transfers, ambulation safety and restraints. lesson objectives (transfers), by the end of this...
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Transfers, Ambulation Transfers, Ambulation Safety and RestraintsSafety and Restraints
Lesson Objectives (Transfers), By Lesson Objectives (Transfers), By the end of this lesson the student the end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:
Describe the procedure for transferring Describe the procedure for transferring the client: moving up in bed, bed to chair, the client: moving up in bed, bed to chair, bed to stretcher, chair to bed,bed to stretcher, chair to bed,
Explain at least three safety factors Explain at least three safety factors practiced while performing a transferpracticed while performing a transfer
List common hazards encountered during List common hazards encountered during a transfera transfer
Explain the importance of knowing the Explain the importance of knowing the diagnoses and capabilities of the clientdiagnoses and capabilities of the client
Lesson Objectives (Ambulation), By Lesson Objectives (Ambulation), By the end of this lesson the student the end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:
List common hazards of ambulation and List common hazards of ambulation and of using assistive devicesof using assistive devices
Explain the importance of knowing the Explain the importance of knowing the diagnoses and capabilities of the clientdiagnoses and capabilities of the client
Describe methods to support the client Describe methods to support the client during ambulationduring ambulation
Discuss various gaits used for walking Discuss various gaits used for walking with a cane, walker or crutcheswith a cane, walker or crutches
Create sample charting after ambulating a Create sample charting after ambulating a client, including the important dataclient, including the important data
Lesson Objectives (Restraints), By Lesson Objectives (Restraints), By the end of this lesson the student the end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:
Discuss rationale for using restraintsDiscuss rationale for using restraints
Define the terms immobilize, legal rights, Define the terms immobilize, legal rights, limb holder, chemical restraintslimb holder, chemical restraints
Explain the patientExplain the patient’’s Bill of Rights regarding s Bill of Rights regarding consent of the client, family or guardian and consent of the client, family or guardian and written medical orders for use of restraintswritten medical orders for use of restraints
Discuss the procedure for applying various Discuss the procedure for applying various physical restraintsphysical restraints
Lesson Objectives (Safety), By the Lesson Objectives (Safety), By the end of this lesson the student end of this lesson the student
vocational nurse will be able to:vocational nurse will be able to:
Define vocabulary related to hospital/client environment.
Discuss purposes of space and how a nurse can respect the client's space.
Describe how to maintain the client's right to privacy.
Describe specific environmental factors that contribute to the comfort and safety of the client.
Discuss the effects of sensory deprivation for the client.
Identify personnel and committees that are involved in maintaining a safe, comfortable and the therapeutic environment in the hospital.
Discuss rationale for using restraints.
List the common types of injury that may occur in the hospital setting
Lesson Objectives (Safety), By the Lesson Objectives (Safety), By the end of this lesson the student end of this lesson the student vocational nurse will be able to:vocational nurse will be able to:
Define the terms:
a. Immobilized
b. Legal rights
c. Limb holder
d. Chemical restraints
Explain the Bill of Rights regarding consent of the client, family, or guardian and written medical orders for use of restraints.
Discuss the procedure for applying various physical restraints.
Transfers, Ambulation, Transfers, Ambulation, RestraintsRestraints
Safety !!!!Safety !!!!
Transfers, Ambulation, Transfers, Ambulation, RestraintsRestraints
(Safety Interventions):(Safety Interventions):
Assess for Orthostatic HypotensionAssess for Orthostatic Hypotension
DangleDangle
Client with special needs: (eg.) blind Client with special needs: (eg.) blind
Lock wheel chairs, stretchers and bedsLock wheel chairs, stretchers and beds
Check floors for safety (wet or clutter)Check floors for safety (wet or clutter)
Tub and shower surfacesTub and shower surfaces
Non-skid slippersNon-skid slippers
Common Hazards Common Hazards Encountered:Encountered:
Unable to assist or follow directionsUnable to assist or follow directions
Client fear Client fear
Client fatigueClient fatigue
Client weakClient weak
Problem with assistive devicesProblem with assistive devices
Inexperience of nurseInexperience of nurse
Size of client Size of client
Size of nurse Size of nurse
Supporting The Client:Supporting The Client:
PhysicallyPhysically
EmotionallyEmotionally
PsychologicallyPsychologically
Tips:Tips:
Moving from bed to chair:Moving from bed to chair:
Chair on strong sideChair on strong side
Pivoting (clientPivoting (client’’s hand on arm of chair)s hand on arm of chair)
Ambulating a Client:Ambulating a Client:
Support weak sideSupport weak side
Match clientMatch client’’s gates gate
Basic Nursing Care:Basic Nursing Care:
ComfortComfort
Safety Safety
Change PositionChange Position
Chair CushionsChair Cushions
ROM ExercisesROM Exercises
Orientation of ClientOrientation of Client
Therapeutic TouchTherapeutic Touch
Personal Items near Client Personal Items near Client
Client Daily HabitsClient Daily Habits
ADLADL’’SS
Documentation:Documentation:
TimeTime
DistanceDistance
Use of Assistive DevicesUse of Assistive Devices
ClientClient’’s Feelingss Feelings
WeaknessWeakness
Poor Balance Dizziness Poor Balance Dizziness
PosturePosture
Other ProblemsOther Problems
Number of People to AssistNumber of People to Assist
Procedure for Transfers:Procedure for Transfers:
Check the doctorCheck the doctor’’s orderss orders
Check diagnosis of the patientCheck diagnosis of the patient
Dangle (usually necessary-after BR)Dangle (usually necessary-after BR)
Assist client to a sitting position, legs at side Assist client to a sitting position, legs at side of bed, not touching the floorof bed, not touching the floor
Allow client to dangle for several minutesAllow client to dangle for several minutes
May be necessary to return client to bed May be necessary to return client to bed
Orthostatic Hypotension (Signs Orthostatic Hypotension (Signs and Symptoms):and Symptoms):
Dizziness Dizziness
WeaknessWeakness
FaintFaint
FatigueFatigue
Lightheadedness Lightheadedness
Orthostatic Blood Orthostatic Blood Pressures:Pressures:
LyingLying
SittingSitting
StandingStanding
Orthostatic Orthostatic Hypotension:Hypotension:
Systolic Blood Pressure Systolic Blood Pressure
drop < 25 mm Hgdrop < 25 mm Hg
Diastolic Blood PressureDiastolic Blood Pressure
drop < 10 mm Hgdrop < 10 mm Hg
Equipment (Transfers): Equipment (Transfers):
Wheel Chair with Replacement ArmWheel Chair with Replacement Arm
Geri ChairGeri Chair
Transfer BeltTransfer Belt
Sliding BoardSliding Board
Mechanical Lifts (Hoyer)Mechanical Lifts (Hoyer)
Bed ScaleBed Scale
Pull Sheet Pull Sheet
Moving Client Up In Moving Client Up In Bed:Bed:
Position on backPosition on back
Ask client to bend knees and push with feet Ask client to bend knees and push with feet on the count of threeon the count of three
Nurse assist client to the top of the bed Nurse assist client to the top of the bed (usually two person assist)(usually two person assist)
Use good body mechanics Use good body mechanics
Transfer (Two Person):Transfer (Two Person):
Very overweight clientVery overweight client
Confused clientConfused client
Uncooperative clientUncooperative client
Transfer To Chair from Bed:Transfer To Chair from Bed:
Dangle Position (may be first step)Dangle Position (may be first step)
StandStand
Pivoting (clientPivoting (client’’s arm on the arm of chair)s arm on the arm of chair)
Place chair on the clientPlace chair on the client’’s strong sides strong side
Ambulation (common hazards Ambulation (common hazards with assistive devices):with assistive devices):
BrokenBroken
Client not know how to useClient not know how to use
Pathways are not clearPathways are not clear
Equipment (ambulation)Equipment (ambulation)
Same with few exceptions Same with few exceptions
Gait BeltsGait Belts
CrutchCrutch
WalkerWalker
Ambulation: Prevent Ambulation: Prevent Falls !!!Falls !!!
Client Posture (head up, eyes open, looking Client Posture (head up, eyes open, looking forward)forward)
Non-skid slippersNon-skid slippers
Walk at clientWalk at client’’s sides side
Match clientMatch client’’s gates gate
Ambulation Ambulation (Procedure):(Procedure):
Walk on clientWalk on client’’s weak side/match gate s weak side/match gate
Stabilization (allow client to hold your elbow Stabilization (allow client to hold your elbow or hand)or hand)
Minimal Support (hold clientMinimal Support (hold client’’s arm with your s arm with your hand)hand)
Moderate Support (encircle clientModerate Support (encircle client’’s waist with s waist with your hand)your hand)
Maximum Support (two persons, one on each Maximum Support (two persons, one on each side of client)side of client)
SafetySafety
Define vocabulary related to hospital/client environment.
Air Pollution – the introduction of checmicals, the introduction of checmicals, particulate matter or biological materials that cause particulate matter or biological materials that cause harm or discomfort to human or other living harm or discomfort to human or other living
Carbon Monoxide - (CO), also called (CO), also called carbonous oxidecarbonous oxide, , is a colorless, odorless, and tasteless gas which is is a colorless, odorless, and tasteless gas which is slightly lighter than air. It is highly toxic to humans and slightly lighter than air. It is highly toxic to humans and animals in higher quantities, although it is also produced animals in higher quantities, although it is also produced in normal animal metabolism in low quantities, and is in normal animal metabolism in low quantities, and is thought to have some normal biological functions.thought to have some normal biological functions.
Carcinogen - s any substance, radionuclide or s any substance, radionuclide or radiation that is an agent directly involved in causing radiation that is an agent directly involved in causing cancer.cancer.
Vocabulary related to hospital/client environment:
Decibels - logarithmic unit that indicates the ratio logarithmic unit that indicates the ratio of a physical quantity relative to a specified or of a physical quantity relative to a specified or implied reference level ( noise ratio).implied reference level ( noise ratio).
Relative humidity - is a term used to describe the is a term used to describe the amount of water vapor in a mixture of air and amount of water vapor in a mixture of air and water vaporwater vapor
Sensory overload
Parasites - Parasites are organisms that obtain Parasites are organisms that obtain food and shelter by living on or within another food and shelter by living on or within another organism.organism.
Pathogens – microorganism that cause disease.Pathogens – microorganism that cause disease.
Space and PrivacySpace and Privacy
Purpose of Space
1. Importance of space
2. Nurse's role in protecting client space
Maintaining the client's right to privacy
1. Screening
2. Requesting family/ friends to leave the room
3. Draping
4. Client consent to view procedures
Environmental factors related to comfort & safety
Temperature of room
Relative humidity
Physical hazards
Carcinogens
Pathogens
Pollution
Developmental factors
Effects of Sensory Deprivation
Cognitive Decreased learning Bizarre thinking
Affective Boredom Restlessness Increased anxiety
Perceptual Decreased attention span Confusion
Personnel Maintaining Client Environment
Medical and Nursing staff
Housekeeping
Engineering /Maintenance/Maintenance
Common Hospital Injuries/Safety
Common Hospital InjuryCommon Hospital Injury
Falls
Client-Incurred Accidents
Procedure-Related Accidents
Equipment-Related Accidents
SafetySafety
Fire Safety
Earthquake Safety
Disaster Preparedness
Preventing FallPreventing Fall
Identifying at-risk patientsIdentifying at-risk patients Assess for a history of fallsAssess for a history of falls Assess for additional risk factorsAssess for additional risk factors
Combining an assessment tool with a care planCombining an assessment tool with a care plan
Accurate assessment and use of appropriate fall Accurate assessment and use of appropriate fall interventionintervention
Preventing Falls: Preventing Falls:
Determine the client's diagnoses and capabilities
Floors Clean and DryFloors Clean and Dry
Floor Free from Clutter Floor Free from Clutter
Anticipate Client Needs (toileting etc.)Anticipate Client Needs (toileting etc.)
Know ClientKnow Client’’ Diagnosis (eg.) CVA Blind Diagnosis (eg.) CVA Blind ClientClient’’s, Alzheimer's s, Alzheimer's
Keep Belongings and Call Light in Reach, Bed Keep Belongings and Call Light in Reach, Bed in Low Position and Locked, Side Rails (!!!) in Low Position and Locked, Side Rails (!!!)
Breaking ClientBreaking Client’’s Fall:s Fall:
Stand with your feet apart slightly behind the Stand with your feet apart slightly behind the clientclient
Grasp the client firmly at waist/axillaGrasp the client firmly at waist/axilla
Your near leg against the clientYour near leg against the client’’s legs leg
Slowly lower the client to the floorSlowly lower the client to the floor
Examine for injuryExamine for injury
Call for helpCall for help
Document as per agency policyDocument as per agency policy
Doctor notifiedDoctor notified
Interventions for a Patient Interventions for a Patient Who Experiences a FallWho Experiences a Fall
Immediately assess the patientImmediately assess the patient’’s conditions condition
Provide care and interventions appropriate for Provide care and interventions appropriate for status/injuriesstatus/injuries
Notify patientNotify patient’’s physician or primary caregiver of s physician or primary caregiver of incident and your assessment of the patientincident and your assessment of the patient
Ensure prompt follow-through for any test ordersEnsure prompt follow-through for any test orders
Evaluate circumstances of the fall and the Evaluate circumstances of the fall and the environment; institute preventive measuresenvironment; institute preventive measures
Document the fall and complete an event reportDocument the fall and complete an event report
Alternatives to Restraints Alternatives to Restraints
Determine whether a behavior pattern existsDetermine whether a behavior pattern exists
Assess for pain and treat appropriatelyAssess for pain and treat appropriately
Rule out physical causes for agitationRule out physical causes for agitation
Involve family membersInvolve family members
Reduce stimulation, noise, and lightReduce stimulation, noise, and light
Check environment for hazards and modify, if necessaryCheck environment for hazards and modify, if necessary
Use therapeutic touchUse therapeutic touch
Investigate discontinuing bothersome treatment devicesInvestigate discontinuing bothersome treatment devices
Restraints:Restraints:PurposePurpose
Applied for safetyApplied for safetyPrevent injuryPrevent injuryPrevent dislodgement Prevent dislodgement
of tubesof tubesPsychiatric SettingPsychiatric Setting
RestraintsRestraintsLegal Consideration:Legal Consideration:
Must be ordered by a physician in writingMust be ordered by a physician in writing
Emergency (can be applied by a nurse, orders Emergency (can be applied by a nurse, orders within 24-48 hours)within 24-48 hours)
Documentation (all that was done to remedy Documentation (all that was done to remedy situation before applying)situation before applying)
Restraints:Restraints:Must !!!Must !!!
Must help client or be needed for medical Must help client or be needed for medical therapytherapy
Must be ordered by a physicianMust be ordered by a physician
Must not be used as a means of pushing or Must not be used as a means of pushing or disciplining the clientdisciplining the client
Must be applied snugly/not tightlyMust be applied snugly/not tightly
Must be removed/Reposition Q2 Must be removed/Reposition Q2
Must notify doctor when no longer neededMust notify doctor when no longer needed
Must intervene to promote safetyMust intervene to promote safety
Must be documented Must be documented
RestraintsRestraintsTypes:Types:
Safety BeltsSafety BeltsWrist Extremity ImmobilizerWrist Extremity ImmobilizerVest (Posey)Vest (Posey)Hand MittensHand MittensLeatherLeatherChemicalChemical
RestraintsRestraintsBasic Principals: Basic Principals:
Know agency policyKnow agency policy
Document use of restraints and patient Document use of restraints and patient monitoringmonitoring
Check client Q 15 minutesCheck client Q 15 minutes
Remove and reposition Q 2 hoursRemove and reposition Q 2 hours
Assist with ROMAssist with ROM
Call light in reachCall light in reach
Comfort measure (eg) water, food, rest Comfort measure (eg) water, food, rest roomroom
RestraintsRestraintsBasic Principals: Basic Principals:
FamilyFamily
Diversional ActivitiesDiversional Activities
Psycho/Social (tough, isolation, confusion)Psycho/Social (tough, isolation, confusion)
ClientClient’’s daily habits (eg) news papers daily habits (eg) news paper
Neuro/Vascular AssessmentNeuro/Vascular Assessment
Rapid Release of RestraintsRapid Release of Restraints
R-E-S-T-R-A-I-N-T AcronymR-E-S-T-R-A-I-N-T Acronym
RR: Respond to the present, not the past: Respond to the present, not the past
EE: Evaluate the potential for injury: Evaluate the potential for injury
SS: Speak with family members or caregivers: Speak with family members or caregivers
TT: Try alternative measures first: Try alternative measures first
RR: Reassess the patient to determine success of : Reassess the patient to determine success of
restraintrestraint
AA: Alert the physician and family of need for restraint: Alert the physician and family of need for restraint
II: Individualize restraint use: Individualize restraint use
NN: Note important information on chart: Note important information on chart
TT: Time limit the use of restraints: Time limit the use of restraints
RestraintsRestraintsLong Term Use Long Term Use
(problems):(problems): Muscle weakness, atrophyMuscle weakness, atrophy
Loss of bone mass, joint contracturesLoss of bone mass, joint contractures
Constipation/incontinenceConstipation/incontinence
Pressure UlcersPressure Ulcers
Cognitive ImpairmentCognitive Impairment
Decrease confidence in ambulationDecrease confidence in ambulation
Withdrawn, detachedWithdrawn, detached
DepressionDepression
Loss of independenceLoss of independence
ConclusionConclusionAsk Yourself:Ask Yourself:
Is my client safe from harm?Is my client safe from harm?
Does my client need anything?Does my client need anything?
Is the bed locked?Is the bed locked?
Is the bed in the low position?Is the bed in the low position?
Is the call light in reach?Is the call light in reach?
Does my client have anything to do?Does my client have anything to do?
How is my clientHow is my client’’s neuro/vascular s neuro/vascular assessment?assessment?
Physical RestraintsPhysical Restraints
Restrict or control movement or behavior. Restrict or control movement or behavior. They may be attached to a person's body They may be attached to a person's body or create physical barriers.or create physical barriers.
wristwrist
vestvest
side railsside rails
wheelchair safetywheelchair safety
hand mittens hand mittens
Securing Restraint to Bed Securing Restraint to Bed FrameFrame
Restraint Secured Behind Restraint Secured Behind ChairChair
Using a Hand MittUsing a Hand Mitt
Child With Elbow Restraint in Child With Elbow Restraint in PlacePlace
Chemical Restraints Chemical Restraints
Chemical Restraints - Chemical Restraints - are any medication are any medication used for the purpose of restraining patients used for the purpose of restraining patients involuntarily to prevent them from harming involuntarily to prevent them from harming themselves or staff. themselves or staff.
Advantages of chemical restraintsAdvantages of chemical restraints
Control violent behavior and patient Control violent behavior and patient agitation agitation
May reduce need for physical restraints May reduce need for physical restraints
Allow examination and performance of Allow examination and performance of radiographic imaging radiographic imaging
Disadvantages of Chemical Disadvantages of Chemical RestraintsRestraints
• May result in complications, such as May result in complications, such as respiratory depression and loss of gag respiratory depression and loss of gag reflex reflex
• Occasional paradoxical reaction results Occasional paradoxical reaction results in increased agitation in increased agitation
• Limit mental status assessment and Limit mental status assessment and neurologic examination during neurologic examination during sedation sedation
Environmental RestraintsEnvironmental Restraints
Change or modify a person's surroundings to Change or modify a person's surroundings to restrict or control movement. For example, a restrict or control movement. For example, a locked door.locked door.
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