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Unit 15; Patient Safety and Positioning

Terms in this set (81)

- Leave the bed in the lowest horizontal position when you have finished giving care.
- Keep brakes locked on beds at all times except when the bed is being moved.
- Check the care plan to find out whether the side rails are to be used.
- Check and adjust protruding objects such as bed wheels or gatch handles.
- Do not block or clutter open areas with supplies and equipment.
- Wipe up spills immediately.
- Encourage patients to use the handrails along corridor walls while walking.
- Monitor patients for signs of weakness, fatigue, dizziness, and loss of balance.
- Monitor patients for safe practice if they independently: propel their wheelchairs, transfer (get out of bed), and ambulate (walk).
- Provide adequate lighting.
- Eliminate noise and other distractions that may increase confusion and create anxiety.
- Avoid leaving patients alone in the tub or shower unless you are given specific permission to do so.
- Check patient's clothing for fit and safety. Loose shoes and laces, long robes, and slacks increase the risk of falling. Footwear should be appropriate for the floor surface. In general, this means using non-skid shoes on tile floor surfaces. However, non-skid shoes may stick to carpeting, causing falls. A leather or synthetic shoe sole may be more appropriate for a carpeted surface.
- Care for the patient's physical needs promptly. Many incidents occur when patients attempt to get out of bed to go to the bathroom.
- Always use the correct technique for transferring and walking patients.
- Use a gait belt when assisting patients to transfer or ambulate.
- Follow the care plan when assisting patients with transfers and ambulation.
- Elevate the rails if you must leave the bedside while the bed is in the high position.
- Wrist/arm and ankle/leg restraints
- Vests
- Belts
- Jackets
- Hand mitts
- Geriatric and cardiac chairs
- Wheelchair safety belts, bars, and tables
- Bed rails (if they meet the definition of a restraint)

Restraints are medical devices. They should never be used as a form of punishment, or for the convenience of the nursing staff. An example of nursing convenience is when a unit does not have enough staff, or staff do not have enough time to monitor a patient.

Another important concern is restraint size. A restraint that does not fit correctly will not hold the patient securely and increases the risk of injury. Using a restraint that does not fit correctly or is not applied according to manufacturer's directions creates a risk of very serious injuries. Manufacturers provide literature, teaching aids, and guidelines for restraint size, based on patient weight. The color of the trim (piping, binding) on a vest restraint is often a visual key to its size. This color coding does not apply to other types of restraints. Belts are usually one-size-fits-all.

Before restraints are used, the registered nurse must assess the patient's capabilities and the reasons for restraint. If the cause can be identified and corrected, the need for a restraint may be eliminated. For example, an unsteady male patient gets up to use the bathroom at night, but does not call for help. His risk of falls can be modified by making sure a urinal is within reach and emptied regularly. The care plan will provide information about the type of restraint to use, the time the restraint is to be applied, and other special information and instructions.
Side rails are routinely attached to hospital beds. Rails can be full length, three-quarter length, half length, or quarter length. Half and quarter length rails may also be called split rails. The rails may be used in any combination. All bed rails can create a hazard in certain circumstances. All are considered restraints in certain situations.

By definition, side rails are restraints. They can also be an enabler. Facilities write their own definitions of restraints. For example, some facilities consider the use of 3 half rails an enabler, and 4 rails a restraint. Some patients pull on rails to position and turn themselves in bed. Others feel more secure if the rails are up. Your facility's policy will define whether rails are restraints or enablers in this situation. Side rails must always be up for patients who are using physical restraints in bed.

Serious injuries can occur if patients attempt to climb over elevated side rails and fall. This is a common cause of hip fractures in confused elderly patients. Leaving the rails down is a much safer alternative. If side rails are raised, monitor the patient frequently.

Monitor the space between the rails, head and footboards, and the mattress. Hospital beds are used for years. Mattresses wear out and are replaced. Patients can become trapped between the mattress, side rails, and other parts of the bed if the replacement mattress is smaller than the original. Make sure that the gap between the mattress and side rails or other parts of the bed is not large enough to cause injury. If a gap is wide enough to entrap a person or body part, notify the nurse promptly. Another bed can be used or the mattress area modified to prevent injury.

The nursing orders often specify the use of padded side rails for patients with certain conditions. Using a commercial side rail pad is the best solution, if they are available and your facility.

Facilities and commercial manufacturers have developed many excellent alternatives to the use of side rails. Possible alternatives to the use of side rails are:
- Beds that can be raised and lowered close to the floor.
- Anticipation of reasons why the patient might get up, including need to use the bathroom, hunger, thirst, restlessness, and pain. Meet these needs and provide calm interventions when you are in the room.
- Use of side rail bolster cushions or body pillows.
- Pressure-sensitive alarms that sound when a patient attempts to get up.
- Self-release belts that sounds an alarm immediately when the closure is released, so staff have time to respond before the person gets up.
- Placement of mats on the floor next to the bed, so that if a fall does occur, the patient will fall on a padded surface. Some mats sound an alarm if the patient's feet or body touch the surface.

Each health care facility has policies addressing when and how side rails may be used. Know and follow your facility's policies.
In addition to the procedures described earlier in this lesson, follow these guidelines when restraints are necessary:
- Use the right type and size of restraint. Do not use a restraint if it is frayed, torn, has parts missing, or is soiled.
- Apply restraints over clothing, never next to bare skin.
- After application, check the fit. You should be able to slip three fingers between the restraint and the patient's body. The device should never restrict breathing.
- The straps must be smooth and not twisted. Position the strap so the person cannot reach the ties. Tie them with slip knots for quick release in case of an emergency.
- Be sure the patient has a signal light and other needed items within reach. Visually check the person every 15 to 30 minutes for comfort and safety. Make changes if needed.
- When the person is restrained in a wheelchair, lock the brakes when the chair is parked. Position the large part of the small front wheels facing forward. This changes the center of gravity of the chair, making it more stable and preventing tripping.
- Release the restraint at least every two hours for ten full minutes for toileting, exercise, and/or ambulation. You may release restraints at other times when you are attending to the patient, such as during feeding.
- Maintain good alignment. Position the person in a comfortable, functional position.
- Do not use restraints in moving vehicles or on toilets unless you are sure the device is intended for that use by the manufacturer. (This does not apply to safety restraints that are part of the vehicle. Follow state laws).
Perform the steps, in order, at the beginning of every procedure.

1.) Wash your hands or use an alcohol-based hand cleanser.
-- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination.
2.) Assemble supplies and equipment and bring them to the patient's room.
-- Improves efficiency, organizes your time, and ensure that you do not have to leave the room.
3.) Knock on the door and identify yourself.
-- Respects the patient's right to privacy. Informs the patient who is giving care.
4.) Identify the patient according to facility policy.
-- Ensures that you are caring for the correct patient.
5.) Ask visitors to leave the room and advise where they may wait (as desired by patient).
-- Respects the patient's right to privacy. Shows respect and courtesy to visitors.
6.) Explain what you are going to do and what is expected of the patient. Answer questions. (Maintain a dialogue with the patient during the procedure and repeat explanations and instructions as needed).
-- Informs the patient what is going to be done and what to expect. Provides information about the procedure and shows respect.
7.) Provide privacy by closing the door, privacy curtain, and window curtain. (All three should be closed even if the patient is alone in the room).
-- Respects the patient's right to privacy. Protect modesty and dignity.
8.) Wash your hands or use an alcohol-based hand cleanser.
-- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination.
9.) Set up supplies and equipment at the bedside. Using overbed table, if possible or other clean area. Cover with a clean under pad, according to nursing judgment, to provide a clean work surface. Open packages. Position items for convenient reach. Position a container for soiled items so that you do not have to cross over clean items to access it.
-- Prepares for the procedure and helps organize time period ensures that equipment and supplies are conveniently positioned and readily available. Reduces the risk of cross-contamination.
10.) Raise the bed to a comfortable working height.
-- Prevents back strain and injury caused by bending at the waist.
11.) Position the patient for the procedure. Support with pillows and props as needed. Place a clean under pad under the area, as needed. Make sure the patient is comfortable and can maintain the position for the duration of the procedure.
-- Ensures that the patient is in the correct anatomic position for the procedure. Ensure that the patient is supported, comfortable, and able to maintain the position throughout the procedure.
12.) Cover the patient with a bath blanket and drape for modesty. Fold the bath blanket back to expose only the area on which you will be working. (This step is essential even if the door, window, and curtains are closed).
-- Respects the patient's modesty and dignity. Ensures that the patient is warm and comfortable.
13.) Apply gloves if contact with blood, moist body fluids (except sweat), secretions, excretions, mucous membranes, or nonintact skin is likely.
-- Applies the principles of standard precautions. Protects the worker and patient from transfer of pathogens.
14.) Apply a gown if your uniform will have substantial contact with linen or other articles contaminated with blood, moist body fluids (except sweat), mucous membranes, secretions, or excretions.
-- Applies the principles of standard precautions. Protects your uniform and skin from contamination with bloodborne pathogens.
15.) Apply a mask and eye protection if splashing of blood or body fluids is likely.
-- Applies the principles of standard precautions. Protect the worker's skin, mucous membranes, and uniform from accidental splashing of bloodborne pathogens.
16.) Lower the side rail on the side where you will be working.
-- Provides an obstacle-free area in which to work.
Perform the steps, in order, upon completion of each procedure.

1.) Remove gloves.
-- Prevents contamination of the patient, the environment, and clean supplies from used gloves.
2.) Reposition the patient to ensure that he or she is comfortable and in good body alignment.
-- All body systems functions better when the body is correctly aligned. The patient is more comfortable when the body is in good alignment.
3.) Replace the bed covers, then remove any drapes used. Place use drapes in plastic bag to discard in trash or soiled linen.
-- Provides warmth and security. Contains linen and drapes that have been contaminated during the procedure.
4.) Elevate the side rails, if used, before leaving the bedside.
-- Prevents contamination of the side rail from gloves. Ensures patient safety. Prevents falls, accidents, and injuries.
5.) Remove other personal protective equipment, if worn, and discard in plastic bag or according to the facility policy.
-- Prevents contamination of the patient, the environment, and clean supplies from used PPE.
6.) Wash your hands or use an alcohol-based hand cleanser.
-- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination.
7.) Return the bed to the lowest horizontal position.
-- Respect patient's right to a safe environment. Ensures patient safety. Prevents falls, accidents, and injuries.
8.) Open the privacy and window curtains.
-- Privacy is no longer necessary unless preferred by the patient.
9.) Position the call signal and needed personal items within reach.
-- Prevents accidents and injuries. Gives the patient a sense of security by ensuring that help is available. Enhances patient convenience. Eliminates the need to call out or reach for needed personal items (which could result in a fall).
10.) Wash your hands or use an alcohol-based hand cleanser.
-- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination. (Although the hands were washed previously, they have contacted the patient and other items in the room. Washing them again before leaving prevents potential transfer of microbes to other patients, equipment, and surfaces outside the patients unit).
11.) Perform a general safety check of the patient and environment.
-- Stays consistent with "think safety" motto when entering and leaving the room; decreases exposure to environmental risks and hazards; helps ensure patient safety.
12.) Remove procedural trash and contaminated linen when you leave the room. Discard in appropriate container or location, according to facility policy.
-- Applies the principles of standard precautions. Prevents the spread of microbes and reduces the risk of cross-contamination.
13.) Inform visitors that they may return to the room.
-- Shows respect, courtesy, and hospitality to visitors and patient.
14.) Document the procedure, your observations, and the patient's response to the procedure.
-- Provides a legal record of ongoing progress and care. Provides a record of what has been done and observations of the patient's condition. Serves as a vehicle for communication for other members of the interdisciplinary team.
1.) Start with the bed flat and the patient lying on the back. The patient's head should be about 2 to 3 inches from the head of the bed.
2.) Place a pillow under the patient's head. It should extend about 2 inches below the patient's shoulders, with the head in the middle of the pillow.
3.) Place a trochanter roll along the affected hip or along both hips if the patient has little control over the legs. A trochanter roll is devised by rolling a bath blanket into a shape about 12 inches long. The roll should be just long enough to reach from above the hip to above the knee. The trochanter roll prevents external rotation of the hip.

Make a trochanter roll or support by:
- Folding a bath blanket lengthwise in thirds.
- Positioning the patient in the center of the folded bath blanket. The blanket should extend from mid to lower thigh to the waist.
- Rolling each side of the blanket under and toward the patient until the blanket roll is firmly against the patient. Then tuck the roll inward toward the bed and patient to maintain the patient's position.

4.) Place pillows under the legs to reach from above the back of the knee to the ankle so that the ankles and heels do not rub on the sheets.
5.) Laying flat on the back is very uncomfortable for some people. This is especially true for persons with low back pain. Elevating the knees with a foam bolster or one or more pillows will relieve pressure on the back and reduce discomfort.
6.) If the care plans so indicates, position a footboard or place a folded pillow to support the patients feet. The ankles should be at 90° angles.
7.) Extend the patient's arms and place small pillows to reach from the elbow to below the wrists. The hand should be in alignment with the wrist and the palm should be down.
The semisupine position is also called the tilt position. It should not be confused with the lateral position. The patient in this position is not lying directly on the side. When correctly used, the semisupine position relieves pressure from the hip, sacrum, coccyx, and buttocks. The spine is straight and the patient is positioned so he is leaning against a pillow for support. Both legs are straight. The top leg is slightly behind the bottom leg. A pillow is placed under the top leg to keep it even with the hip joint. The lower shoulder is pulled slightly forward so that pressure is distributed over the back rather than the shoulder joint. The arms can be at the sides or folded across the abdomen. Begin the procedure with the patient in the supine position. It will be easiest if you move him or her to the side of the bed that will be behind his or her back when you have finished positioning.

1.) Turn the patient on the side, facing away from you. Leave about a 45° angle between the patient's back and the bed.
2.) Position a pillow behind the patient's back. Push the patient slightly back against the pillow, then roll and tuck it under to support the back and relieve pressure on the arm or shoulder.
3.) Pull the bottom shoulder slightly forward to prevent pressure on the shoulder joint.
4.) Position another pillow under the patient's top leg, level with the hip joint.
5.) Straighten both legs, positioning the top leg slightly behind the bottom leg and supported by a pillow.
6.) Position the patient's upper arm in a position of comfort. The wrist may rest on a pillow or the abdomen, according to patient preference.
1.) Carry out each initial procedure action.
2.) Lower the side rail nearest to you. Cross the patient's far leg over the leg that is nearest to you.
3.) Cross the far arm over the patient's chest. Bend the near arm at the elbow, bringing the hand towards the head of the bed.
4.) Place your hand nearest the head of the bed on the patient's far shoulder. Place your other hand on the patient's hips on the far side. Brace your thighs against the side of the bed.
5.) Roll the patient toward you. Do it slowly, gently, and smoothly. Help the patient bring the upper leg toward you and bend it comfortably.
6.) Put up the side rail. Be sure it is secure.
7.) Go to the opposite side of the bed.
8.) Place your hands under the patient's shoulders and then the hips. Pull toward the center of the bed. This helps the patient maintain the side-lying position. Make sure the patient is not lying directly on the lower arm. The lower shoulder should be tipped slightly, so pressure is not centered directly over the joint.
9.) Make sure the patient's body is properly aligned and safely position.
10.) A pillow may be placed behind the patient's back. Secure it by pushing the nearest side under the patient to form a roll.
11.) If the patient is unable to move independently, position the arms and the legs. Support them with pillows between the shoulders, hands and knees, and ankles to prevent friction and contractures. If the patient has an indwelling catheter, make sure the tubing is not between the legs, to prevent traction on the catheter and to prevent pressure ulcers.
12.) Carry out each ending procedure action.
Nope: This procedure is performed when the patient's spinal column must be kept straight, such as following spinal surgery or spinal cord or vertebral column injury. It is a good procedure to use with any dependent patient.
1.) Carry out each initial procedure action.
2.) Get help from another nursing assistant.
3.) Raise the bed to waist height horizontal position. Lock the wheels.
4.) Lower the side rail on the side opposite to which the patient will be turned. Both assistants should be on the same side of the bed.
5.) One assistant places hands under the patient's head and shoulders. The second assistant places hands under the hips and legs. Then move the patient as one unit towards you.
6.) Place a pillow lengthwise between the legs. Fold the patient's arm over the chest.
7.) Raise the side rail. Check for security.
8.) Go to the opposite side of the bed and lower the side rail.
9.) Turning the patient to the side may be done by:
a.) Using a turning sheet that was previously placed under the patient.
-- Reach over the patient, grasping and rolling the turning sheet toward the patient.
-- One nursing assistant should be positioned beside the patient to keep the shoulders and hips straight.
-- A second assistant should be positioned to keep the thighs and lower legs straight.
b.) If a turning sheet is not in position, the first assistant should position hands on the patient's far shoulder and hips.
-- Second assistant position hands on the patient's far thigh and lower leg.
10.) At a specific signal, all the patient toward both assistants in a single movement, keeping the spine, head, and legs straight. If a turning sheet is used, grasp the sheet and move the patient as one unit, onto their side.
11.) Place additional pillows behind the back to maintain the patient's position. A small pillow or folded bath blanket may be permitted under the patient's head and neck. Leave a pillow between the legs. Position a small pillow or folded towels to support the arms.
12.) Carry out each ending procedure action.