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1. Outline strategies to provide a safe patient environment
- • Person who is familiar with one’s surroundings is less likely to experience an accidental injury
- • As part of hospital admission routine, orient the patient to the safety features and equipment in the room
- • Explain and demonstrate the adjustable bed and side rails, call system, telephone, tv, bathroom
- • Patient’s identity bracelet and discussion of agency routine further ensure safety and assist the patient to adapt to the unfamiliar setting
- • Teach the importance of orienting an older person to new surroundings when the older person moves in with a family member or other caregiver
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2. Identify clients who are at high risk of falls pg. 692
- Falls
- • Age older than 65 years
- • Documented history of falls
- • Impaired vision or sense of balance
- • Altered gait or posture
- • A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics
- • Postural hypotension
- • Slowed reaction time
- • Confusion or disorientation
- • Impaired mobility
- • Weakness and physical frailty
- • Unfamiliar environment
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3. Discuss the benefits and risks of using physical restraints pg. 707-708
- Benefits:
- • Maintaining medical treatment
- • Protecting patients from injury
- • Protecting other patients and staff from harm
- Risks:
- • Potentially dangerous
- • Increases the changes of serious injury due to a fall-they do not prevent falls
- • Skin breakdown
- • Contractures
- • Incontinence
- • Depression
- • Delirium
- • Anxiety
- • Aspiration
- • Respiratory difficulties
- • Death
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4. Explain the basis for enacting restraint legislation and National Patient Safety Goals (NPSG) standards.
- • Their risks outweigh their benefits:
- Restrained clients
- • Become increasingly confused
- • Suffer chronic constipation, incontinence, and infections such as pneumonia and pressure ulcers
- • Experience a progressive decline in their ability to perform activities of daily living
- • Are more likely to die during their hospital stay than those who are not restrained
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5. Demonstrate proper application of restraints
- To apply wrist restraints:
- 1. Wrap padded portion of the restraint around wrist or ankle
- 2. Ensure that two fingers can be inserted between the restraint and patient’s extremities
- 3. Use a quick-release knot to tie the restraint at end of bed frame, not side rails which causes less injuries
- To apply vest and on wheelchair
- 1. Appropriate size vest on patient
- 2. Place on patients arm front of the vest and pull zipper up
- 3. Ensure adequate space between vest and client
- 4. Pull vest tails under the arm rest and cross tail
- 5. Wrap using a half-bow knot
- 6. Check if vest is not too tight and client is comfortable
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6. Discuss nursing responsibilities related to use of restraints pg. 721 and Mrs. Natividad
- 1. Release restraints every 2 hours
- 2. Check for ROM, Skin integrity, CMS, urge to use the restroom, cap refill and cyanosis
- 3. Restraints need to be renewed every 24 hours
- 4. Assess the patient every hour or according to agency policy
- 5. Physicians order need to be renew for a client on restraints within an hour
- 6. If inpatient psychiatric patient in restraints requires continual observation, including specific assessments every 15 minutes
- A. Documentation must reflect the
- • Reason for restraining the patient
- • Alternatives measures attempted before applying restraints
- • Patient assessment before application
- • Record family education and understanding regarding restraints used
- • Document family consent if required by facility
- • Date and time of application
- • Type of restraint
- • Times when removed
- • Result and frequency of nursing assessment
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7. Differentiate between a restraint and a restraint alternative pg. 707 and 709
- A. Restraints are physical devices that are used to limit a patient’s movement. Side rails, geriatric chairs with attached trays, and appliances tied at the wrist, ankle or waist are types of physical restraints.
- B. Restraint alternatives are protective or adaptive devices that promote client safety and postural support but that the client can release independently.
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8. List 5 restraint alternatives
Box 26-7 pg. 710
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