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RN responsibilities (5)

1. promote safety
2. prevent injury - know their strengths, can they stand
3. be aware of the development level
4. be aware of the patient's lifestyle (ex. smoker)
5. identify potential hazards (look at what they bring in)

safety considerations: lifestyles (3)

1. occupation/work environment
a. noise, lifting, radiation, needle sticks
2. social behaviors
a. risk takers, seat belts, helmet for bike, stress, substance abuse
3. environment
a. crime area, pollutants, terrorism (could be small - battered by husband)

safety considerations: mobility

unsteady gait, paralysis, supportive devices like walkers or wheelchairs, recent surgery, prolonged illness

safety considerations: sensory perception

sight (stumble), hearing (not hear smoke alarms), taste and smell (tainted food), touch (burns)

safety considerations: knowledge

must be taught about oxygen, meds, etc

safety considerations: ability to communicate

language barriers, aphasia, medication site affects

safety considerations: physical state

weak, recovering from a stroke

safety considerations: psychosocial state

stress narrows perceptual field, confusion, social isolation

assess safety in your patient (7)

1. history of falls or accidents
2. use of assistive devices
3. history of substance abuse
4. mobility status
5. ability to communicate/language (b/c not at the right level of understanding, medical jargon
6. sensory perception
7. home environment = need to know what their home environment is like

falls (5)

1. leading cause of injury fatality among adults 65+
2. very costly to medicare
3. hospitals have fall prevention programs
4. 1/3 of older adults fall at home each year
5. common fall injuries = hip fracture, other fractures, head trauma, soft tissue injury

high risk for falls

65+ years, altered gait/posture, postural hypotension, unfamiliar environment, impaired vision, confusion/disorientation, medications, history of falls, slow reaction time, weak/frail, impaired mobility, impaired balance

fires (3)

1. 80% US fire death occur in the home, usually due to smoke inhalation
2. 50% of home fire deaths no smoke detectors
3. Hospital - escape routes, fire drills

poisoning: unintentional and intention (5)

1. suicide/overdose
2. fumes
3. paint chips/dust contaminated with lead
4. caustics
5. salicylates (aspirin) due to thinning of the blood

suffocation & choking (2)

1. drowning, choking on a foreign substance, gas/smoke inhalation
2. 50% of all drowning victims are children under 5 yo

firearms (2)

1. 25% of all americans who dies from firearms were between 15-24 yo
2. storage, gun safety classes

implementation: the nurse will know these safety items... (3)

1. know basic first aid
2. know OSHA = radiation exposure, chemical exposure, infection control, electrical equipment guidelines
3. reaching boaters safety, swimming lessons, gun safety, monitor internet for children

implementation: development considerations (3)

1. adult: stress, domestic violence, MVA, industrial/work accidents, substance abuse
2. older adult: falls, MVA, elder abuse, sensorimotor changes, fires
3. IPV (intimate partner violence)
• 2 million US adults
• 85% are women
• safety plan

implementation: home interventions

fitted slippers, improve lighting, hand rails, repair or discard broken equipment, encourage physical activity

implementation: restraints (5)

1. JCAHO 2002 studied 381 pts trapped by side rails between 1995-2001
• 60% died, half were in long term care, most were frail confused elderly
2. in an emergency a RN may apply a physical restraint but need a physicians order within 1 hour with intended duration of use. Need physician order every 24 hours
3. cannot order as needed (prn) restraints
4. assess adults in restraints every 4 hours
5. specific documentation in the medical record

implementation: hospital fires (7)

1. know how to operate a fire extinguisher
2. know escape routes
3. practice fire drills
4. R = rescue if in immediate danger
5. A = activate the fire code
6. C = confine the fire
7. E = evacuate pts/others to safety

implementation: poisoning (5)

1. childproof containers
2. syrup of ipecac no longer routinely used
3. activated charcoal in ER through nasogastric tube
4. gastic lavage not routinely done
5. teach carbon monoxide monitors in the home

implementation: equipment (7)

1. lock wheels on wheelchairs & beds & stretchers
2. side rails ( 1 or 2 can be up - depends on how many rails
3. call light in reach
4. no electrical equipment from home
5. 3 prong outlets
6. no frayed wires
7. electrical equipment works properly

implementation: procedures is something happens

1. incident reports (doesn't go in the chart) is filed when anything out of the ordinary results in or has the potential for harm to pts, employees, visitors. (ex.report a fall. In chart = "found patient in sitting position, holding back" not judging or assuming)
• identifies risks for the hospital
• used for training, not used for disciplinary actions
• can be used by the hospital if litigation occurs
• objectively describe circumstance, its response, exam and treatment after incident
• speak openly and honestly w/pt and family

implementation: hospital bed safety (4)

1. lower bed heights
2. lock wheels
3. raise side rails
4. function correctly (electrical beds)

implementation: medication safety (7)

1. in acute care settings (hospital) no medication can be given w/o a medication order from licensed prescriber
2. CPOE- computer prescriber entry systems & scanner bracelet systems - bar codes = fewer errors but less than 5% of hospital have CPOE
3. only verbal orders in emergency situations & only to RN
4. student nurses cannot take verbal orders
5. orders can be written "prn". PRN orders are usually written to treat symptoms (sleep, pain, nausea, etc)
6. one time orders (preoperative medications)
7. stat order" immediately given

parts of a medication order (7)

1. patient name
2. date time ordered
3. drug - generic name is safest (ex. acetylsalicylic acid
- trade name = buffering, bayer
4. dosage
5. route = (ex. oral (po), intramuscular (IM), (IV), (subq)
6. frequency
7. signature of the prescriber

medication errors (3)

1. 20% of medication orders result in an error
2. 7% of these medication errors had potential to cause an adverse effect
3. 1999 IOM (institute of medicine) study = 7,000 deaths a year from medication errors (wrong drug, drug overdose, overlooked medication interactions, overlooked allergies)
• 1.5 million preventable medication errors each year

medication 3 checks

1. nurse checks the medicine when you reach for it
2. check it when you compare it the MAR (medication administration record
3. check it again before you give it

*** 7 rights of medication administration

1. medication
2. patient (JACHO 2005 requires at least 2 patient identifiers should be used)
3. dose
4. route
5. time
6. reason
7. documentation

patient identifiers (3)

1. piece of person specific information
2. patient identifiers can include such things as ID bracelet, date of birth, state their name, photograph of patient, SS#, telephone number, barcodes
3. 2 identifiers are used to match the right patient to the right medication/treatment/test result

patient identifiers : clinical application (2)

1. you are the RN in ER & unresponsive male patient brought in by police with no wallet or identification on him. what 2 identifiers will you use?
2. RN working on psych unit & the patient refuses to have a bracelet on b/c "they" can find him. what 2 identifiers will you use?

controlled substances (4)

1. locked & federal law requires documentation of each narcotic administered
2. nurses check & count narcotics for the federal records several times a day
3. can be part of a computerized medication system
4. nurses witness and document any disposed narcotics

interventions: lifting & moving patients (3)

1. 47% of nurses in the US report back injuries
2. RN's need to use mechanical lifts to reduce cumulative trauma due to musculoskeletal stress
3. using mechanical lifts is easier on the patient than manual lifts

intervention: infections (8)

1. HAI (health associated infections)= usually bacterial (e. coli, staph, strept, etc.) usually traced to an invasive procedure (IV, catheter, ventilator) or surgical wound
2. nosocomial infections = originate in the hospital
• exogenous = from another person
• endogenous = microbial life in patient
3. most common sources for nosocomial infections are UTI< pneumonia, bloodstream
4. latrogenic infection = result from a treatment or a diagnostic procedure
5. antibiotic resistant organisms
• usually transferred by hands of healthcare providers
• can be transferred by surface contact (beds, rails, doorknobs, pens)
6. high mortality
7. MRSA = methicillin resistant staph aureus
8. VRSA: = vancomycin resistant staph aureus

interventions: reporting accidental exposures (7)

1. any needlestick, accidental exposure to body fluids or blood must be reported immediately
2. wash area w/soap & water immediately
3. file incident report w/patients name
4. RN consent to initial baseline test (HIV, HBV, HCV) & then the RN repeats blood tests at 6wks, 3 mo, 1 yr intervals
5. MI: state law mandates that a pt can be tested against their will for HIV< HBV, HCV if a healthcare worker has accidental exposure
6. wait for pt blood test results
7. counseling

interventions: reporting accidental exposures (3)

1. seroconversions: hep B (HBV) 10-30%, Hep C (HCV) 4-10%, HIV 0.1-0.3%
2. HBV: there is a preventable vaccine: 1/3 of world population is positive for HBV. Transmission = unprotected sex, blood transfusions, contaminated needles, childbirth
3. HCV: no vaccine, no symptoms. 1 in 10 US veterans are positive. transmission = #1 sharing needles, blood to blood. Liver cirrhosis & liver cancer

evaluating safety (3)

1. patient's safety & RN safety & hospital safety have been discussed at length
2. how do we protect:
• patient's SO safety
• RN's SO safety
• community safety
3. what can we do to protect SO & our community?

standards of quality (2)

1. TJC: sentinel events
a. serious medication errors
b. significant drug reactions
c. wrong surgical sites
d. blood transfer reactions
e. infant abductions
f. suicides
2. NPSG: national patient safety goals

barriers to improving quality (3)

1. cost
2. loyalty to old practices
3. fail to see the need for change

steps to improving quality "DMAIC"

1. define
2. measure
3. analyze
4. improve
5. control

safety considerations (7)

1. lifestyles
2. mobility
3. sensory
4. knowledge
5.ability to communicate
6. physical state
7. psychosocial state

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