Chapter 38: Client Safety Bonnie M. Wivell, MS, RN, CNS.

Chapter 38: Client SafetyChapter 38: Client Safety

Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS

JCAHO 2010 National Patient JCAHO 2010 National Patient Safety GoalsSafety Goals

Identify patients correctly – 2 identifiersIdentify patients correctly – 2 identifiers Improve staff communication – read back, not using certain Improve staff communication – read back, not using certain

abbreviations, SBARabbreviations, SBAR Uses medicines safely – label, look alike/sound alike, blood Uses medicines safely – label, look alike/sound alike, blood

thinnersthinners Prevent infection – hand hygiene, NO HAIsPrevent infection – hand hygiene, NO HAIs Reconcile medications across the continuum of careReconcile medications across the continuum of care ID patient safety risks – suicideID patient safety risks – suicide Prevent fallsPrevent falls Help patients to be involved in their careHelp patients to be involved in their care Watch patients closely for changes in their health and Watch patients closely for changes in their health and

respond quickly if they need help – Rapid response teamsrespond quickly if they need help – Rapid response teams Prevent errors in surgeryPrevent errors in surgery

Environmental SafetyEnvironmental Safety

A safe environment includes meeting A safe environment includes meeting basic needs, reducing physical hazards, basic needs, reducing physical hazards, reducing the transmission of pathogens, reducing the transmission of pathogens, maintaining sanitation, and controlling maintaining sanitation, and controlling pollution.pollution.

A safe environment also includes one A safe environment also includes one where the threat of attack from biological, where the threat of attack from biological, chemical, or nuclear weapons is prevented chemical, or nuclear weapons is prevented or minimized.or minimized.

Environmental SafetyEnvironmental Safety

Basic NeedsBasic Needs OxygenOxygen

CO2 poisoningCO2 poisoning

NutritionNutrition Keeping perishable foods freshKeeping perishable foods fresh

Temperature and HumidityTemperature and Humidity Extreme cold and heatExtreme cold and heat

Physical HazardsPhysical Hazards

Fractures are the most serious health Fractures are the most serious health consequence of fallsconsequence of falls

Almost 90% of all fractures among older adults Almost 90% of all fractures among older adults are due to fallsare due to falls

LightingLighting ObstaclesObstacles Bathroom Hazards – burns, poisoning, fallsBathroom Hazards – burns, poisoning, falls Security – fire safety, lead poisoning, Security – fire safety, lead poisoning,

contaminated soil and watercontaminated soil and water

Transmission of PathogensTransmission of Pathogens

Pathogen = any microorganism capable of Pathogen = any microorganism capable of producing an illnessproducing an illness

Hand hygiene most effective method of Hand hygiene most effective method of limiting transmissionlimiting transmission

Immunization = resistance to an infectious Immunization = resistance to an infectious disease is produced or augmenteddisease is produced or augmented

Environment Safety Cont’d.Environment Safety Cont’d.

PollutionPollution Air Air Land Land Water Water Noise Noise

TerrorismTerrorism BioterrorismBioterrorism

Risks at Developmental StagesRisks at Developmental Stages

Infant, Toddler, Preschool: Injuries are the Infant, Toddler, Preschool: Injuries are the leading cause of death in children over leading cause of death in children over age 1age 1

School aged child: Sports injuriesSchool aged child: Sports injuries Adolescent: Risk taking behaviorsAdolescent: Risk taking behaviors Adult: Lifestyle habitsAdult: Lifestyle habits Older Adult: Physiological changes result Older Adult: Physiological changes result

in increased risk for falls, burns, MVAsin increased risk for falls, burns, MVAs

Individual Risk FactorsIndividual Risk Factors

LifestyleLifestyle Impaired MobilityImpaired Mobility Sensory or communication ImpairmentSensory or communication Impairment Lack of Safety AwarenessLack of Safety Awareness

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Risks in the Health Care Risks in the Health Care AgencyAgency

3 Types of medical errors accounted for almost 60% of 3 Types of medical errors accounted for almost 60% of the client safety incidentsthe client safety incidents Post-op infectionsPost-op infections Bed soresBed sores Failure to diagnose and treat in timeFailure to diagnose and treat in time

Medication errors Medication errors FallsFalls Patient-Inherent Accidents: self-inflictedPatient-Inherent Accidents: self-inflicted Procedure-related Accidents: occur during therapyProcedure-related Accidents: occur during therapy Equipment-related Accidents: malfunction, disrepair, or Equipment-related Accidents: malfunction, disrepair, or

misusemisuse

Safety and the Nursing ProcessSafety and the Nursing Process

AssessAssess Activity and exerciseActivity and exercise MedicationsMedications History of fallsHistory of falls Home maintenance and safetyHome maintenance and safety

Nursing DiagnosisNursing Diagnosis Risk for injuryRisk for injury

Related to:Related to: General weaknessGeneral weakness Right or Left sided weaknessRight or Left sided weakness Side effects of medicationSide effects of medication Poor eyesightPoor eyesight

As evidenced by:As evidenced by: Recent fallsRecent falls New CVANew CVA ConfusionConfusion Macular degenerationMacular degeneration

ImplementationImplementation

Nursing DiagnosisNursing Diagnosis Risk for injury related to (r/t) generalized weakness as Risk for injury related to (r/t) generalized weakness as

evidenced by recent fallsevidenced by recent falls GoalGoal

Pt. will ask for help to the bathroomPt. will ask for help to the bathroom Pt. will remain free from injury during hospitalizationPt. will remain free from injury during hospitalization

InterventionsInterventions Nurse will ensure call light is in reachNurse will ensure call light is in reach Nurse will work with other care providers to make Nurse will work with other care providers to make

sure patient is seen every hoursure patient is seen every hour Nurse will work with other care providers to ensure pt. Nurse will work with other care providers to ensure pt.

receives required assistance with ADLs/activitiesreceives required assistance with ADLs/activities

Use of Restraints in the Health Use of Restraints in the Health Care SettingCare Setting

Physical or chemical means of stopping a Physical or chemical means of stopping a patient from being free to move.patient from being free to move. 4 bedrails up is considered a restraint4 bedrails up is considered a restraint

Used only in emergency situations to Used only in emergency situations to ensure the patient’s safety.ensure the patient’s safety.

Restraint orders must be specific and Restraint orders must be specific and time-limited.time-limited.

Other Mechanisms to Other Mechanisms to Prevent FallsPrevent Falls

Tab AlarmsTab Alarms Arm BandsArm Bands ID outside of Patient roomID outside of Patient room Notice Inside the Patient roomNotice Inside the Patient room Colors of gowns, slippers, blanketsColors of gowns, slippers, blankets Bed AlarmsBed Alarms Chair AlarmsChair Alarms

Restraint UseRestraint Use

Must have a physician orderMust have a physician order

Order must be rewritten every 24h.Order must be rewritten every 24h.

Restraint policies are specific to health Restraint policies are specific to health care setting care setting

Nursing documentation must occur at least Nursing documentation must occur at least every two hoursevery two hours

Complications from RestraintsComplications from Restraints

Skin breakdownSkin breakdown ConstipationConstipation PneumoniaPneumonia IncontinenceIncontinence Urinary retentionUrinary retention Nerve damageNerve damage Circulatory damageCirculatory damage

Other Safety IssuesOther Safety Issues

FiresFires PoisoningPoisoning Electrical HazardsElectrical Hazards Seizure precautionsSeizure precautions Radiation safetyRadiation safety Bioterrorist attackBioterrorist attack Bomb threatsBomb threats

Chapter 39: HygieneChapter 39: Hygiene

Patient HygienePatient Hygiene

Oral CareOral Care BathingBathing ShavingShaving Hair careHair care Perineal carePerineal care Foot careFoot care Bed making Bed making

Occupied/unoccupiedOccupied/unoccupied

GoalGoal What is the goal of hygiene in the health What is the goal of hygiene in the health

care setting?care setting?a)a) Moving the patient to a higher level of healthMoving the patient to a higher level of health

b)b) Check the box on the nursing Check the box on the nursing documentation sheetdocumentation sheet

c)c) Prevent InfectionPrevent Infection

d)d) All of the aboveAll of the above

Self-AssessmentSelf-Assessment

Have you ever Have you ever bathed another bathed another adult person?adult person?

Someone not in Someone not in your family?your family?

Why is Hygiene Important?Why is Hygiene Important?

Personal hygiene affects a patient’s Personal hygiene affects a patient’s comfort, safety, and sense of well-being.comfort, safety, and sense of well-being.

A variety of personal, social, and cultural A variety of personal, social, and cultural factors influence hygiene practices.factors influence hygiene practices.

Factors Influencing HygieneFactors Influencing Hygiene

Physical ConditionPhysical Condition Ability to care for selfAbility to care for self Energy levelEnergy level Sensory deficitsSensory deficits Incontinence of urine and/or stoolIncontinence of urine and/or stool Dexterity and ROMDexterity and ROM Sedation, Pain levelSedation, Pain level Chronic illnessesChronic illnesses Psychiatric conditionsPsychiatric conditions

Factors Cont’d.Factors Cont’d.

Social practicesSocial practices Personal preferencesPersonal preferences Body imageBody image Socioeconomic statusSocioeconomic status Health beliefs and Health beliefs and

motivationmotivation Cultural variablesCultural variables

AssessmentAssessment Skin: wounds, infectionSkin: wounds, infection Feet and Nails: PVD, diabetic patient with foot Feet and Nails: PVD, diabetic patient with foot

issues, foot fungus around toe nailsissues, foot fungus around toe nails Patients with poor circulation to the feet and lower Patients with poor circulation to the feet and lower

legs needs close assessment of those areaslegs needs close assessment of those areas

Oral Cavity: condition of the mouth and teethOral Cavity: condition of the mouth and teeth Hair: tangles, liceHair: tangles, lice Eyes, Ears, and Nose: Does the patient have Eyes, Ears, and Nose: Does the patient have

any sensory deficits?any sensory deficits?

Critical EvaluationCritical Evaluation

What is the ability of the person to care for What is the ability of the person to care for themselves?themselves? Physical disabilitiesPhysical disabilities Mental disabilitiesMental disabilities

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Specific Issues Needing to be Specific Issues Needing to be Addressed at Bath TimeAddressed at Bath Time

Foot careFoot care Normal vs DiabeticNormal vs Diabetic Do not soak feet of patients with DM and/or Do not soak feet of patients with DM and/or

vascular insufficiencyvascular insufficiency

Sensitive skinSensitive skin InfestationsInfestations InfectionsInfections IncontinenceIncontinence

Types of BathsTypes of Baths

Complete bed bathComplete bed bath Partial bed bathPartial bed bath Sponge at the sinkSponge at the sink Tub bathTub bath ShowerShower Bath in a bagBath in a bag

Critical EvaluationCritical Evaluation

Are there any cultural issues that need to be Are there any cultural issues that need to be addressed prior to bathing?addressed prior to bathing?

What is your patient’s developmental status?What is your patient’s developmental status? Teen, Young adult, Adult, Older Adult, ElderlyTeen, Young adult, Adult, Older Adult, Elderly

How does that affect their hygiene needs and How does that affect their hygiene needs and attitudes?attitudes?

What do you do with this information about the What do you do with this information about the patient?patient? Care PlanCare Plan

Critical EvaluationCritical Evaluation Involve patient as much as possible in Involve patient as much as possible in

bathing decisionsbathing decisions WhenWhen WhereWhere TypeType

TubTub ShowerShower Bed bathBed bath

Nursing DiagnosisNursing Diagnosis

BATHING/HYGIENE SELF-CARE DEFICIT: BATHING/HYGIENE SELF-CARE DEFICIT: R/T CONFUSION: AEB POOR PERSONAL R/T CONFUSION: AEB POOR PERSONAL HYGIENEHYGIENE

BATHING/HYGIENE SELF-CARE DEFICIT: BATHING/HYGIENE SELF-CARE DEFICIT: R/T DECREASED CEREBRAL CIRCULATION R/T DECREASED CEREBRAL CIRCULATION (RECENT CVA) AEB RIGHT SIDED (RECENT CVA) AEB RIGHT SIDED WEAKNESSWEAKNESS

Oral CareOral Care

Oral care is an essential nursing interventionOral care is an essential nursing intervention Assess for decreased saliva, infection, coated Assess for decreased saliva, infection, coated

tongue, cracked lipstongue, cracked lips Brush all tooth surfaces using a soft bristle brushBrush all tooth surfaces using a soft bristle brush Observe for complications such as bleeding gumsObserve for complications such as bleeding gums

Oral care for the patient who is not consciousOral care for the patient who is not conscious Oral care for the patient with partial paralysis of Oral care for the patient with partial paralysis of

the mouththe mouth Oral care for the patient who has had mouth Oral care for the patient who has had mouth

surgery or injurysurgery or injury

OtherOther Hair Care:Hair Care: Gather supplies (plastic trough, Gather supplies (plastic trough,

towels, shampoo, drainage wash basin)towels, shampoo, drainage wash basin) Shaving:Shaving: Check doctor’s orders Check doctor’s orders

AnticoagulantsAnticoagulants Perineal CarePerineal Care (see page 877) (see page 877)

IndependentIndependent Needs assistNeeds assist Dependent Dependent

Foot Care Foot Care (see page 880)(see page 880) Do not soak feet of patients with DM and/or vascular Do not soak feet of patients with DM and/or vascular

insufficiencyinsufficiency

Care of Patient with Sensory AidsCare of Patient with Sensory Aids

Glasses/Contacts (pg. 894)Glasses/Contacts (pg. 894) Dentures (pg. 891)Dentures (pg. 891) Hearing Aids (pg. 895)Hearing Aids (pg. 895) Prosthetic EyesProsthetic Eyes

Basic PrinciplesBasic Principles

Remember body mechanicsRemember body mechanics Raise the bed to a comfortable heightRaise the bed to a comfortable height

Follow medical asepsis when making a Follow medical asepsis when making a bedbed Wear gloves if linen is soiledWear gloves if linen is soiled Keep linen away from uniformKeep linen away from uniform Do not place soiled linen on the floorDo not place soiled linen on the floor

Bed Making – Bed Making – Occupied/UnoccupiedOccupied/Unoccupied

LinenLinen Use appropriate linen for the patientUse appropriate linen for the patientChucks and linen saversChucks and linen saversDraw sheetsDraw sheetsTherapy bedsTherapy beds

Learn to place a bottom flat sheet when there Learn to place a bottom flat sheet when there are no fitted sheetsare no fitted sheets