- Information
- AI Chat
Saunders Provision of a Safe Environment Nclex
Adult Health II (NUR 2211)
Hillsborough Community College
Recommended for you
Students also viewed
- Test Bank - Lewis's Med-Surg Nursing - Ch. 1 Professional Nursing - RN Nclex
- Fundamentals of Nursing - Ch. 45 Nutrition - RN Nclex
- Fundamentals of Nursing - Ch. 44 Pain Management - RN Nclex
- Fundamentals of Nursing - Ch. 43 Sleep - RN Nclex
- Fundamentals of Nursing - Ch. 41 Oxygenation - RN Nclex
- Fundamentals of Nursing - Ch. 40 Hygiene - RN Nclex
Preview text
C H A P T E R 1 3
Provision of a Safe Environment
evolve.elsevier/Silvestri/comprehensiveRN/
Priority Concepts
Infection, Safety
I. Environmental Safety
A. Fire safety (see Priority Nursing Actions)
- Keep open spaces free of clutter.
- Clearly mark fire exits.
- Know the locations of all fire alarms, exits, and extinguishers (Table 13-1; also see Priority Nursing Actions).
P r ior ity Nur sing Actions
Event of a Fire Race 1. Rescue clients who are in immediate danger. 2. Activate the fire alarm. 3. Confine the fire. 4. Extinguish the fire. Pass 5. Obtain the fire extinguisher. 6. Pull the pin on the fire extinguisher. 7. Aim at the base of the fire. 8. Squeeze the extinguisher handle. 9. Sweep the extinguisher from side to side to coat the area of the fire evenly.
Reference
Potter et al. (2017), pp. 392-393.
- Know the telephone number for reporting fires.
- Know the fire drill and evacuation plan of the agency.
- Never use the elevator in the event of a fire.
- Turn off oxygen and appliances in the vicinity of the fire.
- In the event of a fire, if a client is on life support,
maintain respiratory status manually with an Ambu bag (resuscitation bag) until the client is moved away from the threat of the fire and can be placed back on life support. 9. In the event of a fire, ambulatory clients can be directed to walk by themselves to a safe area and, in some cases, may be able to assist in moving clients in wheelchairs. 10. Bedridden clients generally are moved from the scene of a fire by stretcher, their bed, or wheelchair. 11. If a client must be carried from the area of a fire, appropriate transfer techniques need to be used. 12. If fire department personnel are at the scene of the fire, they will help evacuate clients.
Remember the mnemonic RACE (Rescue clients, Activate the
fire alarm, Confine the fire, Extinguish the fire) to set priorities in the event of a fire and the mnemonic PASS (Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep from side to side) to use a fire extinguisher. B. Electrical safety
Any electrical equipment that the client brings into the health care facility must
be inspected for safety before use. 1. Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard; remove equipment that is not in proper working order and notify appropriate staff. 2. Use a 3-pronged electrical cord. 3. In a 3-pronged electrical cord, the third, longer prong of the cord is the ground; the other 2 prongs carry the power to the piece of electrical equipment.
- Check electrical cords and outlets for exposed,
frayed, or damaged wires. 5. Avoid overloading any circuit. 6. Read warning labels on all equipment; never operate unfamiliar equipment. 7. Use safety extension cords only when absolutely necessary, and tape them to the floor with electrical tape. 8. Never run electrical wiring under carpets. 9. Never pull a plug by using the cord; always grasp the plug itself.
risk scale per agency procedures 2. Include the client's own perceptions of their risk factors for falls and their method to adapt to these factors. Areas of concern may include gait stability, muscle strength and coordination, balance, and vision. 3. Assess for any previous accidents. 4. Assess with the client any concerns about their immediate environment, including stairs, use of throw rugs, grab bars, a raised toilet seat, or environmental lighting. 5. Review/analyze the medications, both prescription and nonprescription, that the client is taking that could have side/adverse effects that could place the client at risk for a fall. 6. Determine any scheduled procedures that pose risks to the client. G. Measures to prevent falls (Box 13-2) H. Measures to promote safety in ambulation for the client
- Gait belt may be used to keep the center of gravity midline. a. Place the belt on the client prior to ambulation. b. Encircle the client’s waist with the belt. c. Hold on to the side or back of the belt so that the client does not lean to one side. d. Return the client to bed or a nearby chair if the client develops dizziness or becomes unsteady. e. When finished safely ambulating the client, remove belt and replace it in its appropriate storage area. I. The Joint Commission: National Patient Safety Goals 2018
- See Box 13-3 for a list of the National Patient Safety Goals
- Refer to the following website for detailed information on these goals jointcommission/assets/1/6/NPSG_Chapter_HAP_J
J. Steps to prevent injury to the health care worker (Box 13-4)
K. Restraints (safety devices)
- Restraints (safety devices) are protective devices used to limit the physical activity of a client or to immobilize a client or an extremity. a. The agency policy should be checked
and followed when using side rails. b. The use of side rails is not considered a restraint when they are used to prevent a sedated client from falling out of bed. c. The client must be able to exit the bed easily in case of an emergency when using side rails. Only the top two side rails should be used. d. The bed must be kept in the lowest position. 2. Physical restraints restrict client movement through the application of a device. 3. Chemical restraints are medications given to inhibit a specific behavior or movement. 4. Interventions a. Use alternative devices, such as pressure-sensitive beds or chair pads with alarms or other types of bed or chair alarms, whenever possible. b. If restraints are necessary, the primary health care provider’s (PHCP’s) prescriptions should state the type of restraint, identify specific client behaviors for which restraints are to be used, and identify a limited time frame for use. c. The PHCP’s prescriptions for restraints should be renewed within a specific time frame according to agency policy. d. Restraints are not to be prescribed PRN (as needed). e. The reason for the safety device should be given to the client and the family, and their permission should be sought and documented. f. Restraints should not interfere with any treatments or affect the client’s health problem. g. Use a half-bow, a safety knot (quick release tie), or a restraint with a quick release buckle to secure the device to the bed frame or chair, not to a movable part of bed (including the side rails). h. Ensure that there is enough slack on the straps to allow some movement of the body part.
electrolyte/laboratory values, and other pertinent assessment findings that may provide information about the cause of the client’s confusion. L. Poisons
A poison is any substance that impairs health or destroys life when ingested, inhaled, or otherwise absorbed by the body.
Specific antidotes or treatments are available only for some types of poisons.
The capacity of body tissue to recover from a poison determines the reversibility of the effect.
Poison can impair the respiratory, circulatory, central nervous, hepatic, gastrointestinal, and renal systems of the body.
The infant, toddler, the preschooler, and the
young school-age child must be protected from accidental poisoning.
- In older adults, diminished eyesight and
impaired memory may result in accidental ingestion of poisonous substances or an overdose of prescribed medications.
- A Poison Control Center phone number
should be visible on the telephone in homes with small children; in all cases of suspected poisoning, the number should be called immediately.
- Interventions
a. Remove any obvious materials from the mouth, eyes, or body area immediately. b. Identify the type and amount of substance ingested. c. Call the Poison Control Center before attempting an intervention. d. If the victim vomits or vomiting is induced, save the vomitus if requested to do so, and deliver it to the Poison Control Center. e. If instructed by the Poison Control Center to take the person to the emergency department, call an ambulance. f. Never induce vomiting following
ingestion of lye, household cleaners, grease, or petroleum products. g. Never induce vomiting in an unconscious victim.
The Poison Control Center should be
called first before attempting an intervention. II. Health Care–Associated (Nosocomial) Infections A. Health care–associated (nosocomial) infections also are referred to as hospital-acquired infections. B. These infections are acquired in a hospital or other health care facility and were not present or incubating at the time of a client’s admission.
C. Clostridium difficile is spread mainly by hand-to-hand
contact in a health care setting. Clients taking multiple antibiotics for a prolonged period are most at risk. D. Common drug-resistant infections: Vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant tuberculosis, carbapenem-resistant Enterobacteriaceae (CRE) E. Illness and some medications such as immunosuppressants impair the normal defense mechanisms. F. The hospital environment provides exposure to a variety of virulent organisms that the client has not been exposed to in the past; therefore, the client has not developed resistance to these organisms. G. Infections can be transmitted by health care personnel who fail to practice proper standard precautions (i., hand-washing procedures or failing to change gloves between client contacts). H. At many health care agencies, dispensers containing an alcohol- based solution for hand sanitization are mounted at the entrance to each client’s room; it is important to note that alcohol-based sanitizers are not effective against some infectious agents such as Clostridium difficile spores; therefore, handwashing is necessary. III. Standard Precautions A. Description
- Nurses must practice standard precautions with all clients in any setting, regardless of the diagnosis or presumed infectiveness.
- Standard precautions include hand washing and the use of gloves, as well as washing hands after gloves are removed. Additionally, standard precautions include the use of masks, eye protection, and gowns, when appropriate, for client contact.
- These precautions apply to blood, all body fluids
B. Airborne precautions 1. Diseases a. Measles b. Chickenpox (varicella) c. Disseminated varicella zoster d. Pulmonary or laryngeal tuberculosis
- Barrier protection
a. Used for clients known or suspected to be infected with pathogens transmitted by the airborne route. b. Single room is maintained under negative pressure; door remains closed except upon entering and exiting. c. Negative airflow pressure is used in the room, with a minimum of 6 to 12 air exchanges per hour via high-efficiency particulate air (HEPA) filtration mask or according to agency protocol. d. Ultraviolet germicide irradiation or HEPA filter is used in the room. e. Health care workers wear a respiratory mask (N95 or higher level). A surgical mask is placed on the client when the client needs to leave the room; the client leaves the room only if necessary. C. Droplet precautions
Diseases a. Adenovirus b. Diphtheria (pharyngeal) c. Epiglottitis d. Influenza (flu) e. Meningitis f. Mumps g. Mycoplasmal pneumonia or meningococcal pneumonia h. Parvovirus B i. Pertussis j. Pneumonia k. Rubella l. Scarlet fever m. Sepsis n. Streptococcal pharyngitis
Barrier protection
a. Used for clients with known or
suspected infection with pathogens transmitted by respiratory droplets, generated when coughing, sneezing, or talking. b. Private room or cohort client (a client whose body cultures contain the same organism) c. Wear a surgical mask when within 3 feet of a client; place a mask on the client when the client needs to leave the room. D. Contact precautions
Diseases a. Colonization or infection with a multidrug-resistant organism b. Enteric infections, such as Clostridium difficile c. Respiratory infections, such as respiratory syncytial virus d. Influenza: Infection can occur by touching something with flu viruses on it and then touching the mouth or nose. e. Wound infections f. Skin infections, such as cutaneous diphtheria, herpes simplex, impetigo, pediculosis, scabies, staphylococci, and varicella zoster g. Eye infections, such as conjunctivitis h. Indirect contact transmission may occur when contaminated object or instrument, or hands, are encountered.
Barrier protection
a. Private room or cohort client b. Use gloves and a gown whenever entering the client’s room. V. Emergency Response Plan and Disasters A. Know the emergency response plan of the agency. B. Internal disasters are those that occur within the health care facility. C. External disasters occur in the community, and victims are brought to the health care facility for care.
D. When the health care facility is notified of a disaster, the
nurse should follow the guidelines specified in the emergency response plan of the facility. E. See Chapter 7 for additional information on disaster planning.
Botulism is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium botulinum (death can occur within 24 hours).
Its spores are found in the soil and can spread
through the air or food (improperly canned food) or via a contaminated wound.
- Botulism cannot be spread from person to
person. 4. Symptoms include abdominal cramps, diarrhea, nausea and vomiting, double vision, blurred vision, drooping eyelids, difficulty swallowing or speaking, dry mouth, and muscle weakness. 5. Neurological symptoms begin 12 to 36 hours after ingestion of food-borne botulism and 24 to 72 hours after inhalation and can progress to paralysis of the arms, legs, trunk, or respiratory muscles (mechanical ventilation is necessary). 6. If diagnosed early, food-borne and wound botulism can be treated with an antitoxin that blocks the action of toxin circulating in the blood. 7. For wound botulism, surgical removal of the source of the toxin-producing bacteria may be done; antibiotics may be prescribed. 8. No vaccine is available. E. Plague
Plague is caused by Yersinia pestis, a bacteria found in rodents and fleas.
Plague is contracted by being bitten by a
rodent or flea that is carrying the plague bacterium, by the ingestion of contaminated meat, or by handling an animal infected with the bacteria.
- Transmission is by direct person-to-person
spread. 4. Forms include bubonic (most common), pneumonic, and septicemic (most deadly). 5. Symptoms usually begin within 1 to 3 days and include fever, chest pain, lymph node swelling, and a productive cough (hemoptysis). 6. The disease rapidly progresses to dyspnea, stridor, and cyanosis; death occurs from respiratory failure, shock, and bleeding. 7. Antibiotics are effective only if administered immediately; the usual medications of choice include
streptomycin or gentamicin. 8. A vaccine is available. F. Tularemia
Tularemia (also called deer fly fever or rabbit fever) is an infectious disease of animals caused by the bacillus Francisella tularensis.
The disease is transmitted by ticks, deer flies,
or contact with an infected animal. 3. Symptoms include fever, headache, and an ulcerated skin lesion with localized lymph node enlargement, eye infections, gastrointestinal ulcerations, or pneumonia. 4. Treatment is with antibiotics such as streptomycin, gentamicin, doxycycline, and ciprofloxacin. 5. Recovery produces lifelong immunity (a vaccine is available). G. Hemorrhagic fever
Hemorrhagic fever is caused by several viruses, including Marburg, Lassa, Junin, and Ebola.
The virus is carried by rodents and
mosquitoes.
- The disease can be transmitted directly by
person-to-person spread via body fluids. 4. Manifestations include fever, headache, malaise, conjunctivitis, nausea, vomiting, hypotension, hemorrhage of tissues and organs, and organ failure. 5. No known specific treatment is available; treatment is symptomatic. H. Ebola Virus Disease (EVD)
- Previously known as Ebola hemorrhagic fever
- Caused by infection with a virus of the family Filoviridae, genus Ebolavirus
- First discovered in 1976 in the Democratic Republic of the Congo. Outbreaks have appeared in Africa and in several other countries in the world.
- The natural reservoir host of Ebolavirus remains unknown. It is believed that the virus is animal-borne and that bats are the most likely reservoir.
- Spread of the virus is through contact with objects (such as clothes, bedding, needles, syringes/sharps, or medical equipment) that have been contaminated with the virus.
- Symptoms similar to hemorrhagic fever may appear from 2 to 21 days after exposure.
A. Sarin 1. Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. 2. It enters the body through the eyes and skin and acts by paralyzing the respiratory muscles. B. Phosgene is a colorless gas normally used in chemical manufacturing that if inhaled at high concentrations for a long enough period will lead to severe respiratory distress, pulmonary edema, and death. C. Mustard gas is yellow to brown and has a garlic-like odor that irritates the eyes and causes skin burns and blisters.
D. Nuclear warfare
- Acute radiation exposure develops after a substantial exposure to radiation and is referred to as nuclear warfare.
- Exposure can occur from external radiation or internal absorption.
- Symptoms depend on the amount of exposure to the radiation and range from nausea and vomiting, diarrhea, fever, electrolyte imbalances, and neurological and cardiovascular impairment to leukopenia, purpura, hemorrhage, and death.
VIII. Nurse’s Role in Exposure to Warfare Agents
A. Be aware that, initially, a bioterrorism attack may resemble a naturally occurring outbreak of an infectious disease. B. Nurses and other health care workers must be prepared to assess and determine what type of event occurred, the number of clients who may be affected, and how and when clients will be expected to arrive at the health care agency. C. It is essential to be aware that changes in the microorganism can occur that may increase its virulence or make it resistant to conventional antibiotics or vaccines. D. See Chapter 7 for additional information on disasters and emergency response planning.
Table 13-
Types of Fire Extinguishers
Type Class of Fire A Wood, cloth, upholstery, paper, rubbish, plastic B Flammable liquids or gases, grease, tar, oil-based paint C Electrical equipment
Box 13-
Physiological Changes in Older Clients That
Increase the Risk of Accidents
Musculoskeletal Changes
Strength and function of muscles decrease. Joints become less mobile and bones become brittle. Postural changes and limited range of motion occur.
Nervous System Changes
Voluntary and autonomic reflexes become slower. Decreased ability to respond to multiple stimuli occurs. Decreased sensitivity to touch occurs.
Sensory Changes
Decreased vision and lens accommodation and cataracts develop. Delayed transmission of hot and cold impulses occurs. Impaired hearing develops, with high-frequency tones less perceptible.
Genitourinary Changes
Increased nocturia and occurrences of incontinence may occur.
Adapted from Potter A, Perry P, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby; and Touhy T, Jett K: Ebersole and Hess’ toward healthy aging, ed 8, St. Louis, 2012, Mosby.
Box 13-
Measures to Prevent Falls
▪ Assess the client’s risk for falling; use agency fall risk assessment scale. ▪ Assign the client at risk for falling to a room near the nurses’ station. ▪ Alert all personnel to the client’s risk for falling; use agency fall risk alert procedures and methods as necessary. ▪ Assess the client frequently. ▪ Orient the client to physical surroundings. ▪ Instruct the client to seek assistance when getting up. ▪ Explain the use of the nurse call system.
Louis, 2013, Mosby.
Box 13-
Documentation Points With Use of a Safety Device
(Restraint)
▪ Reason for safety device ▪ Method of use for safety device ▪ Date and time of application of safety device ▪ Duration of use of safety device and client’s response ▪ Release from safety device with periodic exercise and circulatory, neurovascular, and skin assessment ▪ Assessment of continued need for safety device ▪ Evaluation of client’s response
Table 13-
Steps for Donning and Removing Personal Protective Equipment (PPE)
Donning of PPE Removal of PPE⁎ Gown Gloves Fully cover front of body from neck to knees and upper arms to end of wrist. Fasten in the back at neck and waist, wrap around the back.
Grasp outside of glove with opposite hand with glove still on and peel off. Hold on to removed glove in gloved hand. Slide fingers of ungloved hand under clean side of remaining glove at wrist and peel off. Mask or Respirator Goggles/Face Shield Secure ties or elastic band at neck and middle of head. Fit snug to face and below chin. Fit to nose bridge. Respirator fit should be checked per agency policy.
Remove by touching clean band or inner part.
Goggles/Face Shield Gown Adjust to fit according to agency policy. Unfasten at neck, then at waist. Remove using a peeling motion, pulling gown from each shoulder toward the hands. Allow gown to fall forward, and roll into a bundle to discard. Gloves Mask or Respirator Select appropriate size and extend to cover wrists of gown.
Grasp bottom ties then top ties to remove.
⁎ Note: All equipment is considered contaminated on the outside.
FIG. 13-1 Anthrax. (From Swartz, 2010.)
Box 13-
Anthrax: Transmission and Symptoms
Skin
Spores enter the skin through cuts and abrasions and are contracted by handling contaminated animal skin products. Infection starts with an itchy bump like a mosquito bite that progresses to a small liquid-filled sac. The sac becomes a painless ulcer with an area of black, dead tissue in the middle. Toxins destroy surrounding tissue.
Gastrointestinal
Infection occurs following the ingestion of contaminated undercooked meat. Symptoms begin with nausea, loss of appetite, and vomiting. The disease progresses to severe abdominal pain, vomiting of blood, and severe diarrhea.
Inhalation
Infection is caused by the inhalation of bacterial spores, which multiply in the alveoli.
Saunders Provision of a Safe Environment Nclex
Course: Adult Health II (NUR 2211)
University: Hillsborough Community College
- Discover more from:
Recommended for you
Students also viewed
- Test Bank - Lewis's Med-Surg Nursing - Ch. 1 Professional Nursing - RN Nclex
- Fundamentals of Nursing - Ch. 45 Nutrition - RN Nclex
- Fundamentals of Nursing - Ch. 44 Pain Management - RN Nclex
- Fundamentals of Nursing - Ch. 43 Sleep - RN Nclex
- Fundamentals of Nursing - Ch. 41 Oxygenation - RN Nclex
- Fundamentals of Nursing - Ch. 40 Hygiene - RN Nclex