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Focusing on Patient Care

Focusing on Patient Care

Learning Outcomes

After completing the chapter, you will be able to accomplish the following:

  1. Perform a situational assessment.
  2. Implement nursing interventions related to reducing fall risk and risk of fall-related injury.
  3. Implement nursing interventions to be used as alternatives to restraints.
  4. Identify guidelines for the use of physical restraints.
  5. Apply an extremity restraint correctly and safely.
  6. Apply a waist restraint correctly and safely.
  7. Apply an elbow restraint correctly and safely.
  8. Apply a mummy restraint correctly and safely.

Nursing Concepts

Key Terms

Introduction

Safety and security are basic human needs. Safety is a paramount concern that underlies all nursing care, and patient safety is a responsibility of all health care providers. It is a focus in all health care facilities as well as in the home, workplace, and community. Nursing strategies that identify potential hazards and promote wellness from a person-centered perspective evolve from an awareness of individual factors that affect a patient's safety. Fundamentals Review 4-1 outlines patient safety risks related to developmental stage, as well as patient teaching to promote patient safety. Guidelines to promote patient safety are provided by health care accrediting, professional, and governmental organizations and agencies. For example, the Joint Commission identifies National Patient Safety Goals (NPSGs). The purpose of the NPSGs is to improve patient safety, focusing on problems in health care safety and how to solve them. These NPSGs are identified for a range of patient care settings, including ambulatory care, home care, hospitals, behavioral care, and office-based surgery. They are updated yearly and can be found on the Joint Commission website at https://www.jointcommission.org/en/standards/national-patient-safety-goals/.

The American Nurses Association (ANA) is a professional organization that also provides guidance to promote patient safety. A position statement from the ANA defines the nurses' role in reducing restraint use in health care. These recommendations are presented in Box 4-2 in Skill 4-3.

This chapter covers skills nurses will need when working with patients to monitor for safety, prevent injury, and to intervene when safety issues arise. The first skill addresses the use of a general patient and environmental survey to identify immediate patient concerns, as well as safety concerns. The next two skills address prevention of injury and discuss reduction of fall risk and utilizing alternatives to the use of restraints. The remaining skills address how to use several types of physical restraints safely and correctly. A physical restraint is any manual method, physical or mechanical device, material, or equipment that the person cannot remove easily, which immobilizes or reduces the person's freedom of movement or normal access to one's body (CMS, 2006). Physical restraints should be considered as a last resort after other care alternatives have been unsuccessful.

Whether or not a specific device is considered a restraint is determined by several factors:

For example, if a bed rail is used to facilitate a patient's mobility in and out of bed, it is not a restraint. If side rails could potentially restrict a patient's freedom to leave the bed, the rails would be a restraint. If a patient can release or remove a device, it is not a restraint. Side rails that are raised with the intent to prevent the patient from voluntarily attempting or actually getting out of bed, would be considered a restraint; if the intent of raising the side rails is to prevent a patient from inadvertently falling out of bed, or if the patient lacks the physical ability to even attempt to get out of bed, side rails would not be considered a restraint (The Joint Commission, 2017).

When it is necessary to apply a restraint, the nurse should use the least restrictive method and should remove it at the earliest possible time. Consider the laws regulating the use of restraints and facility regulations and policies. Ensure compliance with ordering, assessment, and maintenance procedures. Fundamentals Review 4-2 provides general guidelines for restraint use. Always treat patients with respect and protect their dignity.

Enhance Your Understanding

Focusing on Patient Care: Developing Clinical Reasoning

Integrated Case Study Connection

Suggested Answers for Focusing on Patient Care: Developing Clinical Reasoning and Clinical Judgment

  1. Nursing interventions for Megan should include the use of distraction, such as play, toys, music, games, and so forth. (Refer to Skill 4-3.) Megan's parent should be encouraged to stay with her to provide supervision and distraction, also. Cover the IV access site with a dressing and gauze, or other covering. If all other alternatives to restraints are attempted, and it is necessary to maintain the IV infusion, an elbow restraint (Skill 4-6) or hand mitt (Skill 4-4) would be the least restrictive restraints to prevent dislodgement of Megan's IV access.
  2. You must implement as many alternatives to restraints as possible for Mr. Mallory. Refer to Skill 4-3. In addition, consult with the health care team to discuss a possible time frame for extubation. Increase frequency of monitoring, repeat explanations, and provide distraction as part of the plan of care for this patient. Elbow restraints (Skill 4-6) would be a possible solution if it is determined that restraints are required.
  3. Fall prevention is best achieved through the implementation of multiple strategies. Begin by assessing the patient's motivation for attempting activity unassisted. Provide reassurance and explanations related to care. If possible, Mr. Frawley could be moved to a room closer to the nursing station to allow increased monitoring. Additional nursing interventions to try could include asking family members to stay with Mr. Frawley, providing distraction based on information from the family regarding favorite activities, more frequent rounding to ensure that his toileting needs are met, as well as need for hydration. Provide a low bed for the patient, as well as floor mats, to reduce the risk for serious injury if Mr. Frawley should fall. Refer to Skill 4-2 for additional intervention suggestions.

Bibliography