N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide • Remove any faulty equipment from the patient environment • Encourage the proper use of canes, walkers, crutches, and wheelchairs for patients requiring assistance with ambulation • Understand the facility policy for the use of restraints that limit the patient's movement. In most cases, restraints cannot be used. The prudent nurse will understand when restraints may be used and the requirements for their use. In addition to federal regulations, the individual facility may have more stringent policies and requirements. In all cases, the nurse must be vigilant about ensuring that any restraint should not aggravate the patient's condition or cause additional injury. If restraints are used, the nurse must assess the patient's circulatory and neurological status in any restrained limb by checking color, temperature, movement, capillary refill, and sensation. The timeframe for these assessments should be guided by the facility policy, but should always be done at least every 30 minutes while the patient is restrained. • Make appropriate referrals to facility departments and community agencies to ensure that home safety hazards are addressed prior todischarge • Educate the patient and family about environmental safety hazards. The educational needs that might be addressed include: o Orientation of the patient to the facility o Explanation of the bed and call system o Teach the RACE acronym o Teach about smoke and carbon monoxidedetectors o Teach about the use of assistive devices (crutches, walkers, canes, etc.) o Teach the family of small children about securing poisons and medications o Instruct the patient's family about the use of the Poison Control system o Instruct the patient or family to keep important emergency phone numbersnear the phone o Teach the family of young children about the dangers of suffocation by plastic bags o Teach about the risks of sun and radiation exposure and how to use sun-blocking agents to prevent burning Evaluation During the evaluation phase of the nursing process, the nurse evaluates whether or not expected outcomes are achieved. In order to evaluate the effectiveness of interventions related to environmental safety, the nurse must do frequent reassessments and adjust the plan of care as the patient's condition changes. The nurse must document the teaching provided and the patient's response to the teaching. If the patient modifies her environment based on the teachings provided, it is a clear indication that learning has occurred. In the area of environmental concerns, the nurse's primary role is in ensuring that the immediate environment is free of risks and that the patient and family understands how to modify the home environment to minimize risk upon returning home.

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