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Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 1
Unit – 10
PROMOTING SAFETY IN HEALTH CARE ENVIRONMENT
PHYSICAL ENVIRONMENT OF HOSPITAL
 Location: -The place should not be too much populated. And away from
populated area.
 The place should be elevated so that it is protected in case of any floods during
rainy season.
 It must be away from dust, smoke, bad odor, excessive noise, and traffic to
provide comfort to the patient.
 There must be an open space to provide proper light and ventilation to the
patient.
 Walls and floors: -
 It should be non absorbent, non-porous, shock adsorbing, fire resistant,
attractive and durable for safety of the patient.
 There should not be any cracks in the walls or floor for breeding of insects.
 The floor area should be adequate according to the number of beds
 Windows and doors: - should have adequate availability of natural light to all
the patients and proper ventilation.
 There should be an emergency door in the hospital to protect the patient and all
the staff in case of hazards.
 Rooms: - Rooms should be made in such a way that it facilitates fumigation and
it should not affect the health of patient.
 There should be a provision for the isolation of the patient who is having any
type of infection.
 The reception counter and the in-patient department should be near to the main
entrance of the hospital for easy access
 The kitchen and dining rooms should be away from the rest of the wards to
maintain hygiene and prevent any type of infection & the rooms should be fly
proof to prevent infection.
 The toilet/latrine should be clean and should be placed away from the general
ward.
 There must be timely fumigation done to prevent any type of infection to the
patient and to the public.
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 2
 Stairs and corridors: -
 There must be provision of rails along the sides of the open corridors and stairs
to prevent any type of accidents by falling.
 The stairs must be straight and not slippery and must be wide enough.
 Water supply: -
 There must be provision of safe and clean water supply to all the wards to
prevent any type of water borne infection.
 There must be of both hot and cold water according to the need of the patients.
 Water coolers and tanks should be cleaned regularly.
 Electric and electronic facility: -
 Provision of good electricity in all the wards and
 Must be repaired quickly if it is not working well. Ex. - Fans, coolers, and
heaters.
 Temperature: - The room temperature should be maintained.
 Bed: -
 There should be adequate space between the bed
 adequate number of bed and
 All bed should contain said rail to prevent risk of fall from the bed.
 Outside hospital environment: -
 Separate parking for the vehicle, and it should be away from the hospital
 The excreta and refusal should be disposed, collected and discarded safely to
prevent spread of infection.
 There must be facility of drainage system.
 There must be control of anthropoids, vermin, and animal pests
 There must not be any type of standing water near to the hospitals. Stagnation
of water to be prevented.
 There should be regular spraying of medicine and fumigation to prevent
breeding or vermin’s and pests.
 Other consideration: -
 Aseptic technique should be used for handling infectious patient like using
gloved, masks, and gown.
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 3
 The articles used by infectious patients should be kept separately like bed pan,
bed, linen, pillows, pillow cover, etc. they could be washed separately with an
antiseptic solution and dried in proper sunlight and ironed to kill the
microorganism.
ROLE OF NURSE IN-PROVIDING SAFE AND CLEAN PHYSICAL
ENVIRONMENT
Nurse is the personal who is responsible for the health of the patient in the
hospital. She will provide the curative services to the patient but side by side she must
provide preventive services which helps to avoid the further complications.
Therefore the Nurse is responsible for providing safe and clean physical
environment by:
1. Unit cleaning: - Carbonization of unit with antiseptic solution like Savlon, or
Dettol of all the article properly that come in contact with the patient such as
bed side locker, cardiac table, bed IV stand etc.
2. Fumigation of room: - Fumigate the unit after specific period to keep the
environment free from infection.
3. Care of bed linen: -
 Changed completely on bath days, usually once or twice a weekly, according to
policy
 Pillowcases may be changed more frequently
 Soiled linens should be replaced immediately.
 Top sheet may be used to replace bottom sheet
 Soiled linen folded inward
 Do not shake linen
 Soiled linen held away from uniform
 Soiled linen placed in covered linen hamper after removal from bed.
4. Arrangement of proper Physical set up of unit: - Arrange for different
equipment, room set-ups, Safety features in the resident’s room, furniture, and
equipment etc.
5. Guidelines for arrangement of unit:-
 Don't rearrange items without permission
 Respect private space.
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 4
 Knock on door prior to entering room.
 Speak prior to opening a drawn curtain.
 Close curtains to provide privacy when doing a procedure
 Assure personal items are convenient to promote independence and safety.
 Store clothing and personal belongings in closet
6. Furniture needs to be arranged in patient unit are: -
 Bed
 Bed Side Stand,
 Chairs,
 Call Signal,
 Bathroom,
 Television,
 Waste basket,
 Storage space for clothing
 Over-Bed Table,
 Bedside Stand Top,
 Privacy Curtains,
 Handrails In
 Towel Rack,
 Telephone,
 Reading Lamp
7. Measure to maintain temperature: -
 Room should be sufficiently warm enough
 A room temperature ranging from 68˚F to 72˚F is considered comfortable
 Older people often become hypothermic so sweaters, lap robes and shawls
should be provided for warmth.
 Drapes, shades and screens used to block sun drafts.
 Extra blankets used when sleeping
8. Measure to maintain humidity: -
 Humidity is the amount of moisture in the air it affects the evaporation of
moisture from the skin.
 In it common for humidity to fall well below 30%, Humidity of 40-60% is
considered comfortable.
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 5
 A humidifier will rapidly increase the moisture in the air and help maintain a
comfortable level of humidity.
 Place a bowl of water close to a heating system
 Run a dehumidifier.
 Use exhaust fans, open a window (if the air outside is dry), keep doors closed.
 Tell patient to take shorter showers to lower humidity
9. Provide ventilation: -
 Movement of air is called ventilation. It maintains proper humidity.
 Exhaust air shall be located directly above the patient bed on the ceiling or on
the wall
 No of patient in the unit should be limited with appropriate distance between
the patients for proper ventilation.
10.Preventing bad odor: -
 Good ventilation helps to control odors
 Wastes should be removed and discarded as soon as possible.
 Good personal hygiene should be practices
11.Prevent noise pollution: -
 Patient easily disturbed by unfamiliar noises. The degree of nose may be
reduced by various methods.
 Staff should avoid loud laughter and loud talking.
 Noise caused by friction may be reduced by lubrication
 Use of rubber tires and castors for the trolleys and wheel chairs reduce the
sound when moving furniture
 Make eco-proof rooms avoid dropping objects control the radio television etc.
 During the rest hours loud talking and heavy walking with shoes within the
hearing of ill persons should be avoided.
12.Safe and comfortable lighting: -
 Adjust light to meet needs
 Use shades and drapes to control bright, natural light.
 Provide adequate light for reading
 Control glare and shadowed areas if possible.
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 6
13.Keeping floors maintained: -
 The floor area should be adequate according to the number of beds.
 The floor should be clean, but not slippery from wax.
 No throw rugs
 Floors should be in good repair.
14.Maintaining cleanliness: -
 Remove meal trays and dishes after use.
 Remove crumbs and clean eating areas after use.
 Removing dirt and dust controlled by housekeeping
 Waste containers emptied promptly.
15.Controlling pest: -
 Remove open food left in units that will attract ants and roaches, as well as
microorganisms.
 Family and visitors should consult with charge nurse before bringing in food for
residents
 Ensure proper disposal of food and waste materials.
 Regular spraying of medicines and fumigation to prevent breeding of vermin's
and pests
 The cracks in the wall and floors should be repaired quickly to prevent breeding
of vermin's and pests.
REDUCTION OF PHYSICAL HAZARDS: FIRE, ACCIDENTS
Generally, hospital is considered as a place where the sick and injured are
coming for care like other industries, hospital is also at risk for many physical hazards.
Hazards may occur in mechanical plants, hospital kitchen, and laundry and
diagnostic center etc.
People, who are vulnerable to hospital hazards, are grouped into three
categories:
1. Patient who is ill,
2. The staff and
3. the visitors
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 7
 Preventive measures for the occurrence of fire: -
1. Hospital should have and implement the policy related to preventing the
hospital hazards.
2. Material used for building hospital should be flames proof.
3. In order to prevent accidental fires, there must be proper selection and
installation of equipment's.
4. Sufficient space should be provided around the mechanical equipment and
electrical services.
5. Electric device, appliance and equipment should installed, operated and
maintenance in accordance with manufacturer's recommendation
6. Hospital refrigerator containing flammable liquids must be placed safely in
hospital.
7. Installation of automatic fire detection and alarm system can prevent accidental
fire.
8. All hospital buildings should be provided with an internal fire alarm system.
9. There must be provision of emergency doors in the hospital to protect the
patient and all other staff in case of fire hazards.
10.Every hospital must have effective communication system. This will help in
intimating the authorities to take needy action. Fire extinguishers must be
available in various vulnerable areas of hospital
11.All elevators/lift have emergency signal system as well as safety devices
12."No smoking" sign must be displayed in areas where patient in on oxygen
therapy
 Prevention of accidents in a hospital: -
1. Hospital should have and implement the policy related to preventing
accidents
2. Nurse must be aware of the hospital policy as well as sound knowledge base.
3. At the time of admission, nurse must orient the patient about his immediate
surrounding design of the unit. Patient should be able to call for assistance.
Teach them how to use equipment's in around bed, important safety
precaution.
4. Equipment's used in the hospital is quiet, durable, simple to operate and
easily repairable
5. While giving care to the patient, nurse must ensure the safe working place.
She must make use of good body mechanics.
6. Report regarding accidents should be given to the safety committee of
hospital in instituting the preventive measure.
7. Report regarding any accident's injury must be given to the staff members.
This will help in taking immediate measures
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 8
8. Most common type of accidents in hospital is the fall, falling from bed, chair,
while walking out of bathroom are examples of most common accidents.
 Important Steps to be taken to prevent Fall: -
1. Make the client aware about the dangerous situations. E.g., in order to
ensure safe transfer of patient level of bed can be adjusted.
2. Non slippery material should be used in the floor.
3. Floor should be washed and polished timely. Clean the spillage from the
floor immediately in order to prevent slipping.
4. Keep the necessity item within the reach of the client.
5. Always accompany the disoriented patient.
6. Lock the wheel chair while shifting the patient to the wheel chair.
7. Use other safety measure such as putting side rails, restraining, or using belt
according the situation to prevent accidents.
FALL RISK ASSESSMENT
A fall risk assessment is used to find out whether patient have a low, moderate,
or high risk falling. It is mostly done for older adults.
The assessment usually includes: -
1. An initial screening: - This includes a series of questions about overall health
and previous falls history or problems with balance, standing, and/or walking.
2. A set of tasks, known as fall assessment tools: - These tools tests strength,
balance, and gait (Walking Style) of the patient.
Initial screening questions are: -
1. Have you fallen in the past year?
2. Do you feel unsteady when standing or walking?
3. Are you worried about falling?
 Fall assessment tools are:-
1. Timed Up-and-Go (Tug): - This test checks patient gait (Walking Style).
Patient will start in a chair, stand up, and then walk for about 10 feet at regular pace.
Then he will sit down again, Health care provider will check how long it takes to
do this. If it takes 12 seconds or more, it may mean at higher risk for a fall
2. 30-Second Chair Stand Test: - This test checks strength and balance. Patient
will sit in a chair with arms crossed over his chest. When provider says "go." he will
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 9
stand up and sit down again. Patient will repeat this for 30 seconds. Provider will
count how many times he can do this. A lower number may mean at higher risk
for a fall. The specific number that indicates a risk depends on age.
3. 4-Stage Balance Test: - This test checks how well patient can keep his balance.
Patient will stand in four different positions, holding each one for 10 seconds.
The positions will get harder as he goes,
 Position – 1 - Stand with feet side-by-side.
 Position - 2 - Move one foot halfway forward, so the instep is touching the
big toe of other foot
 Position – 3 - Move one foot fully in front of the other, so the toes are
touching the heel of other foot.
 Position – 4 - Stand on one foot
If patient can't hold position 2 or position 3 for 10 seconds or he can't stand on one leg
for 5 seconds, it may mean at higher risk for a fall
 Fall assessment scale: -
The Morse Fall Scale (MFS) is a brief fall risk assessment tool used widely in acute
care settings. The MFS assesses a patient's fall risk upon admission, following a
change in status and at discharge or transfer to a new setting. Prevention
interventions are based on the Morse Fall Scale score.
The Morse Fall Scale (MFS)
Item Response
History of Falling immediate or within
3 months
No = 0
Yes = 25
Secondary Diagnosis No = 0
Yes = 15
Ambulatory Aid None, Bed Rest, Wheel Chair, Nurse =
0 Crutches, Cane, Walker = 15
Furniture = 30
IV/ Heparin Lock No = 0
Yes = 20
Gait/ Transferring Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20
Mental status
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 10
Score and interpretation of the Morse Fall Scale (MFS)
Risk Factor MFS Score Action
No risk 0-24 None
Low risk 25-50 Initiate Standard fall
prevention interventions
High risk >51 Initiate High Risk fall
prevention interventions
SAFETY DEVICES
Definition of safety devices: - “A device that is used during a surgical, diagnostic,
dental other medical procedure or a voluntary mechanical support used to achieve
proper body position, balance, or alignment to allow greater freedom of mobility than
would be possible without the mechanical support or other devices to protect patients
that are not restrictive” (helmet, code alert, bed alarms, camera monitoring, lap
boards, etc.). Safety devices do as meet requirement for restraint monitoring and
documentation.
RESTRAINTS
“A restraint is any manual method, physical or mechanical device, material or
equipment that immobilizes or reduces the ability of a patient to move his/her arms,
legs, body or head freely” (e.g. -Safe keeper bed, Posey bed, safety mitt, soft limb
restraint), or a restraint is a drug or medication when it is used as a restriction to
manage the patient's behavior or restrict the patient's freedom of movement and is not
standard treatment or dosage for the patient's condition A restraint does not include
devices, such as orthopedically prescribed devices, surgical dressings or bandages,
protective helmets, or other methods that involve the physical holding of a patient for
the purpose of conducting routine physical examinations or tests, or to protect the
patient from falling out of bed, or to permit the patient to participate in activities
without the risk of physical harm., side rails, airways, trapeze etc.
 Purpose of restraints: -
1. For behavioral control
2. To prevent fall and avoid injury
3. To reduce the risk of injury to others.
4. To immobilize the part
5. To prevent interruption of therapy
 Indication: -
1. Behavior that is putting themselves at risk of harm
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 11
2. Behavior that is putting others at risk of harm
3. Treatment by a legal order, for example, under the Mental Health Act 2007
4. Requiring urgent life-saving treatment
5. Needing to be maintained in secure settings
 Types of restraints: -
Restraints may be classified in to four types. They are:
1. Environmental restraint,
2. Physical restraint,
3. Mechanical restraint,
4. Chemical restraint.
1. Environmental restraint: - Environmental restraint limits the area where
patient can move freely.
2. Physical restraint: - Physical restraint involves having one or more persons
restrain patient through body contact alone.
3. Chemical restraint: - Chemical restraint may be any medicine that helps
patient to calm down and relax.
4. Mechanical restraint: - Mechanical restraint involves the use of devices placed
on the wrists, ankles, or chest.
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 12
TYPES AND PURPOSES OF MECHANICAL RESTRAINTS AND METHODS
OF APPLICATIONS
S. No. Type and Purposes Methods of Application
1  Mummy restraints are
immobilize the arms and legs of
an infant or a small child for a
brief period of time
 It is used when a child's
 Head or neck is to be
examined or treated
 Jugular puncture is to be
done
 Scalp vein is to be inserted
 Gastric lavage or gavage is
to be done
 Place blanket on examination
table on diagonal. Fold down
one comer
 Place child on the blanket with
shoulders in line with the fold.
Use firm gentle motions
Continually speak soothingly
to child
 Firmly pull one comer of the
blanket over the infant's body
and tuck under the opposite.
Pull the bottom up and secure
ends of the blanket with tape to
keep in place
 Do not cover child's face.
Ensure that the wrapping is
not obstructing child's airway
or circulation. Monitor airway
and circulation throughout
restraint.
2  Modified mummy restraint:-
 Modified version of the
mummy restraint with chest
exposed.
 It is used when the child's
chest or groin is to be
examined
Instead of wrapping the blanket
corner over the mummy chest,
promptly wrap blanket around the
infant arms and under back. Roll
the edges around the legs and
secure with tape. Ensure that the
wrap does not obstruct circulation
of the limbs
3  Jacket restraint:-
Jacket restraint is used to help
child remain flat in bed in a supine
position or to prevent the child
from falling from a high chair,
wheel chair, or other conveyance
o Obtain a jacket of the
appropriate
o Place child's arms through the
arm holes
o Secure jacket on child. Most
jacket have ties in the back or
wrap the ties across the back
and loop through the side
o Secure ties of jacket to a non-
movable part of the bed frame
or wheel chair Use a knot that
can be quickly released
o Reposition the child, release
restraints and perform room
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 13
every 1 to 2 hours.
 Complication:
o Strangulation through
pressure of a restraint that has
slipped out of place and
encircled neck of the child.
4 Abdominal restraint:-
Abdominal restraint is used to hold
the infant in a supine position on
the bed.
 It must not be applied so
securely that respiratory
movements of the abdomen art
inhibited
 The restraint tied to the frame
of the crib is the danger of
entanglement of the child in
the strings, resulting in
possible suffocation or
impairment of circulation
 It is important that the
restraints be applied correctly
and that the child be observed
frequently when such
restraints are used
5 Elbow restraints:-
 Elbow restraint is used to
hold the elbow in an
extended position so that the
infant cannot reach the face
 This is of special importance
if the child had
o Surgery of face or head
o Eczema or the other skin
disorders
o Scalp vein needle is in place.
 The elbow restraint is made
of a double piece of muslin or
other strong material, with
pockets sewn into which
tongue blades, pieces of x-ray
films or other string cards
are inserted
o Obtain appropriately sized
elbow restraints that keep arms
straight with either tongue
depressors or commercial
plastic devices
o Pad child's skin under restraint
with towel or gauze padding
o Secure restraint using ties
o Remove restraints and check
skin condition at least every 2
hours. Provide room and
document
 Complications:
o Axillary nerve damage
o Thrombus formation
o Axillary injury
6 Extremity/ clove hitch
restraint:-
 Extremity restraint is used
to immobilize one or more
extremities
 Strip of gauze bandage of 2
inches wide and 1 yards long,
o Spread the gauze strip on the
bed with one end towards the
nearer side of the bed
o Place the gauze waddling
around wrist or ankle as
necessary
o Place circles of the restraints
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 14
cotton waddling covered
with gauze, cut to 2 inches
wide and long enough to
encircle the patient wrist or
ankle.
around the padding on the
extremity.
o Then the ends of the gauze are
tied to the frame of the crib.
o Care must be exercised to
prevent cutting off the
circulation and yet have the
tight enough not to slip over
the infant's hand or foot.
 Complications:
o Impaired circulation
o Coldness
o Discoloration
7 Crib with dome restraint:-
If an infant or toddler is capable of
Climbing over the crib sides, a crib
net or a plastic dome (bubbler top)
may be used to keep the child safely
in bed.
And also used for burns patient to
prevent irritation by preventing
direct contact of clothes over bum
wound.
A crib net should be applied
smugly over the top If an infant or
toddler is capable of and sides of
the crib and tied to the frame The
knots used must be of the type that
can be untied quickly in case of
emergency
8 Mitten restraints:
It is used for children and confused
patient to prevent them using their
fingers or hands for removing
tubes, dressing and other
appliances used in treatment.
Principles of Applying Restraint
1. The reason for applying restraint must be explained to both the patient and the
patient attendant
2. When applying the restraint and periodically during the period of restraint, the
nurse should talk soothingly to the patient to provide stimulation and diversion.
3. When restraints are applied, they should be put on effectively, yet as loosely as
possible to prevent interferences with respirations and circulations so that the
patient can move safely to some degree.
4. Sufficient padding must be used under extremity restraint to prevent skin
irritation
5. The ties on restraints should be attached to the frame of the bed instead of side
rails to prevent traction on the restraint or injury to the patient when the bed
rail is raised and lowered
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 15
6. Restraints must be checked every 15 to 30 minutes to determine whether they
are constricting the respirations or circulation in any way.
7. Periodically, at least every 2 hours the patient should be removed from the
restraints
8. Before the restraints are reapplied, the patient position should be changed to
improve physiologic functioning
Potential Risks and Side Effects of Restraint use
Risk and side effect of restraint
1.
Psychological/Emotional risk
2.
Physical risk
 Increased agitation and hostility
 Feelings of humiliation, loss of
dignity
 Increased confusion
 Fear
 Pressure ulcers, skin trauma
 Decreased muscle mass, tone,
strength, endurance
 Contractures, loss of balance &
Dislocation/fracture
 Reduced heart and lung capacity
 Physical discomfort, increased pain
 Increased constipation, increased
risk of fecal impaction
 Increased incontinence and urinary
stasis
 Obstructed and restricted circulation
 Reduced appetite, Dehydration
 Impaired Circulation
Legal implications and consent
1. Doctors order physician order in must to implement restraint
2. Informed consent it is must to get consent from the patient or guardian
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 16
Restraint order
Situational restraints Medical restraints Behavioral restraints
Initiation of Restraints
(ALWAYS after
alternatives tried)
Obtain written or verbal
order within 12 hours of
initiation, physician exam
within 24 hours Every 24
hours
May apply in emergency,
but get doctor order with
in 1 hour. Physician must
do face-to-face assessment
within 1 hour of restraint
initiation.
Renewing Order Every 24 hours In accordance with
following limits up to a
total of 24 hours
4 hrs for adults 18 and up
o 2 hrs for children 9-17
years of age
o 1 hr for children nine
and under
NURSES RESPONSIBILITIES
 Restraint:
1. The patient in restraint or with safety devices will have a call light within reach
or other means of obtaining assistance or making needs known
2. All restraints and devices are to be applied to a body part but should not
interfere with circulation or cause pressure on a nerve. Restraint must be
released every 2 hours and reapply as necessary.
3. Hygiene and toileting needs are assessed and provided as needed with each
assessment.
4. If an upper and lower extremity requires restraint, apply to one upper and
opposite lower extremity if possible.
5. Tie restraints securely and out of reach of the patient. For bedridden patients
the restraint should be tied under the bed, to the bed frame only, not to the side
rails, and tied for easy release by healthcare providers
6. An order to discontinue the restraint will be written in the medical record by a
doctor when the restraint is no longer indicated.
7. While removing remove one restraints at a time
8. Skin fold should be clean and dry before application of restraints
9. Ensure that there are no wrinkles in restraints
10.Do not apply linen restrain with a regular knot
11.Never use restraint over IV site.
Kuldeep Vyas
Associate Professor
Dept. – Community Health Nursing 17
 Safety devices:
1. Safety interventions and devices may be implemented after thorough
assessment and documentation by a nurse.
2. The physician will be notified of the implementation of the safety device in
morning rounds.
3. The patient's condition will be assessed and documented every shift by an RN,
while a safety device is in use.
OTHER SAFETY DEVICES
Side rails: - These are safety measures that come under the category of environmental
restraint. These are attached to both sides of the bed to prevent client from getting
out or failing out of bed. Side rails must be kept raised in bed of the client who has
altered level of consciousness.
Indication for side rains:
1. Client with altered level of consciousness
2. The elderly clients
3. The debilitated clients
4. Children
Alarms: - Alarms are one of the patient safety devices. It alerts the nurses for towards
potential dangers facing patients. Alarms or bells should place near patient bed and at
toilet in an approachable distance.
Trapeze: - When a patient is bed ridden, it's very important that their positions are
changed to avoid accumulating bed sores and skin deterioration. The bed trapeze units
are designed to assist individuals to changing positions in bed and transferring them
in and out of bed. The triangular-shaped trapeze bar for bed helps gives patients
something to grasp to reposition themselves and prepare for bed transfer
Non-skid slipper: - Anti-slip stripes are designed at the sole of the slipper, these
friction- enhanced slippers prevent accidental slipping, which is perfects the patient
from slippery floor, bathrooms etc.
Grab bar: - a graspable bar attached to the wall in a shower or near a bathtub as
assistance to a bather in maintaining balance or getting in and out.
Thank You…

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Promoting Safety in Healthcare Environments

  • 1. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 1 Unit – 10 PROMOTING SAFETY IN HEALTH CARE ENVIRONMENT PHYSICAL ENVIRONMENT OF HOSPITAL  Location: -The place should not be too much populated. And away from populated area.  The place should be elevated so that it is protected in case of any floods during rainy season.  It must be away from dust, smoke, bad odor, excessive noise, and traffic to provide comfort to the patient.  There must be an open space to provide proper light and ventilation to the patient.  Walls and floors: -  It should be non absorbent, non-porous, shock adsorbing, fire resistant, attractive and durable for safety of the patient.  There should not be any cracks in the walls or floor for breeding of insects.  The floor area should be adequate according to the number of beds  Windows and doors: - should have adequate availability of natural light to all the patients and proper ventilation.  There should be an emergency door in the hospital to protect the patient and all the staff in case of hazards.  Rooms: - Rooms should be made in such a way that it facilitates fumigation and it should not affect the health of patient.  There should be a provision for the isolation of the patient who is having any type of infection.  The reception counter and the in-patient department should be near to the main entrance of the hospital for easy access  The kitchen and dining rooms should be away from the rest of the wards to maintain hygiene and prevent any type of infection & the rooms should be fly proof to prevent infection.  The toilet/latrine should be clean and should be placed away from the general ward.  There must be timely fumigation done to prevent any type of infection to the patient and to the public.
  • 2. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 2  Stairs and corridors: -  There must be provision of rails along the sides of the open corridors and stairs to prevent any type of accidents by falling.  The stairs must be straight and not slippery and must be wide enough.  Water supply: -  There must be provision of safe and clean water supply to all the wards to prevent any type of water borne infection.  There must be of both hot and cold water according to the need of the patients.  Water coolers and tanks should be cleaned regularly.  Electric and electronic facility: -  Provision of good electricity in all the wards and  Must be repaired quickly if it is not working well. Ex. - Fans, coolers, and heaters.  Temperature: - The room temperature should be maintained.  Bed: -  There should be adequate space between the bed  adequate number of bed and  All bed should contain said rail to prevent risk of fall from the bed.  Outside hospital environment: -  Separate parking for the vehicle, and it should be away from the hospital  The excreta and refusal should be disposed, collected and discarded safely to prevent spread of infection.  There must be facility of drainage system.  There must be control of anthropoids, vermin, and animal pests  There must not be any type of standing water near to the hospitals. Stagnation of water to be prevented.  There should be regular spraying of medicine and fumigation to prevent breeding or vermin’s and pests.  Other consideration: -  Aseptic technique should be used for handling infectious patient like using gloved, masks, and gown.
  • 3. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 3  The articles used by infectious patients should be kept separately like bed pan, bed, linen, pillows, pillow cover, etc. they could be washed separately with an antiseptic solution and dried in proper sunlight and ironed to kill the microorganism. ROLE OF NURSE IN-PROVIDING SAFE AND CLEAN PHYSICAL ENVIRONMENT Nurse is the personal who is responsible for the health of the patient in the hospital. She will provide the curative services to the patient but side by side she must provide preventive services which helps to avoid the further complications. Therefore the Nurse is responsible for providing safe and clean physical environment by: 1. Unit cleaning: - Carbonization of unit with antiseptic solution like Savlon, or Dettol of all the article properly that come in contact with the patient such as bed side locker, cardiac table, bed IV stand etc. 2. Fumigation of room: - Fumigate the unit after specific period to keep the environment free from infection. 3. Care of bed linen: -  Changed completely on bath days, usually once or twice a weekly, according to policy  Pillowcases may be changed more frequently  Soiled linens should be replaced immediately.  Top sheet may be used to replace bottom sheet  Soiled linen folded inward  Do not shake linen  Soiled linen held away from uniform  Soiled linen placed in covered linen hamper after removal from bed. 4. Arrangement of proper Physical set up of unit: - Arrange for different equipment, room set-ups, Safety features in the resident’s room, furniture, and equipment etc. 5. Guidelines for arrangement of unit:-  Don't rearrange items without permission  Respect private space.
  • 4. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 4  Knock on door prior to entering room.  Speak prior to opening a drawn curtain.  Close curtains to provide privacy when doing a procedure  Assure personal items are convenient to promote independence and safety.  Store clothing and personal belongings in closet 6. Furniture needs to be arranged in patient unit are: -  Bed  Bed Side Stand,  Chairs,  Call Signal,  Bathroom,  Television,  Waste basket,  Storage space for clothing  Over-Bed Table,  Bedside Stand Top,  Privacy Curtains,  Handrails In  Towel Rack,  Telephone,  Reading Lamp 7. Measure to maintain temperature: -  Room should be sufficiently warm enough  A room temperature ranging from 68˚F to 72˚F is considered comfortable  Older people often become hypothermic so sweaters, lap robes and shawls should be provided for warmth.  Drapes, shades and screens used to block sun drafts.  Extra blankets used when sleeping 8. Measure to maintain humidity: -  Humidity is the amount of moisture in the air it affects the evaporation of moisture from the skin.  In it common for humidity to fall well below 30%, Humidity of 40-60% is considered comfortable.
  • 5. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 5  A humidifier will rapidly increase the moisture in the air and help maintain a comfortable level of humidity.  Place a bowl of water close to a heating system  Run a dehumidifier.  Use exhaust fans, open a window (if the air outside is dry), keep doors closed.  Tell patient to take shorter showers to lower humidity 9. Provide ventilation: -  Movement of air is called ventilation. It maintains proper humidity.  Exhaust air shall be located directly above the patient bed on the ceiling or on the wall  No of patient in the unit should be limited with appropriate distance between the patients for proper ventilation. 10.Preventing bad odor: -  Good ventilation helps to control odors  Wastes should be removed and discarded as soon as possible.  Good personal hygiene should be practices 11.Prevent noise pollution: -  Patient easily disturbed by unfamiliar noises. The degree of nose may be reduced by various methods.  Staff should avoid loud laughter and loud talking.  Noise caused by friction may be reduced by lubrication  Use of rubber tires and castors for the trolleys and wheel chairs reduce the sound when moving furniture  Make eco-proof rooms avoid dropping objects control the radio television etc.  During the rest hours loud talking and heavy walking with shoes within the hearing of ill persons should be avoided. 12.Safe and comfortable lighting: -  Adjust light to meet needs  Use shades and drapes to control bright, natural light.  Provide adequate light for reading  Control glare and shadowed areas if possible.
  • 6. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 6 13.Keeping floors maintained: -  The floor area should be adequate according to the number of beds.  The floor should be clean, but not slippery from wax.  No throw rugs  Floors should be in good repair. 14.Maintaining cleanliness: -  Remove meal trays and dishes after use.  Remove crumbs and clean eating areas after use.  Removing dirt and dust controlled by housekeeping  Waste containers emptied promptly. 15.Controlling pest: -  Remove open food left in units that will attract ants and roaches, as well as microorganisms.  Family and visitors should consult with charge nurse before bringing in food for residents  Ensure proper disposal of food and waste materials.  Regular spraying of medicines and fumigation to prevent breeding of vermin's and pests  The cracks in the wall and floors should be repaired quickly to prevent breeding of vermin's and pests. REDUCTION OF PHYSICAL HAZARDS: FIRE, ACCIDENTS Generally, hospital is considered as a place where the sick and injured are coming for care like other industries, hospital is also at risk for many physical hazards. Hazards may occur in mechanical plants, hospital kitchen, and laundry and diagnostic center etc. People, who are vulnerable to hospital hazards, are grouped into three categories: 1. Patient who is ill, 2. The staff and 3. the visitors
  • 7. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 7  Preventive measures for the occurrence of fire: - 1. Hospital should have and implement the policy related to preventing the hospital hazards. 2. Material used for building hospital should be flames proof. 3. In order to prevent accidental fires, there must be proper selection and installation of equipment's. 4. Sufficient space should be provided around the mechanical equipment and electrical services. 5. Electric device, appliance and equipment should installed, operated and maintenance in accordance with manufacturer's recommendation 6. Hospital refrigerator containing flammable liquids must be placed safely in hospital. 7. Installation of automatic fire detection and alarm system can prevent accidental fire. 8. All hospital buildings should be provided with an internal fire alarm system. 9. There must be provision of emergency doors in the hospital to protect the patient and all other staff in case of fire hazards. 10.Every hospital must have effective communication system. This will help in intimating the authorities to take needy action. Fire extinguishers must be available in various vulnerable areas of hospital 11.All elevators/lift have emergency signal system as well as safety devices 12."No smoking" sign must be displayed in areas where patient in on oxygen therapy  Prevention of accidents in a hospital: - 1. Hospital should have and implement the policy related to preventing accidents 2. Nurse must be aware of the hospital policy as well as sound knowledge base. 3. At the time of admission, nurse must orient the patient about his immediate surrounding design of the unit. Patient should be able to call for assistance. Teach them how to use equipment's in around bed, important safety precaution. 4. Equipment's used in the hospital is quiet, durable, simple to operate and easily repairable 5. While giving care to the patient, nurse must ensure the safe working place. She must make use of good body mechanics. 6. Report regarding accidents should be given to the safety committee of hospital in instituting the preventive measure. 7. Report regarding any accident's injury must be given to the staff members. This will help in taking immediate measures
  • 8. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 8 8. Most common type of accidents in hospital is the fall, falling from bed, chair, while walking out of bathroom are examples of most common accidents.  Important Steps to be taken to prevent Fall: - 1. Make the client aware about the dangerous situations. E.g., in order to ensure safe transfer of patient level of bed can be adjusted. 2. Non slippery material should be used in the floor. 3. Floor should be washed and polished timely. Clean the spillage from the floor immediately in order to prevent slipping. 4. Keep the necessity item within the reach of the client. 5. Always accompany the disoriented patient. 6. Lock the wheel chair while shifting the patient to the wheel chair. 7. Use other safety measure such as putting side rails, restraining, or using belt according the situation to prevent accidents. FALL RISK ASSESSMENT A fall risk assessment is used to find out whether patient have a low, moderate, or high risk falling. It is mostly done for older adults. The assessment usually includes: - 1. An initial screening: - This includes a series of questions about overall health and previous falls history or problems with balance, standing, and/or walking. 2. A set of tasks, known as fall assessment tools: - These tools tests strength, balance, and gait (Walking Style) of the patient. Initial screening questions are: - 1. Have you fallen in the past year? 2. Do you feel unsteady when standing or walking? 3. Are you worried about falling?  Fall assessment tools are:- 1. Timed Up-and-Go (Tug): - This test checks patient gait (Walking Style). Patient will start in a chair, stand up, and then walk for about 10 feet at regular pace. Then he will sit down again, Health care provider will check how long it takes to do this. If it takes 12 seconds or more, it may mean at higher risk for a fall 2. 30-Second Chair Stand Test: - This test checks strength and balance. Patient will sit in a chair with arms crossed over his chest. When provider says "go." he will
  • 9. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 9 stand up and sit down again. Patient will repeat this for 30 seconds. Provider will count how many times he can do this. A lower number may mean at higher risk for a fall. The specific number that indicates a risk depends on age. 3. 4-Stage Balance Test: - This test checks how well patient can keep his balance. Patient will stand in four different positions, holding each one for 10 seconds. The positions will get harder as he goes,  Position – 1 - Stand with feet side-by-side.  Position - 2 - Move one foot halfway forward, so the instep is touching the big toe of other foot  Position – 3 - Move one foot fully in front of the other, so the toes are touching the heel of other foot.  Position – 4 - Stand on one foot If patient can't hold position 2 or position 3 for 10 seconds or he can't stand on one leg for 5 seconds, it may mean at higher risk for a fall  Fall assessment scale: - The Morse Fall Scale (MFS) is a brief fall risk assessment tool used widely in acute care settings. The MFS assesses a patient's fall risk upon admission, following a change in status and at discharge or transfer to a new setting. Prevention interventions are based on the Morse Fall Scale score. The Morse Fall Scale (MFS) Item Response History of Falling immediate or within 3 months No = 0 Yes = 25 Secondary Diagnosis No = 0 Yes = 15 Ambulatory Aid None, Bed Rest, Wheel Chair, Nurse = 0 Crutches, Cane, Walker = 15 Furniture = 30 IV/ Heparin Lock No = 0 Yes = 20 Gait/ Transferring Normal, bed rest, immobile = 0 Weak = 10 Impaired = 20 Mental status
  • 10. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 10 Score and interpretation of the Morse Fall Scale (MFS) Risk Factor MFS Score Action No risk 0-24 None Low risk 25-50 Initiate Standard fall prevention interventions High risk >51 Initiate High Risk fall prevention interventions SAFETY DEVICES Definition of safety devices: - “A device that is used during a surgical, diagnostic, dental other medical procedure or a voluntary mechanical support used to achieve proper body position, balance, or alignment to allow greater freedom of mobility than would be possible without the mechanical support or other devices to protect patients that are not restrictive” (helmet, code alert, bed alarms, camera monitoring, lap boards, etc.). Safety devices do as meet requirement for restraint monitoring and documentation. RESTRAINTS “A restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely” (e.g. -Safe keeper bed, Posey bed, safety mitt, soft limb restraint), or a restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not standard treatment or dosage for the patient's condition A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm., side rails, airways, trapeze etc.  Purpose of restraints: - 1. For behavioral control 2. To prevent fall and avoid injury 3. To reduce the risk of injury to others. 4. To immobilize the part 5. To prevent interruption of therapy  Indication: - 1. Behavior that is putting themselves at risk of harm
  • 11. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 11 2. Behavior that is putting others at risk of harm 3. Treatment by a legal order, for example, under the Mental Health Act 2007 4. Requiring urgent life-saving treatment 5. Needing to be maintained in secure settings  Types of restraints: - Restraints may be classified in to four types. They are: 1. Environmental restraint, 2. Physical restraint, 3. Mechanical restraint, 4. Chemical restraint. 1. Environmental restraint: - Environmental restraint limits the area where patient can move freely. 2. Physical restraint: - Physical restraint involves having one or more persons restrain patient through body contact alone. 3. Chemical restraint: - Chemical restraint may be any medicine that helps patient to calm down and relax. 4. Mechanical restraint: - Mechanical restraint involves the use of devices placed on the wrists, ankles, or chest.
  • 12. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 12 TYPES AND PURPOSES OF MECHANICAL RESTRAINTS AND METHODS OF APPLICATIONS S. No. Type and Purposes Methods of Application 1  Mummy restraints are immobilize the arms and legs of an infant or a small child for a brief period of time  It is used when a child's  Head or neck is to be examined or treated  Jugular puncture is to be done  Scalp vein is to be inserted  Gastric lavage or gavage is to be done  Place blanket on examination table on diagonal. Fold down one comer  Place child on the blanket with shoulders in line with the fold. Use firm gentle motions Continually speak soothingly to child  Firmly pull one comer of the blanket over the infant's body and tuck under the opposite. Pull the bottom up and secure ends of the blanket with tape to keep in place  Do not cover child's face. Ensure that the wrapping is not obstructing child's airway or circulation. Monitor airway and circulation throughout restraint. 2  Modified mummy restraint:-  Modified version of the mummy restraint with chest exposed.  It is used when the child's chest or groin is to be examined Instead of wrapping the blanket corner over the mummy chest, promptly wrap blanket around the infant arms and under back. Roll the edges around the legs and secure with tape. Ensure that the wrap does not obstruct circulation of the limbs 3  Jacket restraint:- Jacket restraint is used to help child remain flat in bed in a supine position or to prevent the child from falling from a high chair, wheel chair, or other conveyance o Obtain a jacket of the appropriate o Place child's arms through the arm holes o Secure jacket on child. Most jacket have ties in the back or wrap the ties across the back and loop through the side o Secure ties of jacket to a non- movable part of the bed frame or wheel chair Use a knot that can be quickly released o Reposition the child, release restraints and perform room
  • 13. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 13 every 1 to 2 hours.  Complication: o Strangulation through pressure of a restraint that has slipped out of place and encircled neck of the child. 4 Abdominal restraint:- Abdominal restraint is used to hold the infant in a supine position on the bed.  It must not be applied so securely that respiratory movements of the abdomen art inhibited  The restraint tied to the frame of the crib is the danger of entanglement of the child in the strings, resulting in possible suffocation or impairment of circulation  It is important that the restraints be applied correctly and that the child be observed frequently when such restraints are used 5 Elbow restraints:-  Elbow restraint is used to hold the elbow in an extended position so that the infant cannot reach the face  This is of special importance if the child had o Surgery of face or head o Eczema or the other skin disorders o Scalp vein needle is in place.  The elbow restraint is made of a double piece of muslin or other strong material, with pockets sewn into which tongue blades, pieces of x-ray films or other string cards are inserted o Obtain appropriately sized elbow restraints that keep arms straight with either tongue depressors or commercial plastic devices o Pad child's skin under restraint with towel or gauze padding o Secure restraint using ties o Remove restraints and check skin condition at least every 2 hours. Provide room and document  Complications: o Axillary nerve damage o Thrombus formation o Axillary injury 6 Extremity/ clove hitch restraint:-  Extremity restraint is used to immobilize one or more extremities  Strip of gauze bandage of 2 inches wide and 1 yards long, o Spread the gauze strip on the bed with one end towards the nearer side of the bed o Place the gauze waddling around wrist or ankle as necessary o Place circles of the restraints
  • 14. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 14 cotton waddling covered with gauze, cut to 2 inches wide and long enough to encircle the patient wrist or ankle. around the padding on the extremity. o Then the ends of the gauze are tied to the frame of the crib. o Care must be exercised to prevent cutting off the circulation and yet have the tight enough not to slip over the infant's hand or foot.  Complications: o Impaired circulation o Coldness o Discoloration 7 Crib with dome restraint:- If an infant or toddler is capable of Climbing over the crib sides, a crib net or a plastic dome (bubbler top) may be used to keep the child safely in bed. And also used for burns patient to prevent irritation by preventing direct contact of clothes over bum wound. A crib net should be applied smugly over the top If an infant or toddler is capable of and sides of the crib and tied to the frame The knots used must be of the type that can be untied quickly in case of emergency 8 Mitten restraints: It is used for children and confused patient to prevent them using their fingers or hands for removing tubes, dressing and other appliances used in treatment. Principles of Applying Restraint 1. The reason for applying restraint must be explained to both the patient and the patient attendant 2. When applying the restraint and periodically during the period of restraint, the nurse should talk soothingly to the patient to provide stimulation and diversion. 3. When restraints are applied, they should be put on effectively, yet as loosely as possible to prevent interferences with respirations and circulations so that the patient can move safely to some degree. 4. Sufficient padding must be used under extremity restraint to prevent skin irritation 5. The ties on restraints should be attached to the frame of the bed instead of side rails to prevent traction on the restraint or injury to the patient when the bed rail is raised and lowered
  • 15. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 15 6. Restraints must be checked every 15 to 30 minutes to determine whether they are constricting the respirations or circulation in any way. 7. Periodically, at least every 2 hours the patient should be removed from the restraints 8. Before the restraints are reapplied, the patient position should be changed to improve physiologic functioning Potential Risks and Side Effects of Restraint use Risk and side effect of restraint 1. Psychological/Emotional risk 2. Physical risk  Increased agitation and hostility  Feelings of humiliation, loss of dignity  Increased confusion  Fear  Pressure ulcers, skin trauma  Decreased muscle mass, tone, strength, endurance  Contractures, loss of balance & Dislocation/fracture  Reduced heart and lung capacity  Physical discomfort, increased pain  Increased constipation, increased risk of fecal impaction  Increased incontinence and urinary stasis  Obstructed and restricted circulation  Reduced appetite, Dehydration  Impaired Circulation Legal implications and consent 1. Doctors order physician order in must to implement restraint 2. Informed consent it is must to get consent from the patient or guardian
  • 16. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 16 Restraint order Situational restraints Medical restraints Behavioral restraints Initiation of Restraints (ALWAYS after alternatives tried) Obtain written or verbal order within 12 hours of initiation, physician exam within 24 hours Every 24 hours May apply in emergency, but get doctor order with in 1 hour. Physician must do face-to-face assessment within 1 hour of restraint initiation. Renewing Order Every 24 hours In accordance with following limits up to a total of 24 hours 4 hrs for adults 18 and up o 2 hrs for children 9-17 years of age o 1 hr for children nine and under NURSES RESPONSIBILITIES  Restraint: 1. The patient in restraint or with safety devices will have a call light within reach or other means of obtaining assistance or making needs known 2. All restraints and devices are to be applied to a body part but should not interfere with circulation or cause pressure on a nerve. Restraint must be released every 2 hours and reapply as necessary. 3. Hygiene and toileting needs are assessed and provided as needed with each assessment. 4. If an upper and lower extremity requires restraint, apply to one upper and opposite lower extremity if possible. 5. Tie restraints securely and out of reach of the patient. For bedridden patients the restraint should be tied under the bed, to the bed frame only, not to the side rails, and tied for easy release by healthcare providers 6. An order to discontinue the restraint will be written in the medical record by a doctor when the restraint is no longer indicated. 7. While removing remove one restraints at a time 8. Skin fold should be clean and dry before application of restraints 9. Ensure that there are no wrinkles in restraints 10.Do not apply linen restrain with a regular knot 11.Never use restraint over IV site.
  • 17. Kuldeep Vyas Associate Professor Dept. – Community Health Nursing 17  Safety devices: 1. Safety interventions and devices may be implemented after thorough assessment and documentation by a nurse. 2. The physician will be notified of the implementation of the safety device in morning rounds. 3. The patient's condition will be assessed and documented every shift by an RN, while a safety device is in use. OTHER SAFETY DEVICES Side rails: - These are safety measures that come under the category of environmental restraint. These are attached to both sides of the bed to prevent client from getting out or failing out of bed. Side rails must be kept raised in bed of the client who has altered level of consciousness. Indication for side rains: 1. Client with altered level of consciousness 2. The elderly clients 3. The debilitated clients 4. Children Alarms: - Alarms are one of the patient safety devices. It alerts the nurses for towards potential dangers facing patients. Alarms or bells should place near patient bed and at toilet in an approachable distance. Trapeze: - When a patient is bed ridden, it's very important that their positions are changed to avoid accumulating bed sores and skin deterioration. The bed trapeze units are designed to assist individuals to changing positions in bed and transferring them in and out of bed. The triangular-shaped trapeze bar for bed helps gives patients something to grasp to reposition themselves and prepare for bed transfer Non-skid slipper: - Anti-slip stripes are designed at the sole of the slipper, these friction- enhanced slippers prevent accidental slipping, which is perfects the patient from slippery floor, bathrooms etc. Grab bar: - a graspable bar attached to the wall in a shower or near a bathtub as assistance to a bather in maintaining balance or getting in and out. Thank You…