Promoting safety and preventing injury for the patient is fundamental for nursing practice.

No matter what type of patient you care for, safety is a high priority. One of the most common risks is that of a fall.

It is important that nurses be aware of the potential for injury and promote safety at all times.

Not Toileting is a leading cause of patient

falls in hospitals

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Patients, families, and staff often suffer anxiety, anger and a feeling that a fall should not have been ‘allowed to happen’ in a supposed place of safety and that someone must be at fault

For all these reasons, there has been an increasing focus on risk management to prevent falls.

It is one of the major National Patient Safety Goals – “Preventing Patients from Falling”.

No matter what type of patient you, as the nurse, care for, safety is a high priority.

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True or False

A nurse whose behavior is reasonable and prudent and similar to the behavior that would be expected of another nurse in similar circumstances is still likely to be found liable (legally responsible) if a patient falls.

A. TrueB. False

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There are many risk assessment tools available. The Hendrich Fall Risk Assessment is one example:

Note: A patient with a history of falling is a great risk to fall again hence the highest score above of 7!

Risk Factor Scale Score

Recent History of Falls Yes 7No 0

Altered Elimination (incontinence, nocturia, frequency)

Yes 3

No 0Confusion / Disorientation Yes 3

No 0Depression Yes 4

No 0Dizziness / Vertigo Yes 3

No 0Poor Mobility / Generalized Weakness Yes 2

No 0Poor Judgment (if not confused) Yes 3

No 0

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Orient to new surroundings Keep two side rails up (depending on policy) Keep call light, bedside table, water, glasses,

etc. within easy reach Use a night light Keep bed in low position Make sure patient has non-skid footwear Ambulate only with assistance when

appropriate Locate patient close to the nurses station Upon exiting the room, always ask the 4P’s –

pain, possessions, positioning and POTTY!

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Sometimes the Patient’s safety is still at risk so restraints are a necessity for Medical Care.

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What are restraints?

A.A device used to prevent wandering.B.A device that limits movement to the extent necessary for treatment and/or protection of the patient.C.A device that is used for 48 hours to keep the patient in bed.D.A device that once applied should be checked at least every 4 hours.

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What are is a restraint?A.A device uses to prevent wandering. This behavior is not an indication for restraints.B.A device that limits movement to the extent necessary for treatment and/or protection of the patient.C.A device that is used for 48 hours to keep the patient in bed. A HCP order is needed every 24 hours.D.A device that once applies should be checked at least every 4 hours. Assessment should be done at least every 2 hours.

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Most commonly used to: 1. Prevent the patient from falling and sustaining

injury Disoriented patients Prolonged bedrest Patients who are hypotensive, have lost a lot of

blood, receiving narcotics, etc.

2. Position and protect patient during treatments and to maintain ongoing care Prevent pulling on catheter, nasogastric tube,

stitches

3. Protect patients who are combative and agitated and may cause harm to self or others 11

The use of The use of restraints is restraints is generally not generally not

advocated and advocated and should be used should be used onlyonly as a last as a last

resortresort

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Emotional issue on the part of the patient, family, and staff. The patients response to being restrained is rarely submissive

Many view restraints as a personal physical assault, and are frightened, and respond by becoming combative.

The application of restraints may subject the nurse to allegations of false imprisonment,

battery, and lack of informed consent.

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TJC has identified misuse of protective restraints as one of the main sentinel events (unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof).

Since TJC began tracking sentinel events in 1996, there have been many cases related to deaths of patients who were being physically restrained.

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1. Mechanical/Physical ◦ Wrist, ankle, elbow, mitten restraints◦ Belts**Use of vest restraints is no longer

advocated

2. Chemical◦ Medications used to calm an

individual’s behavior – tranquilizers and hypnotics

3. Environmentalo Side rails – all 4 up on bed.

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See Skill Procedure in Taylor

◦Skill 26-1: Applying an Extremity Restraint; p. 645-647.

What do the nurse do if the patient needs a restraint and there is NO health care provider order?

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Suffocation from entrapment

Impaired circulation

Altered skin integrity — pressure ulcers

Diminished muscle and bone mass / Fractures

Altered nutrition and hydration

Aspiration and breathing difficulties

Incontinence

Changes in mental status18

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Patients or residents with an impaired ability to understand or follow directions, or appreciate the potential for self-harm as a consequence of his/her actions, may have a sitter prescribed by a physician to provide continuous one-to-one observation. Sitters are responsible for observing the patient and maintaining a safe environment.

When sitters are used, they are under the direction and delegation of a registered nurse who monitors the patient’s or resident’s actions. Sitters may be non-licensed patient care staff, or other hospital employees who have completed sitter competencies.

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Use a bed alarm system◦ Senses when patient gets out of bed

◦ Senses when patient steps on it when getting out of bed

Provide a familiar environment◦ May need to bring items from home

Increase the monitoring frequency◦ May ask family to help with the monitoring, but it is

difficult for family to commit to this amount of time

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If a patient complains of a restraining device causing them pain or

discomfort, what should the nurse do?

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True or False

As the primary reason for applying restraints, nurses consistently cite is the risk for injury to patients and healthcare workers from irrational behavior.

A. TrueB. False

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True or False

As the primary reason for applying restraints, nurses consistently cite is the risk for injury to patients and healthcare workers from irrational behavior.

A. TrueB. False

The primary reason the nurses cite forapplying restraints is falls.

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