N210 Week 5 Lab Safety & Restraints

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Leon
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309528
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N210 Week 5 Lab Safety & Restraints
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2015-10-12 22:31:01
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N210 Week Lab Safety Restraints
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N210
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  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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.
  8. 8. List 5 restraint alternatives
    Box 26-7 pg. 710

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