention must be balanced with the need to mobilize patients. It may be tempting to leave patients in bed to prevent falls, but patients need to transfer and ambulate to maintain their strength and to avoid complications of bed rest.
Fall prevention is one of many activities needed to protect patients from harm during their hospital stay. Health care staff must consider how to prevent falls while maintaining focus on other priorities, such as infection control.
Fall prevention is interdisciplinary. Nurses, physicians, pharmacists, physical therapists, occupational therapists, patients, and families need to cooperate to prevent falls.
Fall prevention needs to be individualized. Each patient has a different set of fall risk factors, so care must thoughtfully address each patient's unique needs.
1. Accurate patient identification is crucial to safety before any procedures are begun.
2. Safety begins with a patient’s immediate environment. The call light/bed control system allows patients to adjust bed position and signal caregivers. Explain to patients and visiting family members how to operate a call system correctly.
3. Always be alert to conditions within a patient’s environment that pose risks for patient injury.
[Ask students: what are some examples of environmental conditions that cause risk for patient injury? Discuss: hazards along walking paths, liquid spilled on the floor, poorly functioning equipment.]
4. Follow policy and procedure in the institution where you work. Do not use work-arounds when performing skills or procedures. A work-around occurs when a person improvises or works around intended work practices.
5. Communicate clearly to other health care providers the plan of care, including procedures to be performed, procedures completed, and patient response. Communicate all important test results to the right staff person in a timely manner.
[Ask students: how many inpatient falls do you think occur in the United States every year? Discuss: each year approximately 700,000 to 1,000,000 people in the United States fall in hospitals.]
A fall may result in fractures, bruises, lacerations, or internal bleeding, leading to increased diagnostic tests and treatments, extended hospital stays, and discharge to rehab or long-term care instead of home.
Research shows that approximately one-third of falls can be prevented.
Falls are multifactorial.
Individual intrinsic factors such as co-morbidities, muscle weakness, and urinary incontinence increase the risk of falling in a hospital and community setting. Transient factors that can change over time such as postural hypotension, polypharmacy, and use of high-risk medications also are fall risks.
Extrinsic fall risks such as a health care agency’s environment (e.g., poor lighting, slippery flooring, improper use of assist devices also contribute to falls.
As a nurse, your role is to assess these factors in each patient and then determine the most suitable preventive interventions that match the patient’s risks and behavior.
The Centers for Medicare and Medicaid Services (CMS) have identified select serious adverse events as “Never Events” (i.e., adverse events that should never occur in a health care setting).
One of these “Never Events” is hospital-acquired injury from external causes (e.g., fractures, head injury, crushing injury), as in the case of falls. The CMS denies hospitals higher payment for any hospital-acquired condition resulting from or complicated by the occurrence of a “Never Event.”
[Review Box 14-1: Components of Evidence-Based Fall Prevention Interventions in Hospital Settings.
[Ask students: how can fall prevention strategies be targeted to specific patient risks? Discuss: for example, if a patient has postural hypotension, the nurse might choose a low bed and the practice of dangling the patient for 5 minutes on the side of the bed before trying to ambulate. Or a patient with a history of urinary incontinence might be given a bedside commode to use.]
Wheelchair-related injuries from falls include fractures, concussions, dislocations, amputations, and serious head and spinal injuries. An example of a wheelchair characteristic that increases risk for falls is having smaller and harder front wheels that cause a chair to tip when striking uneven terrain.
Caregivers are also at risk for injury by not handling patients correctly or not asking for assistance. Injuries can occur while caregivers transfer patients who are agitated, fearful, unsteady, or too weak to transfer.
Tripping over the front foot or leg rest and leaning over the back of the wheelchair to engage or disengage the wheel lock are common sources of injury.
The Joint Commission’s Center for Transforming Healthcare aims to prevent inpatient falls with injury. Seven hospitals in the United States worked with the center and successfully reduced total number of falls and falls with injury by creating awareness among staff, empowering patients to take an active role in their own safety, using a validated fall risk assessment tool, engaging patients and their families in the fall safety program, providing hourly rounding that includes proactive toileting, and engaging all hospital staff to ensure no patient walks unaccompanied.
It is important for nurses to identify patients’ fall risks and communicate these risks to patients, their visiting family members, and members of the health care team.
Patient-centered care is important, with nurses making patients their partners in recognizing fall risks and taking preventive action. Fall prevention strategies must be targeted to specific patient risks. For example, if a patient has postural hypotension, a nurse might choose a low bed and the practice of dangling the patient for 5 minutes on the side of the bed before trying to ambulate. Or a patient with a history of urinary incontinence might be given a bedside commode to use.
Note that the tasks performed to prevent falls can be delegated.
[Ask students: what are some examples of safety precautions? Discuss: bed locked in low position and nonskid footwear.]
Examples of behaviors that are precursors to falls include disorientation, wandering, and anxiety.
Correct answer: C
Rationale: “L” is location of the fall. Location associated with a fall provides further details on causative factors and how future falls can be prevented.
Record fall risk assessment findings, specific interventions used to prevent falls, and patient’s response to teach-back in nurses’ notes and or/care plan on flow sheet or nurses’ notes in EHR or chart.
Report to health care personnel specific risks to patient’s safety and measures taken to minimize risks.
If a fall occurs, document a description of the fall as given by patient or you as witness. Be sure to include baseline assessment, any injuries noted, tests or treatments given, follow-up care, and additional safety precautions taken after fall. Complete an agency’s adverse event report.
The Centers for Disease Control and Prevention (CDC) has resources on fall prevention at http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html.
Encourage patients to have annual vision and hearing examinations. Adaptive devices such as a hearing aid or glasses are sometimes necessary or need modification.
Emphasize to patients the need to always look ahead when ambulating and to use good posture.
Instruct patients on how to use assistive devices and keep them in good repair.
Pediatric
CDC recommendations for parents and children:
Play safely. Be sure that the playground equipment that a child uses is properly designed and maintained, and that there is a safe, soft landing surface below.
Make home safety improvements. Use home safety devices such as guards on windows that are above ground level, stair gates, and guardrails.
Keep sports safe. Be sure that a child wears protective gear such as wrist guards, knee and elbow pads, and a helmet for biking or skating when playing active sports.
Supervision is key. Supervise young children at all times around fall hazards, whether at home or out to play.
Keep side rails of hospital beds down to allow toddlers and preschoolers easy exit and to decrease the need to crawl over the rails (Hockenberry and Wilson, 2015).
When caring for infants, keep a hand on a child when you turn away from the bedside.
Gerontological
Interventions to improve confidence in balance have yielded benefits, including multicomponent behavioral group interventions and exercise (including tai chi), which increases lower body strength and dynamic balance.
Correct answer: A
Rationale: Patients who take less than 20 seconds to complete the test demonstrate adequate independent mobility. The patient who takes longer than 30 seconds is dependent and is at risk for a fall.
Restraints can be physical or chemical.
Current federal and state regulations have standards for restraint use.
[Ask students: what are physical and chemical restraints? Discuss: a physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to freely move his or her extremities, body, or head. A drug may be considered a chemical restraint when it is given to manage behavior or restrict freedom of movement and is not part of the standard treatment for a patient’s condition (i.e., wrist/jacket restraints, medications). Why do you think these can cause complications?]
Patients at risk for falls or wandering present special safety challenges in attempts to create a restraint-free environment.
Wandering is the meandering, aimless, or repetitive locomotion that exposes a patient to harm and often conflicts with boundaries, limits, or obstacles. This is a common problem in patients who are confused or disoriented. Interrupting a wandering patient can increase distress.
Common strategies to manage wandering include environmental adaptations, use of signaling tags, distraction, social interaction, regular exercise, and circular design of a patient care unit. More frequent observation of patients, involvement of family during visitation, and frequent reorientation are also helpful measures.
The skills of assessing patient behaviors and orientation to the environment and determining the type of restraint-free interventions to use cannot be delegated to NAP.
[Ask students: what are some examples of patient behaviors and actions that the NAP should report to the nurse? Discuss: confusion, getting out of bed unassisted, combativeness.]
[Ask students: why is it important to record the interventions taken to mediate behaviors? Discuss.]
Teaching
Teach family members ways to involve patient in their visits, keeping patient appropriately stimulated.
Teach the family how to adapt the home environment (see Chapter 42) to minimize patient wandering.
Gerontological
Keep older adults active and ambulatory to increase endurance and function.
Reminiscence helps older adults remain oriented.
Home care
Patients at risk for self-injury or violence to others need intensive supervision. Family and health care providers need to recognize this and take appropriate preventive measures.
Have family members set up an area in the home where it is safe for an older adult to wander.
Physical or chemical restraints should be the last resort and should be used only when reasonable alternatives fail.
Restraints are most commonly used in hospitals to prevent disruption of therapy, such as pulling out intravenous (IV) tubes or removing urinary catheters.
The Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and the National Quality Forum (NQF) all have standards regarding restraints.
The CMS released revisions to the Medicare conditions of participation, outlining standards for the safe use of restraints in hospitals and defining patients’ rights and choices regarding restraints. It requires that a restraint be used only under the following circumstances:
To ensure the immediate physical safety of the patient, a staff member, or others.
When less restrictive interventions have been ineffective.
In accordance with a written modification to the patient’s plan of care.
When it is the least restrictive intervention that will be effective to protect the patient, staff members, or others from harm.
In accordance with safe and appropriate restraint techniques as determined by hospital policies.
It is discontinued at the earliest possible time.
Research has shown that patients suffer fewer injuries if left unrestrained.
A patient’s or family member’s informed consent is necessary in the long-term care setting.
The Food and Drug Administration (FDA) regulates restraints as medical devices and requires manufacturers to label them “prescription only.” Most patient deaths in the past have resulted from strangulation from a vest or jacket restraint. Numerous agencies no longer use vest restraints. For these reasons this text does not describe their use.
The skills of assessing a patient’s behavior and level of orientation, the need for restraints, the appropriate restraint type, and the ongoing assessments required while a restraint is in place cannot be delegated to NAP. Applying and routinely checking a restraint can be delegated to NAP. The Joint Commission requires training in first aid for anyone who monitors patients in restraints.
The nurse directs NAP to:
Review correct placement of the restraint and how to routinely check the patient’s circulation, skin condition, and breathing.
Review when and how to change a patient’s position and provide range-of-motion (ROM) exercises, toileting, and skin care.
Instruct NAP to notify nurse immediately if there is a change in the level of patient agitation, skin integrity, circulation of extremities, or patient breathing.
Record consent when required.
[Ask students: what are examples of routine observations that should be made every 15 minutes? Discuss: skin color, pulses, sensation, vital signs, behavior.]
Record purpose for restraint, the type and location, the time applied, the time ending the restraints, and the routine observations made every 15 minutes (e.g., skin color, pulses, sensation, vital signs, behavior) in the flow sheets or nurses notes.
Teaching
Explain thoroughly to patient and family the use of restraints. Caution family against removing, repositioning, or retying restraint.
Pediatric
Limit the use of restraints to clinically appropriate and adequately justified situations (e.g., examination or treatment that involves the head and neck) after using all appropriate alternatives. Remain with the infant while restrained, and remove the restraint immediately after treatment is completed.
When a child needs to be restrained for a procedure, it is best if the person applying the restraint is not the child’s parent or guardian.
When an infant or a small child requires a restraint, a papoose board with straps or a mummy wrap using a blanket or sheet effectively controls his or her movements.
Gerontological
Restrained older adults often respond with anger, fear, depression, humiliation, demoralization, discomfort, and resignation.
Consider the risks for older adults associated with restraints (e.g., pressure ulcers, impaired strength, and balance). All of the complications of immobility are amplified, leading to greater risk for functional decline.
Physical and chemical restraints are an environmental risk factor for the development of delirium (Young and Inouye, 2007). Being restrained causes a level of stress, combined with the effects of illness, medications, and co-morbidities to trigger delirium to develop.
Home care
A health care provider’s order is needed for use of a restraint in the home. Provide clear, detailed instructions to the family caregiver, with a return demonstration of restraint application. Do not send a restraint home with the family unless the device is necessary to protect the patient from injury. Carefully assess the family caregiver for competency and understanding of intent for using the restraint.
[Ask students: what other source of fire do you think poses a risk in a health care setting? Discuss: although smoking is not allowed in health care facilities, smoking-related fires still pose a significant risk because of unauthorized smoking in beds or bathrooms. In the home setting, oxygen-related fires are a risk for patients requiring continuous oxygen therapy.]
Biomedical devices must have a safety inspection sticker with an expiration date, and all electrical equipment should have a three-prong plug for grounding.
Hospital engineers should inspect any electrical devices a patient brings to the hospital; discourage patients from bringing nonessential devices.
If a fire occurs, health care personnel report the exact location of the fire, contain it, and extinguish it only if it is safe and possible. All personnel are then mobilized to evacuate patients if needed.
Most agencies have fire doors that are held open by magnets and close automatically when a fire alarm sounds. Fire doors should never be blocked.
Chemicals in many medications, anesthetic gases, cleaning solutions, and disinfectants are potentially toxic. They injure the body after skin or mucous membrane contact, ingestion, or vapor inhalation.
A Safety Data Sheet (SDS) form contains information about the properties of the particular chemical and information for handling the substance in a safe manner.
When an event occurs, a nurse leads the health care team in an emergency response.
In the event of fire, the health care team collaborates with the local fire department.
When an electrical or chemical event occurs, the team collaborates with the safety officer of the agency.
Seizures are sudden, abnormal, and excessive electrical discharges from the brain that change motor or autonomic function, consciousness, or sensation.
Seizures may be epileptic or nonepileptic.
The two basic types of seizures are partial (simple and complex) and generalized.
Status epilepticus involves 5 minutes or more of either continuous clinical or electrographic (shown on an electroencephalogram [EEG]) seizure activity or recurrent seizure activity without recovery between seizures.
Status epilepticus can be convulsive (rhythmic jerking of the extremities) or nonconvulsive (activity on EEG).
Traditionally patients who have a seizure are immediately placed in the side-lying position to prevent aspiration of oral secretions. This is still a standard of practice. However, more recent findings suggest that in the case of patients who go into status epilepticus, the side-lying position may cause more harm than good.
Patients who have been rolled onto their side during a major motor seizure are at greater risk for self-injury, such as a dislocated shoulder.
Because patients do not breathe during a generalized tonic-clonic seizure, they are not at high risk for aspiration until the seizure ends. Patients usually take a deep breath immediately after such a seizure and should be rolled over onto their side immediately after motor activity stops.
The Neurocritical Care Society practice guidelines for patients with status epilepticus include
Within first 2 minutes, establish and protect the airway when patient loses consciousness.
Provide noninvasive airway protection and gas exchange with head positioning, keeping the airway patent and administering oxygen.
Measure vital signs: O2 saturation, BP, HR immediately and every 2 minutes.
Establish an intravenous route for emergency medications.
When seizure begins to subside, intubation (insertion of an artificial airway) should be attempted only if gas exchange is compromised or if patient is believed to have increased intracranial pressure Cross reference verified.
Refer to your agency policy for positioning guidelines.
The task of assessing a patient on seizure precautions cannot be delegated to nursing assistive personnel (NAP).
However, the skills for making a patient’s environment safe and the ongoing care of patients on seizure precautions can be delegated.
The nurse instructs NAP about:
The patient’s prior seizure history and factors that may trigger a seizure.
Taking immediate action in the event of a seizure by protecting the patient from falling or injury, not trying to restrain the patient and not placing anything into the mouth.
Informing the nurse immediately when seizure activity develops.
Observing the patient’s seizure pattern.
Record in nurses’ notes and EHR what you observed before, during, and after seizure. Provide detailed description of the type of seizure activity and sequence of events (e.g., presence of aura [if any], level of consciousness, vital signs and oxygen saturation, color, movement of extremities, incontinence, patient’s status immediately following seizure, and time frame of events)
Record treatments administered: establishment of IV, fluid infusing, airway.
Alert primary health care provider immediately as seizure begins. Status epilepticus is an emergency situation requiring immediate medical therapy
[Ask students: what are some examples of the observations you should record?” Discuss: presence of aura (if any), level of consciousness, color, movement of extremities, incontinence, patient’s status immediately following seizure, and time frame of events.]
Teaching
Inform an adult with an unprovoked first seizure that their seizure recurrence risk is greatest early within the first 2 years (21% to 45%). The patient’s physician is likely to order immediate antiepileptic drug (AED) therapy to reduce recurrence risk within the first 2 years.
Patients need to know that antiepileptic medications help control epilepsy. Warn them to take prescribed medications regularly. They should never stop medications suddenly because this precipitates seizures.
Advise patient to avoid alcohol, which is often incompatible with anticonvulsive medications and intensifies central nervous system depression.
Proper oral hygiene and frequent dental care are necessary when patient takes phenytoin long term, because gingival hyperplasia is a side effect.
Encourage patient to wear a medical alert bracelet or to carry an identification card noting the presence of seizure disorder and listing medications taken.
Fatigue, stress, and illness can potentiate seizures. Teach patients to eat a balanced diet at regular intervals, to get adequate sleep, and to consult their health care provider promptly when ill.
A seizure disorder usually imposes driving limitations. It is recommended that a waiting period of 1 seizure-free year elapse before patient attempts to drive or operate dangerous equipment (see state law).
Pediatric
Teach parents what they should observe during seizures because many times these events are present at the onset.
Child should wear a medical alert bracelet noting presence of a seizure disorder.
Encourage children with severe atonic seizures to wear helmets to protect them when they fall. A child with tonic-clonic seizures should have side rails padded and suction and oxygen available to manage respiratory secretions for airway maintenance.
Gerontological
Older adults often have symptoms that make it difficult to recognize a seizure disorder. Confusion lasting several days, receptive and expressive speech problems, and unusual behaviors are often the result of a seizure.
Older adults metabolize antiepileptics more slowly, allowing drugs to accumulate, possibly resulting in toxicity.
If a patient has dentures, do not try to remove them during a seizure. If they loosen, tilt the head slightly forward and remove them after the seizure.
Home care
Instruct family members about steps to take when patient experiences a seizure.
Assess patient’s home for environmental hazards that could increase the risk of injury in the event of a fall.
Until a seizure condition is well controlled (usually for at least 1 year), make sure that patient does not take a tub bath or engage in activities such as swimming unless a knowledgeable family member is present.
Refer patient to the Epilepsy Foundation or a similar community resource for support groups.
Correct answer: B
Rationale: The head rails should remain up when the patient is having a seizure. The head rails help protect the patient from striking his head on furniture near the bed, and help keep the patient in the safest place during the seizure—in the bed.
