Providing Safety

Prof. Jericho G. Dapula, R.N.

Safety
Freedom from psychological and physical injury

Environmental Safety
An environment includes all of the many physical and psychological factors that influence and affect the life and survival of the client. It reduces the incidence of illness and injury Shortens the length of hospital stay and treatment. Improves or maintains clients functional status. Increases clients sense of well being.
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Fire
Causes of Fire in Hospital
Smoking Faulty Electrical wiring

3 Elements that can cause Burns:

Heat Combustion Oxygen

Nurses Major Goals:

Protect client Injury Contain and put out the Fire
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Scalds and Burns

Scalds
Burn from hot liquid, vapor, steam

Burns
Results from excessive exposure to thermal, chemical, electrical or radio active agents.

Common Home Hazards:

Pot Handles Electrical Appliances Excessively hot bath water
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Falls
People of any age can fall but it is most common in infants and elderly. Causes:
Wet floors Equipments crowded on Bed Furnitures Equipments obstructing access to bed, chairs, bathrooms. Poor Lighting Glair
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Poisoning
It is any substance that can cause injury or kills through its chemical action when inhaled, injected, applied or absorbed. Poison Control Centers
Provides accurate up-to-date information about potential hazards and treatment as needed

Causes of Child Poisoning:

Inadequate supervision Improper Storage (over 500 in an average Home)

Causes of Adolescent Poisoning:

Snake Bites Recreational Drugs and Suicide Attempts
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Poisoning
Causes of Poisoning in Elderly
Accidental Ingestion due to poor eye sight Overdose of Prescribed Medication

Nurse Health Teaching

Place the clients head in one side or in between legs to prevent aspiration. Search for the open container or empty bottle to know the specific poison. Note the amount ingested Call the poison control centre and report the poison ingested, amount, clients age and state, and any apparent # symptoms.

Preventing Poisoning
Put away in a safe storage, out of reach of infants and children any toxic substance. Lock cupboards with any cleaning agents insides. Avoid storing toxic chemicals in food containers. Do not remove container labels Teach children not to eat any part of an unknown plant, Do not drink medicine in front of a children, they might imitate you.

Preventing Poisoning
Place poison warning stickers on bottles. Never call medicine candy when giving to children. Read and follow directions from the label before using them. Keep syrup of ipepac (emetic) at hand at all times Display emergency numbers such as poison control centre near or on all telephones.
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Electric Shock
Electrical Equipment must be used with proper grounding.
This can be identified as 3rd long prong, which transmits short, stray electric circuit to the ground.

Absence of grounding may cause sparks and if near an explosive gas, this can cause a fire. If an Individual receives a shock, DO NOT touch the person until the power shuts down.
This can cause burns, cardiac, and respiratory arrest.
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Reducing Electrical Hazards

Check cord for any fraying or apparent damage. Avoid overloading fuse boxes. Use grounded outlets and plugs. Pull the appliances by firmly gripping the plug and pulling it straight out. Never use appliances near water areas. Keep electrical cords out of reach of children. Put wall outlet covers to protect children.
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Excessive Noise
A heath hazard that can cause hearing loss depending on:
Over-all noise level Frequency range of the noise Duration of exposure

120 db is painful and can cause hearing impairment even for a short period of time. 85 to 95 db for several hours a day can cause progressive or permanent hearing loss. Below 85 db and below cannot cause any hearing damage.
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Physiologic Effects of Noise

Increased Heart Rate Increased Respiratory Rate Increased Muscular Activity Nausea Hearing Loss

Minimizing Noise
Playing a musical background Placing acoustic tiles on ceilings, walls, and walls Putting on a drape or curtain

Radiation
It is a health hazard of recent concern due to its importance to medicine, for diagnostic and therapeutic procedures. This can cause treatment to some tissues but can also damage other tissue.
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Principles on Radiation
The longer the time in the presence of radiation, the greater the exposure. The closer the person to Radioactive Materials, the greater the exposure. The more extensive the use of lead and other radiation shields, the greater the protection.
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Nursing Action
The Client with Radio active implant is an immediate source of radiation to its environment. The nurse who is in contact with patient who has lead implant must wear a lead apron. The nurse must also deals with radioactive bodily discharges.
Must Put the waste on a special container Wash GLOVED hands properly before removing it and disposing it also to a special container.
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Suffocation or Choking
Suffocation or asphyxiation happens where there is a lacked or cutting off of oxygen or air. Causes:
Drowning Placement of Plastic Bag Foreign Body Anatomical changes (Acute pharyngitis)

This can lead to Cardiac and Respiratory Arrest and can be the cause of DEATH.
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Universal Sign of Choking

Preventive Measures
Keep away plastic bags from children. Wear safety life jackets when going fishing and boating. Encourage children to learn how to swim. Educate adults not to leave children unsupervised near pools and beaches. Encourage non skid surface in bathtubs and bathrooms. Always use ABC for CPR.
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Factors Affecting Safety

Age
Infants
Baby Proof Home. Use Car seats with safety straps. Guard infant when on bed or changing table. Use gate on stairs. Never shake or vigorously jiggles the baby. Make sure the bath water is not too Hot, never leave the baby unattended. Do not hold infant while drinking or working near hot liquids. Cool vaporizers instead of hot liquids ahould be used to avoid burns.
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Factors Affecting Safety: Age

Avoid foods that can cause blockage of airway. Be sure toys have no small pieces. Hanging toys should be out of reach to prevent strangulation. Avoid placing large toys in the crib that can be use for climbing Position cribs away from curtains and cords. Cover electrical outlets. Remove hazardous objects within reach. Keep syrup of ipepac and poison control number available.
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Factors Affecting Safety: Age

Toddler
Should be supervised at play for they are eager to explore the world around them. Should use a car seat when driving a vehicle, the car seat should be used until the child weighs 40 lbs. Regardless of age. child-lock car doors. Keep the child away from the stove when preparing hot meals. Keep dangling cords of appliances from childrens reach . Place inaccessible locks on doors and windows Place furniture away from windows.
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Factors Affecting Safety: Age

Secure screen on all windows. Place gates on stairs. Do not permit toddlers to play or sleep in an upper bunk bed. Never leave toddler near any body of water. Keep toilet lid closed. Keep away any poisonous products out of reach. Keep syrup of ipepac and poison control number available.
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Factors Affecting Safety: Age

Pre-School
Pre-Schools tends to be imaginative when playing, they tend to defy fear and attempt things they see in cartoons or television. Can learn simple and verbal safety instructions. When the child is over 40 lbs, he/ she can put in a booster seat until 60 lbs or when the head is higher than the back seat, wherein the seatbelt can be positioned properly. Teach pre-school basic safety rules when playing in a play ground near swings and ladders. Never allow the pre-school to play with match or lighters.
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Factors Affecting Safety: Age

Pre-schoolers should be taught what to do in case of fire or if fire caught his or her clothes. Guns should be locked away unloaded, and tell the pre-school to walk away if he founds one and tell an adult. Pre-school should be taught never to point a toy gun to another person. Teach the pre-school that if another person touches his or her body part inappropriately, tell an adult. Teach the preschool the proper way of saying his or her private part, instead of flower pot or birdie. Teach them not to talk or accept gifts of any kind from a stranger.
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Factors Affecting Safety: Age

Teach the pre-school their full name, complete address, and parents name. Teach the child to dial 911 in an emergency situation. Keep syrup of ipepac and poison control number available.

Factors Affecting Safety: Age

School Age
Less fear in playing. Imitates by using tools in real life and household items. Can fit snugly into a car seat belt without seat booster. Common cause of injuries: bicycles, skate boards, team games and sports as the child is increasing in motor activities and independence. Should wear protective gears when at play. Teach the school aged child water safety. Avoid teasing and playing rough with animals. Never allow them to play match and lighters. They should be taught what to do in case of fire.
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Factors Affecting Safety: Age

Guns should be locked away unloaded, and tell the school aged child to walk away if he founds one and tell an adult. Teach the pre-school that if another person touches his or her body part inappropriately, tell an adult. Teach them not to talk or accept gifts of any kind from a stranger. Teach the child safety traffic rules, especially when crossing the streets. Teach the child to dial 911 in an emergency situation. Keep syrup of ipepac and poison control number available.
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Factors Affecting Safety: Age

Adolescent
Risk Takers Have the urge to experiment and be independent. Teach dangers related to drugs and alcohol. Help to recognize that there are choices when difficult or potentially dangerous situation arise. Advocate the use of seat belts. Instruct the consequences of injuries that motor vehicle accidents can cause. Instruct water safety, especially in unknown or unfamiliar waters. Instruct about the dangers of violence, guns, and gangs.
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Factors Affecting Safety

Lifestyle
Occupational hazards Neighborhood Poverty Drugs

Mobility Status
Muscle weakness Paralysis Poor balance

Sensory/ Perceptual Alterations

Impairment of the 5 senses People suffering from Hallucinations (perception of a stimuli in absence of such stimuli) or Illusions
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Factors Affecting Safety

Level of Awareness
Awareness is the ability for the person to perceive environmental stimuli and body reactions and to respond appropriately through thought and action. Lack of sleep Unconscious or semiconscious Disoriented person Under the influence of drugs

Emotional State
Anxious Angry persons Depression
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Factors Affecting Safety

Ability to Communicate
Illiterate Aphasia-inability to use language normally and express ideas by speech, writing, or signs, or inability to comprehend spoken or written language.

Knowledge of Safety Precautions

Lack of knowledge in performing a procedure or operating equipments can produce further damage or injury to client.
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ASSESSING: Risk Factors for Falls

Age greater than 65 Previous Hx of falls in home or hospital Difficulty Walking Difficulty getting out of Bed or Chair Episodes of dizziness and seizures Difficulty asking someone for help Use of assistive or ambulatory devices Impaired Vision or Hearing Altered mental state Current Medication: Sedatives, Hypnotics, Tranquilizers, Analgesics, Diuretics, or Laxatives

ASSESSING: RISK tool

Reassessment Is Safe Kare Tool Four Element of RISK Tools
Unsteady Gait/ Dizziness/ Imbalance Impaired Memory/ Judgement Weakness Hx of Falls

Client in wheel chair is at greater risk

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ASSESSING: Home Hazard Appraisal

Walkways and Stairways
Handrails Uneven, loose, and broken pathways or floors Lighting

Floors
Uneven Highly Polished, slippery floors

Furniture
Placement and sharp corners Level of chairs and tools
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ASSESSING: Home Hazard Appraisal

Bathrooms
Grab bars on toilets and tubs Non-Slip mat Lighting Level of toilet

Kitchen
Inaccessible areas Lighting furnitures
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ASSESSING: Home Hazard Appraisal

Bedrooms
Lighting Night light Floors Furniture Accessibility of light switches

Electrical
Frayed Cord Overloaded Outlets Outlets near Water
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ASSESSING: Home Hazard Appraisal

Fire Protection
Smoke Detectors Fire Extinguisher Fire Escape plan Fire Exit Emergency numbers Storage of combustible material

Toxic Substances
Expired Drugs Improper labelling of chemicals
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DIAGNOSIS
High Risk for Injury
A state which an individual is at risk for injury as result to an environmental conditions interacting with individuals adaptive and defensive resources. Risk Factors:
Perceptual or Physiologic Deficit Developmental Age Lack of Awareness of environmental hazards Insufficient knowledge of safety precautions Substance Abuse
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DIAGNOSIS
High Risk for Poisoning
A state which an individual is at accentuated risk for accidental exposure to or ingestion of drugs or dangerous substance in amounts sufficient to cause poisoning. Risk Factors:
Individual (Internal ) Factors
Reduced Vision Lack of Drug Education Cognitive or Emotional Difficulties
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DIAGNOSIS
Environmental (External) Factors
Large supplies of Drugs and toxic chemicals at Home Wrong placement of Drugs and chemical (Unlocked Cabinets and within the reach of Children) Flaking or Peeling Paint within the presence of a child Chemical contamination of food and water Unprotected contact with toxic chemicals or radiation Poisonous Vegetation Poor Ventilation Pollutants in the Atmosphere
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DIAGNOSIS
High Risk for Suffocation
A state in which an individual is at accentuated risk of accidental suffocation (inadequate air for inhalation). Risk Factors:
Individual (Internal ) Factors
Reduced Olfactory sensation Reduced Motor Abilities Lack of Safety Education Cognitive and Emotional Difficulties

DIAGNOSIS
Environmental (External) Factors
Pillow placed in infant cribs Vehicular warming in closed garage Children Playing with plastic bags Children placing small objects in mouth and nose Children left near body of water Poor ventilation Large amounts of food Pacifier tied in infants neck

DIAGNOSIS
High Risk for Trauma
A state in which an individual is at accentuated risk for accidental tissue injury (e.g.: Wound, Burn, Fracture) Risk Factors:
Perceptual or Physiologic Deficit Developmental Age Lack of Awareness of environmental hazards Insufficient knowledge of safety precautions Substance Abuse
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PLANNING
The plan of care for client must include:
Prevent the progression of problem into actual injury
When Assisting older clients in walking with visual impairment the nurse should stand at the non dominant side one step ahead grasping the nurses arm with the non dominant hand.

Educating Clients for preventive Actions Modifying clients environment to make it safe
Arranging the furniture so the client wont trip and arranging the bed side item within the clients reach. Use of side rails, proper positioning and lighting, and reducing noise levels.
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PLANNING
OUTCOME Criteria: The client....
Must remain free or avoids personal injury
During hospitalizations Or at home setting

Identifies Environmental Hazards that increase potential injury Identifies preventive measures for specific hazard Reports use of appropriate # countermeasures to protect self from injury.

IMPLEMENTATION
Maintaining Fire Safety
Health Care Agency
Telephone numbers of emergency services must be displayed on all telephones As a health personnel you must know the location opf the fire exits Know the location and types of fire extinguishers and how to use them. Fire Drill and Fire Evacuation Plan in place. Clear Hallway of unnecessary furniture and equipments. Sign posted in Elevators: Use Stairs in Case of Fire Location of Fire Exits is clearly marked.
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IMPLEMENTATION
In Case of FIRE
Evacuate who are in immediate danger:
First, direct ambulatory clients to safe area Enlist or direct those who can help in moving clients in wheel chairs, those can be moved by stretcher, carried or dragged in blankets.

Activate Fire Alarm if One is Nearby. Notify the hospital switch board for the location of the fire. If the fire is small use fire extinguisher. Contain the fire by closing windows and doors. Turn OFF and OXYGEN and any electrical appliances in the vicinity of the fire. Clear Fire exits if necessary. Contain smoke by placing damp blankets or clothes around the edges of the doors. Protect clients from smoke inhalation by giving them or instructing them to breathe in wet wash cloth. #

IMPLEMENTATION
In case of Fire remember the mnemonic RACE R-escue: remove all clients from the vicinity of the fire. A-larm: Activate the alarm: report the fire before extinguishing it. C-onfine: close doors and windows when fire is detected E-xtinguish: extinguish the fire using the proper extinguisher.
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Types of Fire Extinguishers

Class of Fire
Class A Paper, Upholstery, Rags, Ordinary Rubbish Class B Flammable Liquids and Gases Class C Electrical Class D Designated Metals

Types of Fire Extinguishers

Types of Extinguisher Water Pump Class of Fire A Precautions/ Comments Do not use in electrical appliances (can cause Electric Shock) Do not use in flammable liquid (can cause splatter that can spread fire) Limited range, use close to fire and small fires only Can cause grease to splatter and use in small fires 0nly Good for home use For Garage Use Dray powder absorbs heat # which is perfect for metal

Carbon Dioxide (CO2) Dry Chemicals Multi-Purpose Foams Special Dry Powder

B&C B&C A, B, & C B D

How to Use a Fire Extinguisher

Remember the mnemonic PASS P-ull the pin A-im at the base of the fire S- queeze the handle S-weep the fire from side to side
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IMPLEMENTATION
Preventing Fires at Home
Keep Emergency Numbers near telephone Be aware of the nearest exits Use fire extinguishers and keep it in good working condition Make sure fire detectors are in good working condition. Never let an open flame unattended. Unplug appliances when not in use. #

IMPLEMENTATION
Preventing Falls
Orient client upon admission in the hospital surrounding and call system. Assess clients ambulation and mobility for assistance and devices. Closely supervise clients that are risk for falls. Encourage client use of call bell (with in reach) for assistance. Placed bed side and over bed tables near the bed or chair so the client wont over reach and loose their balance. Proper use of side rails in sedated, confused, resteless, unconscious patients.
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IMPLEMENTATION
Always put the bed in low position when not giving care so the client can move in and out of bed without difficulty. Encourage client to use handle bars in toilets and hallways. Make sure non skid mats are available in bath tubs and shower room. Encourage client to use non skid foot wear Modify environment Remove poor lighting and glare that causes client to squint their eyes.
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IMPLEMENTATION
Device used in Preventing Falls
Ambularm Safety Monitoring Device
a device which is position sensitive switch that triggers an audio alarm when the client attempts to get out of bed unassisted which signals the nurse to intervene.

AMBULARM

Restraining Clients
RESTRAINTS
Are protective devices used to limit clients physical activity or part t of the body of the client.

Two Types of Restraints

Physical Restraints- Manual or with the used of an equipment or device. Chemical Restraints- use of medication
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Restraining Clients
Purpose:
Falling out of a bed or chair Pulling out intravenous line, Catheters, feeding tubes, and such devices. Breaking open sutures Wandering and entering unsafe place Infringing in the rights of others or Causing harm to others.
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Restraining Clients
OBRA Law
Omnibus Budget Reconciliation Act It clearly states that restraints should be used as a last resort.
Applied under physicians written order Client agreed to be restrained That clients be free of physical restraints not required to treat medical symptoms.

General Law:
Authorized in writing by a physician. Used for only a specified period of time. Applied only by a physician or other qualified licensed nurse or personnel under the supervision of the physician.

Avoiding Legal Problems of Restraints

Inappropriate decisions regarding restrains may subject the nurse to allegations of false imprisonment, battery and assault, and lack of informed consent. Know the agencies policy regarding restraints. When determining the need for restraints, assess the clients underlying condition for restlessness or the need for restraints. Apply restraints for clients SAFETY and HEALTH, not to cope for the agencies under staffing. Avoid being influenced by the family member not to restraint the client, Nurses cannot legally delegate the responsibility to the family member.

Avoiding Legal Problems of Restraints

Always obtain a physicians order. Recognize the clients ability for decision making regarding his/ her treatment. If the client refuse for application of restraint, let the patient sign a release of liability form for any injury resulted. For the incompetent client in decision making, let the clients guardian or immidiate family relative to sign the form. Keep in mind the Principle of Least Restriction. Make sure the restraints fits properly
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Restraining Clients
Implementation
If necessary, the physician orders the restraints, the type of restraints and the duration of use. Doctors Order should be renewed every 24 hours. If the order is through phone, verify it by another nurse and obtained the written order within 24 hours. Restraints is not ordered PRN. Reasons should be given to the family and informed consent must be signed. Use a Clove Hitch Knot on restraints. Ensure enough slack on the straps to allow movement of other body parts. Secure restraints on bed frame NOT on side rails. Assess clients skin integrity, circulatory and vascular system, and allow periodic exercise every 30 mins. #

Alternatives to Restraints
Nurses can act as Buddies. Place unstable clients to an area which can be closely supervised. Prepare client first before moving to another unit to prevent confusion. Frequently assist confused client to prevent falls from climbing out of bed. Discuss with the physician the time for use of laxatives and diuretics so the peak action should occur on the favourable time. Stay with the client using bed side commode which is high risk for falling. Monitor clients medication. Lower the level of the bed.

Alternatives to Restraints
Replace whole length side rails to half or quarter length side rails in confused clients to prevent climbing out of bed resulting to falls. Use rocker chair or frequent walks to decline clients energy thus the clients will be less inclined to wander. Properly positioned clients in wheel chair with the used of pillow. Warm beverage, back rub , soft lights or walks can be recommended to agitated clients. Use environmental restraints. Place a picture or clients personal item on the clients door to help them identify their room.

Alternatives to Restraints
Determine the possible cause of Clients SUNDOWNERS SYNDROME (nocturnal wandering and disorientation when darkness falls, associated with dementia), such as poor eyesight, poor hearing, and pain. Establish ongoing assessment to clients changes in physical and cognitive functional abilities and risk factors. #

Documentation Points when Restraining a Client

Reason for Restraint Method of Restraints Date and time of Application Duration of the use or restraints and clients response Release from restraints for assessment of skin, circulatory, and neurovascular system and periodic exercise.

Selecting a Restraints
It restricts the clients movement as little as possible It is the least obvious to others It does not interfere with the clients treatment or health problem It is readily changeable It is safe for the particular client
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Kinds of Restraints
Jacket Restraints

Kinds of Restraints

Kinds of Restraints
Belt or Safety Strap Body Restraints

Kinds of Restraints
Pelvic Holder Vest Holder

Kinds of Restraints
Mitt or Hand Restraints

Kinds of Restraints
Limb Restraints

Kinds of Restraints
Elbow Restraints

Kinds of Restraints
Mummy Restraints (No Picture) Crib Dome or Net

Applying Restraints
Purpose:
To enable the client to receive treatment and to allow the treatment to proceed without the client interference

Applying Restraints
1. Explain to the client and support system the procedure of restraints. 2. Apply the selected Restraints.
1. Belt Restraint
1. 2. Determine the good condition of the belt, if Velcro is to be used, make sure both sides are intact. If the belt has a Long Portion and a Short Portion, tie the Long Portion on the movable part of the bed and the short portion around the clients waist over the gown. Make sure there is a finger width between the belt and the client.
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3.

Applying Restraints
2. Jacket Restraint
1. 2. Place the Client on the vest with opening on either front or back. Pull the tie at the end of the vest flap across the chest and place it on the slit opening on the opposite side of the chest. Repeat no.2 for the other tie. Use Half Bow Knot to secure each tie around the movable bed or square (reef) knot behind a chair. Ensure the client position approximately to enable maximum chest expansion for breathing.
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3. 4. 5.

Applying Restraints
3. Improvised Wrist or Ankle Restraint
1. Cushion the wrist or ankle with padded dressing. 2. Wrap a long narrow strip if gauze or cloth tie around the padding 3. Secure the wrist or ankle to the bed by using a clove hitch knot to the movable part of the bed.

Applying Restraints
4. Elbow Restraints
1. 2. 3. 4. 5. 6. Examine the restraints, make sure that the tongue depressors are intact and not broken. Place the infants elbow at the centre of the restraints. Wrap the restraints smoothly around the arm. Secure the restraints by using safety pins, ties or tapes. Ensure that the restraint is not so tight that it obstructs blood circulation. After this you can pin the restraints to the childs shirt, to prevent from sliding down.
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Applying Restraints
5. Mummy Restraints
1. 2. 3. 4. 5. 6. 7. Obtain a blanket that the distance of one corner to the order is twice the width of the baby. Lay it on a flat dry surface. (diamond shaped) Fold the upper corner and lay the baby in a supine position. Fold the right corner leaving the left arm free. Fold the excess blanket at the bottom. Fold the left corner covering also the left arm and tuck the blanket under the body. Remain with the infant until the procedure is done.
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Applying Restraints
6. Crib Net
1. Place the net over the sides and ends of the crib. 2. Secure the ties to the frame of the crib which the crib side can be freely moved without removing the net. 3. Test with your hand to a certain that the net will stretch if the child stands in the cribs against it.

Applying Restraints
3. Documentation
1. 2. 3. 4. 5. 6. Record the time you notified the physician, The type of restraint Time it was applied Reason for application Clients response Number of times the restraints has been removed # 7. Number of times skin care given.

EVALUATION
Have precautions have been taken to prevent trauma? What precaution does the client desire and know about? Did the client agree to follow any precautions? Did the nurse write and implement teaching plan for the client? Do the support persons understand and agree to follow precautions? Is there any medications affecting the clients abilities?
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