Study Notes: Environmental Safety and Patient Safety (Chapter 27 - Potter & Perry Fundamentals

of Nursing, 11th Edition)

Key Terms:
● Aura: A sensory warning or feeling that may precede a seizure, helping patients recognize
when one is about to occur.
● Immunization: The process of stimulating the body’s immune system to recognize and fight
pathogens, critical in preventing infection and promoting patient safety.
● Poison: Substances that can cause harm to the body through ingestion, inhalation, or
absorption, posing a significant safety risk.
● Restraint: Physical or chemical methods used to limit a patient’s movement, typically used in
certain medical situations, though alternatives should be explored to ensure patient safety.
● Root Cause Analysis: A method for identifying the underlying causes of safety issues or
adverse events in healthcare, aimed at preventing recurrence.
● Seizure: A sudden, uncontrolled electrical disturbance in the brain that can affect physical
and mental function.
● Seizure Precautions: Measures taken to prevent injury during a seizure, such as removing
harmful objects and ensuring a safe environment.
● Status Epilepticus: A medical emergency characterized by prolonged or repeated seizures
without regaining consciousness, requiring immediate intervention.
● Workplace Violence: Acts of physical violence, threats, or verbal abuse directed at
healthcare workers, affecting both their safety and the quality of patient care.
● Environmental Safety: Refers to the physical and psychosocial factors in a patient’s
surroundings that affect their health and safety. A safe environment is essential for both
patients and healthcare staff, supporting optimal function.
Scientific Knowledge Base - Environmental Safety:
● Patient’s Environment: This includes both physical and psychosocial factors that
influence a patient's well-being. The environment encompasses various healthcare settings,
such as hospitals, long-term care facilities, clinics, and homes.
○ A safe environment meets basic human needs and reduces physical hazards and the
transmission of pathogens.
○ The vulnerable populations most at risk for safety alterations include:
■ Infants, children, and older adults
■ Individuals with chronic diseases or disabilities (physical or mental)
■ Individuals with difficulty communicating
■ Those with low income or who are homeless
● Basic Human Needs:
○ According to Maslow's hierarchy of needs, physiological needs (e.g., oxygen,
nutrition, and temperature control) must be met before a person can achieve safety
and security.
○ Meeting basic needs is essential for ensuring both physical and psychological
safety.
● Oxygen:
○ Supplemental oxygen may be necessary for some patients, but it also introduces
safety risks. Oxygen is highly flammable, especially in environments where smoking
or heat sources are present.
○ Strict regulations govern the use and storage of medical oxygen in healthcare
settings. However, these are often less stringent in home environments.
 ○ It is critical that no one smokes or introduces heat sources in areas where
supplemental oxygen is used. Small sparks or flames in the presence of oxygen can
lead to rapid fires, causing burns and potentially fatal injuries.
● Carbon Monoxide (CO) Poisoning:
○ Improperly functioning heating systems (e.g., furnace, fireplace, or stove) that are
poorly vented can release carbon monoxide (CO) into the environment.
○ CO poisoning occurs when CO binds to hemoglobin, reducing the blood's ability to
carry oxygen. Low concentrations of CO can cause symptoms such as nausea,
dizziness, headache, and fatigue.
○ Unintentional non-fire-related (UNFR) CO poisoning is common in the U.S., with
approximately 50,000 people visiting emergency departments each year due to
accidental CO poisoning (CDC, 2020a).
Patient Safety and Environmental Risk Factors:
● Vulnerable Populations: People at higher risk for environmental hazards include:
○ Infants, children, and older adults
○ Individuals with chronic health conditions, mental or physical disabilities, or
limited access to care.
○ Individuals who have difficulty communicating or face economic hardship (e.g.,
low income, homelessness).
● Fire Safety:
○ When managing patients on oxygen therapy, ensuring fire safety is crucial. No
smoking, open flames, or other ignition sources should be near patients receiving
supplemental oxygen.
Environmental Safety Interventions:
● Nurses must ensure that environmental hazards are minimized in both healthcare settings
and home environments.
○ Regular inspection and maintenance of heating systems are necessary to prevent
CO buildup.
○ Educating patients and families about the risks of CO poisoning and the importance
of proper venting and oxygen safety can reduce these risks significantly.
Patient-Centered Safety:
● The environment must be considered when planning and delivering patient care. Nurses
should assess not only the physical safety of the patient’s environment but also the
psychosocial factors that may affect safety (e.g., access to healthcare, living conditions).
Key Takeaways:
● Environmental safety is a fundamental aspect of patient care that directly impacts both patient
and staff well-being.
● Nurses must assess environmental factors, educate patients, and take appropriate actions to
ensure a safe environment.
● Protecting vulnerable populations from environmental risks is particularly important in both
healthcare and home settings.
Additional Learning Resources:
● Video Clips: Visual demonstrations on maintaining environmental safety in various care
settings.
● Skills Performance Checklists: Tools to evaluate proficiency in ensuring environmental
safety measures.
● Case Studies: Scenario-based exercises to apply knowledge of environmental safety in
patient care settings.
This information is important for understanding environmental safety, which is an essential aspect of
patient safety and may be tested on exams such as ATI. Review these concepts to ensure your
preparedness.
Study Notes: Environmental Safety, Nutrition, and Common Hazards (Chapter 27 - Potter & Perry
Fundamentals of Nursing, 11th Edition)
Key Terms:
● Nutrition: Meeting patients' nutritional needs requires knowledge of healthy food choices and
food safety.
● Temperature Extremes: Exposure to extreme cold or heat can result in serious health
issues, especially for vulnerable populations.
● Motor Vehicle Accidents: Injuries and fatalities from accidents are a major safety concern,
especially among young drivers.
● Poison: Any substance that impairs health or causes death when ingested, inhaled, injected,
or absorbed.
● Foodborne Illness: Illness caused by eating contaminated food, often linked to improper
food handling and storage.
● Food Safety: Practices to prevent foodborne illnesses, which include proper food storage,
preparation, and hygiene.
Scientific Knowledge Base - Nutrition and Safety:
Nutrition and Food Safety
● Balanced Nutrition:
○ Understanding balanced nutrition is essential for meeting the nutritional needs of
patients.
○ Health care agencies must follow State Board of Health regulations for the safe
storage, preparation, and provision of food.
○ The CDC estimates that 48 million people suffer from foodborne illness annually,
leading to 128,000 hospitalizations and 3000 deaths (CDC, 2020b).
● Food Safety Principles:
○ Foodborne illnesses can be caused by improperly stored, prepared, or handled
food.
○ Escherichia coli, Salmonella, Listeria, and norovirus are common pathogens
responsible for foodborne illnesses.
○ For patients returning home or those in home health, education about food safety
is crucial, including proper food storage and preparation.
● Water Safety:
○ Patients require access to clean, safe drinking water and must also have water
available for washing fresh produce and dishes.
○ Improper food storage and handling increase the risk of **in
Study Notes: Environmental Safety, Nutrition, and Common Hazards (Chapter 27 - Potter & Perry
Fundamentals of Nursing, 11th Edition)
Key Terms:
● Poison: Any substance that impairs health or results in death when ingested, inhaled,
injected, or absorbed.
● Lead Poisoning: Poisoning due to exposure to lead, affecting fetuses, infants, and children
most severely.
● Falls: Inadvertent events where individuals end up on the ground or lower level, often
causing serious injury.
● Fire: Unintentional fires caused by cooking, heating, or careless actions.
 ● Disasters: Natural or man-made events that can result in mass injury or death, including
bioterrorism.
● Pathogens: Microorganisms that cause illness, often transmitted through poor hygiene or
direct contact.
Scientific Knowledge Base - Environmental Safety and Nutrition:
Lead Poisoning
● Lead was banned in house paint and plumbing materials in 1978, but older homes may still
contain hazardous levels of lead.
● Lead exposure also comes from soil, water, and industrial sources (e.g., former lead
smelters).
● Fetuses, infants, and children are more vulnerable to lead poisoning due to their higher
absorption rates.
● Effects of lead poisoning in children include growth issues, learning difficulties,
behavioral problems, and damage to the brain and kidneys.
Falls
● A fall is defined as an event where a person comes to rest on the ground or lower level
unintentionally (WHO, 2018).
● Falls are the second leading cause of accidental deaths worldwide and contribute to
significant disability, lost work time, and long-term care, especially in older adults.
● Risk factors for falls include:
○ Occupational hazards (e.g., working at heights)
○ Alcohol or substance use
○ Socioeconomic factors (poverty, overcrowded housing, young maternal age)
○ Underlying medical conditions (neurological, cardiovascular, orthopedic issues)
○ Polypharmacy and side effects of medications
○ Poor mobility, balance, or coordination
○ Unsafe environments (e.g., broken stairs, icy sidewalks, exposed cords)
○ Foot problems (pain, unsafe footwear)
● Fall prevention is a critical focus in health care, with multiple resources available for
monitoring and improvement (e.g., TJC, IHI).
Fire Safety
● In 2018, there were 379,600 residential fires, with cooking (50.7%) and heating (9.4%) as
the top causes (USFA, 2021).
● Careless fire incidents result from improper disposal of cigarettes or the use of candles.
● Fire prevention includes education on:
○ Safe cooking practices and fire-resistant appliances.
○ Proper handling and disposal of flammable materials.
● Health care agencies, especially nursing homes, have regular fire drills to ensure staff
readiness.
Disasters and Bioterrorism
● Natural disasters like floods, hurricanes, and wildfires can lead to death, injury, and
homelessness.
● Bioterrorism involves the use of biological agents (e.g., anthrax, smallpox) to harm
individuals or groups.
● Health care agencies must have disaster preparedness plans to respond effectively,
including:
○ Communication
○ Resource management
○ Staff responsibilities
 ○ Patient safety and clinical care
Transmission of Pathogens
● Pathogens are microorganisms capable of causing illness, and they are often transmitted by
poor hand hygiene or improper infection control.
● Nosocomial infections (HAIs) are acquired within health care settings and are a significant
safety risk.
○ Examples include surgical site infections and catheter-associated urinary tract
infections.
● The most effective way to prevent pathogen transmission is hand hygiene.
Food Safety
● Foodborne illnesses result from improper food storage, preparation, and hygiene.
● Major pathogens involved in foodborne illness include Escherichia coli, Salmonella,
Listeria, and norovirus.
● Nurses should educate patients, especially those returning home, on food safety principles.
Temperature Extremes
● Cold: Prolonged exposure can cause frostbite and hypothermia, with higher risk for older
adults, young children, and those with cardiovascular conditions.
● Heat: Extreme heat can result in heat exhaustion or heatstroke, particularly among
chronically ill patients, older adults, and infants.
Key Safety Strategies for Nurses:
● Lead Poisoning Prevention: Assess for potential exposure in older homes and educate
parents on the risks to children.
● Fall Risk Prevention: Conduct thorough fall risk assessments and create safety plans in
both the home and health care settings.
● Fire Safety: Educate patients about the dangers of cooking accidents and heating
appliances. Ensure fire drills are performed regularly in healthcare settings.
● Disaster Preparedness: Work with agencies to ensure disaster preparedness plans are in
place. Educate patients on safety protocols during natural disasters.
● Infection Control: Emphasize the importance of hand hygiene and proper infection
control to minimize the risk of nosocomial infections.
Study Notes: Environmental Safety, Nutrition, and Common Hazards (Chapter 27 - Potter & Perry
Fundamentals of Nursing, 11th Edition)
Key Terms:
● Poison: Any substance that impairs health or results in death when ingested, inhaled,
injected, or absorbed.
● Lead Poisoning: Poisoning due to exposure to lead, affecting fetuses, infants, and children
most severely.
● Falls: Inadvertent events where individuals end up on the ground or lower level, often
causing serious injury.
● Fire: Unintentional fires caused by cooking, heating, or careless actions.
● Disasters: Natural or man-made events that can result in mass injury or death, including
bioterrorism.
● Pathogens: Microorganisms that cause illness, often transmitted through poor hygiene or
direct contact.
● Immunization: A process that helps prevent the transmission of disease, crucial for both
children and adults.
Scientific Knowledge Base - Environmental Safety and Nutrition:
Immunization
 ● Immunization reduces, and in some cases prevents, the transmission of disease from
person to person.
● Concerns: Some parents have raised concerns about the link between vaccines and autism
or sudden infant death syndrome (SIDS). However, studies have shown there is no such link
(CDC, 2020f).
● Vaccination Rates: As of 2017, early childhood vaccination rates for the recommended
seven-vaccine series (diphtheria, tetanus, pertussis, polio, measles, mumps, rubella) were at
70.4% in the U.S. The rates varied by region, with higher rates for polio and measles,
mumps, rubella combination vaccines.
● Vulnerable Populations: Children from lower-income families or certain racial/ethnic groups
may have lower vaccination rates. Missed well-child visits are a significant driver of
undervaccinated children (Blue Cross Blue Shield, 2021).
● Nurses' Role: Nurses play a crucial role in educating parents about the importance of
immunization schedules and addressing concerns.
● Adult Vaccines: Adults need regular vaccinations based on age, lifestyle, and health
conditions. Older adults, for example, are at higher risk for infections and should be
immunized against the flu, pneumonia, and shingles (CDC, 2019b). Health care workers
should also be vaccinated for hepatitis B.
Lead Poisoning
● Lead was banned in house paint and plumbing materials in 1978, but older homes may still
contain hazardous levels of lead.
● Lead exposure also comes from soil, water, and industrial sources (e.g., former lead
smelters).
● Fetuses, infants, and children are more vulnerable to lead poisoning due to their higher
absorption rates.
● Effects of lead poisoning in children include growth issues, learning difficulties,
behavioral problems, and damage to the brain and kidneys.
Falls
● A fall is defined as an event where a person comes to rest on the ground or lower level
unintentionally (WHO, 2018).
● Falls are the second leading cause of accidental deaths worldwide and contribute to
significant disability, lost work time, and long-term care, especially in older adults.
● Risk factors for falls include:
○ Occupational hazards (e.g., working at heights)
○ Alcohol or substance use
○ Socioeconomic factors (poverty, overcrowded housing, young maternal age)
○ Underlying medical conditions (neurological, cardiovascular, orthopedic issues)
○ Polypharmacy and side effects of medications
○ Poor mobility, balance, or coordination
○ Unsafe environments (e.g., broken stairs, icy sidewalks, exposed cords)
○ Foot problems (pain, unsafe footwear)
● Fall prevention is a critical focus in health care, with multiple resources available for
monitoring and improvement (e.g., TJC, IHI).
Fire Safety
● In 2018, there were 379,600 residential fires, with cooking (50.7%) and heating (9.4%) as
the top causes (USFA, 2021).
● Careless fire incidents result from improper disposal of cigarettes or the use of candles.
● Fire prevention includes education on:
○ Safe cooking practices and fire-resistant appliances.
 ○ Proper handling and disposal of flammable materials.
● Health care agencies, especially nursing homes, have regular fire drills to ensure staff
readiness.
Disasters and Bioterrorism
● Natural disasters like floods, hurricanes, and wildfires can lead to death, injury, and
homelessness.
● Bioterrorism involves the use of biological agents (e.g., anthrax, smallpox) to harm
individuals or groups.
● Health care agencies must have disaster preparedness plans to respond effectively,
including:
○ Communication
○ Resource management
○ Staff responsibilities
○ Patient safety and clinical care
Transmission of Pathogens
● Pathogens are microorganisms capable of causing illness, and they are often transmitted by
poor hand hygiene or improper infection control.
● Nosocomial infections (HAIs) are acquired within health care settings and are a significant
safety risk.
○ Examples include surgical site infections and catheter-associated urinary tract
infections.
● The most effective way to prevent pathogen transmission is hand hygiene.
Food Safety
● Foodborne illnesses result from improper food storage, preparation, and hygiene.
● Major pathogens involved in foodborne illness include Escherichia coli, Salmonella,
Listeria, and norovirus.
● Nurses should educate patients, especially those returning home, on food safety principles.
Temperature Extremes
● Cold: Prolonged exposure can cause frostbite and hypothermia, with higher risk for older
adults, young children, and those with cardiovascular conditions.
● Heat: Extreme heat can result in heat exhaustion or heatstroke, particularly among
chronically ill patients, older adults, and infants.
Key Safety Strategies for Nurses:
● Lead Poisoning Prevention: Assess for potential exposure in older homes and educate
parents on the risks to children.
● Fall Risk Prevention: Conduct thorough fall risk assessments and create safety plans in
both the home and health care settings.
● Fire Safety: Educate patients about the dangers of cooking accidents and heating
appliances. Ensure fire drills are performed regularly in healthcare settings.
● Disaster Preparedness: Work with agencies to ensure disaster preparedness plans are in
place. Educate patients on safety protocols during natural disasters.
● Infection Control: Emphasize the importance of hand hygiene and proper infection
control to minimize the risk of nosocomial infections.
● Immunization Education: Provide guidance to parents about the safety and importance of
following the recommended immunization schedules for their children and discuss vaccines'
role in preventing disease.
Study Notes: Environmental Safety, Immunizations, and Individual Risk Factors
Immunizations
 ● Childhood Vaccination is one of the most effective public health strategies for controlling
and preventing disease (Ventola, 2016).
● Immunizations reduce the transmission of diseases and protect individuals from preventable
infections. For example, vaccines for diseases like measles, mumps, and rubella have been
highly effective in preventing widespread outbreaks.
● Vaccines play a critical role in maintaining community health, especially by protecting
vulnerable populations, including infants, older adults, and those with weakened immune
systems. Nurses, through education and advocacy, ensure that families adhere to vaccination
schedules to protect both individual and public health.
Adolescents and Risk Factors
● As adolescents mature, they test boundaries by experimenting with risky behaviors like
alcohol or substance use, which increases the risk of accidents, motor vehicle accidents, and
drowning.
● Psychosocial Risks: Adolescents are particularly vulnerable to emotional challenges. Key
risk factors for suicide and mental health issues include:
○ Recent loss (e.g., family member, friend)
○ Psychiatric disorders (such as depression)
○ Substance abuse or risky behaviors
○ Bullying (victimization or perpetration)
○ Lack of social support and acceptance of sexual orientation
○ Access to lethal means, such as firearms or drugs (Kaslow, 2021).
● School Violence: Adolescents may experience or contribute to school violence, including
bullying, physical fights, and cyberbullying. The role of school nurses includes identifying at-
risk students and providing resources to prevent and manage violence (CDC, 2020).
Adults and Safety Risks
● Lifestyle-related Risks: Adults often face risks from their lifestyle habits. Risky behaviors
such as excessive alcohol consumption and smoking increase the likelihood of injuries
and chronic conditions such as cardiovascular disease or pulmonary conditions.
○ Alcohol Use: Increases the likelihood of motor vehicle accidents and home injuries.
○ Tobacco Use: Smoking leads to long-term diseases such as heart disease, stroke,
and respiratory disorders.
● Stress: High stress can contribute to accidents, illness (e.g., headaches, gastrointestinal
disorders), and decreased safety awareness. Chronic stress increases the risk of both
physical and mental health problems.
Older Adults and Safety Risks
● Age-Related Physiological Changes: As people age, changes in mobility, cognitive
ability, and medication effects significantly increase the risk of falls and accidents. Over
one-quarter of adults 65 and older fall each year (CDC, 2017a), and once a fall occurs, the
risk of falling again increases.
○ Cognitive Changes: Cognitive decline can be normal with aging, but it may also
indicate conditions like dementia (e.g., Alzheimer's disease). Dementia impairs the
ability to perform daily tasks and increases the risk of accidents.
○ Wandering: A common risk in older adults with dementia, wandering can lead to
dangerous situations such as getting lost or encountering environmental hazards.
● Dementia: A clinical syndrome characterized by progressive cognitive decline, dementia
significantly impairs an older adult’s ability to process information and perform tasks safely. It
also increases the risk of wandering, which can be particularly hazardous if the person
leaves a care facility or home unsupervised.
Individual Risk Factors
 ● Workplace Safety Culture: Factors influencing adherence to safety practices include
workplace culture, attitudes, and the availability of equipment. For example, in healthcare
settings, the adherence to personal protective equipment (PPE) usage depends on
individual knowledge, environmental factors, and organizational policies (Institute of
Medicine, 2008).
○ Safety culture within the workplace plays a critical role in reducing workplace injuries
and ensuring that safety protocols are followed.
● Lifestyle: Lifestyle factors such as working in high-risk occupations (e.g., construction or law
enforcement) or engaging in risky behaviors (e.g., texting while driving, operating machinery
under the influence) significantly increase safety risks. Stress, anxiety, and fatigue also
increase the likelihood of accidents or injuries.
● Impaired Mobility: Mobility issues due to conditions like muscle weakness, paralysis, or
poor coordination significantly increase the risk of falls. Ensuring that patients with impaired
mobility have appropriate accommodations (e.g., accessible environments, mobility aids) is
crucial for their safety.
○ Deconditioning: Immobilization can lead to physical deconditioning, where the
patient loses strength and coordination, further increasing their vulnerability to
accidents.
Nurses' Role in Patient Safety:
● Nurses are key in assessing and preventing risks in individuals of all ages. By addressing
issues like immunization, fall prevention, and substance abuse education, nurses can
significantly reduce the occurrence of accidents and health issues.
● Nurses should be proactive in identifying environmental hazards, assessing individual risk
factors (e.g., mobility, substance abuse), and advocating for lifestyle changes that promote
safety.
● Patient education is essential in helping patients understand safety measures, such as the
importance of immunization, the dangers of risky behaviors, and strategies to prevent falls
and accidents, especially in older adults.
Conclusion:
Understanding the unique safety risks at different life stages, including childhood, adolescence,
adulthood, and old age, allows nurses to tailor interventions effectively. Preventive strategies such as
promoting immunization, educating about substance abuse risks, and assessing mobility issues are
essential for promoting overall health and safety.
It looks like you're putting together a detailed exploration of patient safety and quality in healthcare,
covering numerous risk factors and contributing aspects such as childhood immunizations, individual risk
factors, and procedure-related accidents. This content offers a comprehensive perspective on patient
safety and could be very useful in addressing the factors that contribute to patient outcomes.
You’ve included several critical elements that contribute to safety in healthcare settings, such as:
1. Immunizations: Emphasizing childhood vaccinations as key public health measures.
2. Age-related risks: Addressing the different risks specific to adolescents, adults, and older
adults.
3. Individual Risk Factors: How cognitive, mobility, communication, and economic
impairments can affect safety.
4. Healthcare Settings & Procedure-Related Accidents: Discussing the potential risks that
arise from healthcare procedures and environments.
5. Falls and Safety Protocols: Detailing the significant risks of falls and how healthcare
systems track and prevent these incidents.
This content is critical in understanding how multifaceted patient safety is, as it ties together
environmental, organizational, and individual factors. It also highlights both the human and systemic
aspects that must be addressed to ensure safe patient care. If you have any specific sections you want to
expand on, or need additional information on certain topics (like fall risk tools or specific safety protocols),
feel free to ask!
Here are study notes based on the content you provided from Chapter 27 of Pottery and Perry’s
Fundamentals of Nursing, 11th Edition. I have bolded key terms and used bullet points for clarity. This
should help with identifying important concepts that could appear on the ATI exam.

Universal Fall Precautions

● Universal Fall Precautions apply to all patients regardless of fall risk.
● Focus on creating a safe and comfortable environment for patients.
● AHRQ (2018) recommendations for Universal Fall Precautions:
○ Familiarize the patient with the environment.
○ Have the patient demonstrate call light use.
○ Keep the call light within reach.
○ Keep patient’s personal possessions within safe reach.
○ Ensure sturdy handrails in patient bathrooms, rooms, and hallways.
○ Place the hospital bed in low position when resting and raise bed to a comfortable
height when transferring.
○ Lock hospital bed brakes.
○ Lock wheelchair wheel locks when stationary.
○ Ensure patient wears nonslip, well-fitting footwear.
○ Use night lights or supplemental lighting.
○ Keep floor surfaces clean and dry.
○ Maintain uncluttered patient care areas.
○ Follow safe patient-handling practices.
● Additional individualized interventions are recommended based on fall risks, but no
conclusive evidence supports a set of interventions to consistently prevent falls (Fehlberg et
al., 2017).
● Fall Prevention Tips (AHRQ, 2018):
○ Balance fall prevention with other patient care priorities.
○ Promote mobility; prevent complications from bed rest.
○ Fall prevention requires interprofessional cooperation to ensure proper
communication and care.
○ Individualized fall prevention based on unique patient risk factors (e.g., urinary
urgency).

Workplace Safety and Violence Prevention

● Workplace violence includes any act or threat of violence, ranging from verbal abuse to
physical assault.
● Sources of violence: Patients, visitors, intruders, co-workers.
● Impact of workplace violence: Psychological effects (e.g., PTSD, compassion fatigue) and
physical injury.
● NIOSH (2020) defines workplace violence as occurring when individuals are on duty.
● Health care workers are 4 times more likely to require time off due to violence compared to
other professions (Campbell, 2019).
Risk Factors for Violence in Health Care:
● Working with patients who have a history of violence.
● Overcrowded waiting areas and poor lighting.
● Working in isolation and in high-crime areas.
 ● Transporting or lifting patients and presence of firearms.
● Workplace violence continuum: Includes bullying, verbal threats, and physical aggression
(e.g., hitting, kicking).
● Prevention: Safety policies, environmental adaptations, and incident reporting.

Fall Risk Factors

Intrinsic Factors (Related to the Patient)
● History of Previous Falls.
● Behavioral Issues:
○ Patient doesn’t seek assistance for toileting.
○ Patient forgets or chooses not to use call light.
● Altered Cognition:
○ Conditions like dementia, delirium, or sedation.
○ Awareness of fall risks may be impaired.
● Altered Mobility:
○ Lower extremity weakness or abnormal gait.
○ Shuffling, stumbling, or requires assistance with mobility.
● Sensory Deficits:
○ Difficulty seeing walking path clearly or reduced visual field.
● Medications:
○ Drugs like benzodiazepines, antipsychotics, antidepressants, opiates,
antihistamines, etc.
● Toileting Issues:
○ Diuretic use or urgency/frequency.
● Disease Conditions:
○ Dizziness, peripheral neuropathy, pain, and hypotension.
Extrinsic Factors (External Hazards)
● Communication Issues:
○ Inconsistent or incomplete communication of patient fall risks.
○ Frequency of rounding and staff communication gaps.
● Education Issues:
○ Inadequate fall prevention education for patient and family.
○ Improper procedure performance or shortcuts.
● Physical Hazards:
○ Liquids on the floor, electrical cords in walking paths, and improper medical device
use.
● Competency:
○ Improper use of restraints, assistive devices, or footwear.
○ Lack of supervision or decreased efforts to mobilize patients.

Building Competency in Safety

● Example: A patient receiving chemotherapy who becomes confused and pulls out her IV
line, causing the chemotherapy drug to leak onto the linens and floor.

Key Terms for ATI Exam

● Universal Fall Precautions
● AHRQ (2018)
● Workplace Violence
● Intrinsic Factors
 ● Extrinsic Factors
● Safety Policies
● Interprofessional Cooperation
● Patient Mobility
● Fall Risk Assessment
● Post-traumatic Stress Disorder (PTSD)
● Environmental Hazards

These study notes emphasize key terms and concepts that are important for understanding patient safety
and preventing falls, as well as workplace safety in healthcare settings. Be sure to review the material
regularly, and good luck with your studies!
Here are the study notes incorporating the additional information you've provided, focusing on critical
thinking and patient safety, which is crucial for the ATI exam:

Patient Safety and Critical Thinking in Nursing Practice

Patient Risk Factors
● Mrs. Cohen’s Case Study (Cerebrovascular Accident / Stroke)
○ Risks for the Patient:
■ Impaired motor function: Stroke can result in loss or reduction of motor
function, leading to impaired gait and balance, increasing fall risk.
■ Age: Being 78 years old increases her risk for injury due to normal
physical and cognitive changes.
■ Environmental risks: Assessing her home environment for hazards like
uneven floors, poor lighting, or obstacles that can cause falls.
○ Risks for the Nurse:
■ Nurses must ensure their own safety by identifying potential hazards in the
home environment (e.g., uneven flooring, clutter).
■ Nurses are responsible for managing distractions in the clinical setting, as
neglecting a patient’s needs (e.g., leaving a patient on a bedside commode
unattended) could lead to a fall or injury.
■ Ensuring safe patient handling and not overexerting physical limits during
care (especially with patients who have mobility limitations).

Managing Patient Safety and Risk

● Critical Thinking in Nursing Practice:
○ Synthesis of Knowledge: Nurses must use a combination of knowledge,
experience, and environmental factors to anticipate and assess risks for patient
safety.
○ Patient Assessment: Nurses should holistically assess the patient's neurological
and musculoskeletal systems, along with considering age-related changes (e.g.,
Mrs. Cohen’s age).
○ Anticipating Changes: Nurses must recognize that patient safety can change
rapidly due to altered conditions such as changes in cognition, mobility, or pain.
○ Patient Engagement: Nurses should actively engage patients in their care plan to
gather insights on how they perceive safety issues, helping to tailor fall prevention
measures.
● Environmental Factors:
○ Nurses must identify and manage environmental risks such as:
■ Broken equipment
 ■ Uneven floor surfaces
■ Poor lighting
○ Nurses should anticipate common environmental conditions that pose safety risks
and take proactive steps to address them, like ensuring proper lighting and clearing
obstacles.
○ Distractions in a clinical environment can increase the risk of injury if patient needs
are not met immediately (e.g., leaving a patient unassisted).

Critical Thinking and Decision Making Process

● Clinical Decision Making:
○ Recognizing Cues: Anticipate and identify potential risks, such as a patient's fall
history or mobility issues, and prioritize care to mitigate those risks.
○ Analyzing Cues: Interpret clinical data, including neurological assessments and
the physical condition of the patient, to determine safety needs.
○ Generate Solutions: Develop tailored safety strategies (e.g., use of assistive
devices, fall risk assessments, involving family in care).
○ Take Action: Implement appropriate actions to ensure patient safety, such as
making sure the home environment is free of obstacles, assessing medication side
effects, and ensuring adequate support from family or caregivers.

Competency and Standards in Safety

● ANA Standards for Nursing Practice:
○ Nurses are responsible for ensuring patient safety by adhering to professional
standards, including the ANA Standards of Practice, Clinical Practice Guidelines,
and ethical standards.
○ TJC (2021) also provides standards for maintaining patient safety, emphasizing the
need for accurate fall risk assessments and environmental safety measures.
● Competency Development:
○ Nurses must demonstrate confidence and preparedness when conducting safety
assessments.
○ Creativity in involving family caregivers during the assessment process can help
identify home safety hazards and ensure continuous patient safety.
○ Nurses must maintain a high level of skill competence and follow agency policies
and procedures to promote safety in the healthcare setting.

Key Concepts for ATI Exam

● Cerebrovascular Accident (CVA) / Stroke
○ Impaired motor function and increased fall risk.
● Critical Thinking
○ Synthesis of knowledge, experience, and environmental factors.
○ Active patient engagement for safety measures.
● Fall Risk Assessment
○ Home environment assessment for hazards (e.g., uneven floors, clutter).
○ Age-related changes and comorbidities as risk factors for injury.
● Patient and Environmental Safety
○ Identify physical hazards (e.g., poor lighting, uneven flooring) and manage
distractions.
○ Environmental factors like broken equipment can compromise patient safety.
● Nursing Competency and Standards
 ○ ANA Standards and TJC (2021) guidelines.
○ Clinical decision making and professional standards of care.

These study notes integrate critical thinking in clinical decision-making and patient safety practices
with a focus on fall risk assessment and environmental safety. Understanding these concepts will be
crucial for the ATI exam, particularly in nursing roles related to patient assessment, safety management,
and adherence to professional standards.
Study Notes: Chapter 27 – Patient Safety and Quality (Potter & Perry, Fundamentals of Nursing,
11th Edition)

Critical Thinking Model for Assessing Safety

● Key organizations:
○ AGS: American Geriatrics Society
○ ANA: American Nurses Association
○ BGS: British Geriatrics Society
○ TJC: The Joint Commission
● Clinical Judgment Measurement Model: Used to assess and ensure patient safety.
Nursing Process & Patient Safety
● Applying critical thinking helps in making clinical judgments that maintain or promote
patient safety.
Assessment Phase
● Thoroughly assess:
○ The patient (health status, environment)
○ Environmental factors (potential risks such as falls, fire, electrical, and chemical
safety)
○ Compare findings to expected standards for safe care.
Patient’s Perspective on Safety
● Patients have unique views on safety based on their personal experiences, culture, and
background.
○ Different perceptions: What’s considered safe by the nurse may differ from the
patient's perception.
○ Example: Ethnic minority patients may face increased stress or fear in unfamiliar
health care settings (hospitalization).
Key Elements of Patient-Centered Safety Assessment
● Patient’s perceptions of risk factors
● Patient’s values and beliefs about safety
● Patient’s concerns about being in a health care setting
● Patient’s knowledge on how to adapt to safety risks
● Patient’s past experiences with accidents
● Consult with family caregivers when necessary.
Involvement of Patients & Families
● Patients and families are key partners in safety assessments.
○ Patients often detect medical errors or risks.
○ Research findings: A study involving 19,000+ patients in 11 countries highlighted
common safety concerns:
■ Poor care coordination: 10.9% of patients reported missing test results or
medical records.
■ Conflicting information from healthcare providers: 19.6% of patients.
 ■ Redundant tests: 10.5% of patients underwent tests that had been
previously performed.
Important Terms for ATI Exam:
● Critical Thinking Model
● Clinical Judgment Measurement Model
● Risk factors
● Patient-centered care
● Cultural perceptions of safety
● Patient safety concerns (coordination, errors, redundant tests)

This study note breaks down the chapter’s key concepts in patient safety, emphasizing the importance of
assessing safety from the patient’s point of view and involving both patients and families in the process.
These topics are likely to be tested on the ATI exam.
Study Notes: Chapter 27 – Patient Safety and Quality (Potter & Perry, Fundamentals of Nursing,
11th Edition)

Critical Thinking Model for Assessing Safety

● Key organizations:
○ AGS: American Geriatrics Society
○ ANA: American Nurses Association
○ BGS: British Geriatrics Society
○ TJC: The Joint Commission
● Clinical Judgment Measurement Model: Used to assess and ensure patient safety.
Nursing Process & Patient Safety
● Applying critical thinking helps in making clinical judgments that maintain or promote
patient safety.
Assessment Phase
● Thoroughly assess:
○ The patient (health status, environment)
○ Environmental factors (potential risks such as falls, fire, electrical, and chemical
safety)
○ Compare findings to expected standards for safe care.
Patient’s Perspective on Safety
● Patients have unique views on safety based on their personal experiences, culture, and
background.
○ Different perceptions: What’s considered safe by the nurse may differ from the
patient's perception.
○ Example: Ethnic minority patients may face increased stress or fear in unfamiliar
health care settings (hospitalization).
Key Elements of Patient-Centered Safety Assessment
● Patient’s perceptions of risk factors
● Patient’s values and beliefs about safety
● Patient’s concerns about being in a health care setting
● Patient’s knowledge on how to adapt to safety risks
● Patient’s past experiences with accidents
● Consult with family caregivers when necessary.
Nursing History and Examination
● Nursing History (see Chapter 30):
○ Data includes:
 ■ Medical history
■ Medications
■ Psychosocial and cultural background
■ Presence of fall risk factors
○ Helps identify underlying conditions that could pose threats to safety.
● Physical Examination:
○ Focuses on bodily functions affecting mobility and interaction with the environment.
○ Assess for:
■ Cognitive status
■ Gait (ability to walk)
■ Lower-body muscle strength & coordination
■ Balance
■ Visual and hearing status
■ Cardiovascular health (important for activity tolerance)
■ Example: A patient with shortness of breath has unstable stance,
increasing fall risk.
○ Always observe physical assessment, especially gait and balance, rather than
relying on patient self-report.
● Developmental Status:
○ Consider the patient’s age and potential risks based on developmental stage (e.g.,
adolescents may have risks for suicide, drug abuse, or alcohol use).
● Medication History & Risks:
○ Example: Diuretics increase frequency of urination, causing patients to rush to the
toilet—a risk for falls.
Psychosocial and Cultural Background
● Intercultural care challenges arise when patients from different backgrounds are admitted to
the healthcare system.
○ Challenges:
■ Language barriers
■ Lower health literacy
■ Higher socioeconomic stressors in ethnic minority groups
■ Scarcity of hospital resources (time, money, staff)
■ Cultural differences in understanding illness, treatment, and healthcare.
■ Negative attitudes among patients and caregivers.
Involvement of Patients & Families
● Patients and families are key partners in safety assessments.
○ Patients often detect medical errors or risks.
○ Research findings: A study involving 19,000+ patients in 11 countries highlighted
common safety concerns:
■ Poor care coordination: 10.9% of patients reported missing test results or
medical records.
■ Conflicting information from healthcare providers: 19.6% of patients.
■ Redundant tests: 10.5% of patients underwent tests that had been
previously performed.
Important Terms for ATI Exam:
● Critical Thinking Model
● Clinical Judgment Measurement Model
● Risk factors
● Patient-centered care
 ● Cultural perceptions of safety
● Patient safety concerns (coordination, errors, redundant tests)
● Fall risk factors
● Medication side effects (e.g., diuretics)
● Intercultural care challenges

This updated study note incorporates the additional information regarding nursing history, physical
examinations, and psychosocial and cultural considerations, all of which are important for patient
safety and critical thinking in nursing assessments. These concepts are likely to be included in ATI exam
content.
Study Notes: Chapter 27 – Patient Safety and Quality (Potter & Perry, Fundamentals of Nursing,
11th Edition)

Critical Thinking Model for Assessing Safety

● Key organizations:
○ AGS: American Geriatrics Society
○ ANA: American Nurses Association
○ BGS: British Geriatrics Society
○ TJC: The Joint Commission
● Clinical Judgment Measurement Model: Used to assess and ensure patient safety.
Nursing Process & Patient Safety
● Applying critical thinking helps in making clinical judgments that maintain or promote
patient safety.
Assessment Phase
● Thoroughly assess:
○ The patient (health status, environment)
○ Environmental factors (potential risks such as falls, fire, electrical, and chemical
safety)
○ Compare findings to expected standards for safe care.
Patient’s Perspective on Safety
● Patients have unique views on safety based on their personal experiences, culture, and
background.
○ Different perceptions: What’s considered safe by the nurse may differ from the
patient's perception.
○ Example: Ethnic minority patients may face increased stress or fear in unfamiliar
health care settings (hospitalization).
Key Elements of Patient-Centered Safety Assessment
● Patient’s perceptions of risk factors
● Patient’s values and beliefs about safety
● Patient’s concerns about being in a health care setting
● Patient’s knowledge on how to adapt to safety risks
● Patient’s past experiences with accidents
● Consult with family caregivers when necessary.

Perceptions of Safety
● Understanding safety:
○ What does it mean to feel safe?
○ Describe any changes to improve safety at work or at home.
Lifestyle Considerations
 ● Assistive devices: Does the patient use a wheelchair, walker, or cane? Ensure the patient
demonstrates safe use.
● Activities of daily living:
○ Difficulty with bathing, dressing, or toileting.
○ Meal preparation safety (e.g., using stove and appliances safely).
○ Laundry: How is it done? Location of appliances?
● Social activities: What types of social activities does the patient engage in?
● Driving: Does the patient drive? When and how far? Use of seat belts or helmets?
Medication History
● Medications: Ask about prescription, over-the-counter, and herbal medicines.
● Review: Has the doctor or pharmacist reviewed medications in the last year?
● Side effects: What side effects has the patient experienced?
History of Falls
● Past falls: Ask if the patient has ever fallen or tripped, or had any near misses.
● Cause of fall: What was the patient doing when the fall happened?
● Injury from fall: Any injury sustained? How did it happen?
● Symptoms before fall: Did the patient experience any symptoms before the fall?
Home Maintenance and Safety
● Home maintenance: Who does minor home repairs and snow removal or lawn mowing?
● Safety at home: Does the patient feel safe? Describe any environmental hazards.
● Emergency contacts: Who can the patient call for help during an emergency?
● Home modifications: Would the patient consider modifying their home for increased safety?

Health Care Environment

● Assessing hazards in a health care setting:
○ Placement of equipment and furniture that could impede ambulation.
○ Bed positioning for patient comfort and mobility.
○ Availability of assistive devices (e.g., gait belts).
○ Ensuring hand hygiene practices are followed by staff and visitors.
○ Access to nurse call systems.

Risk for Medical Errors

● Distractions in the workplace increase risk of errors (e.g., phone calls, alarms).
● Fatigue from long shifts can impair concentration and lead to errors.
● Two identifiers: Always verify patient identity using two identifiers (e.g., name and birthday).

Disasters & Emergency Preparedness

● Responding to community disasters: Hospitals must be prepared for influxes of patients
during emergencies like pandemics or bioterrorist attacks.
● Early signs of bioterrorism-related illnesses (e.g., nausea, vomiting, diarrhea) often mimic
general viral symptoms.
● Community education: The Federal Emergency Management Agency (FEMA) and
American Red Cross offer resources for disaster preparedness.

Key Terms for ATI Exam:

● Critical Thinking Model
● Patient-centered care
● Lifestyle safety (assistive devices, activities of daily living, social activities, driving)
● Medication safety
 ● History of falls
● Home safety and maintenance
● Health care environment hazards
● Medical errors
● Disaster preparedness
● Cultural competence in health care

These study notes cover critical aspects related to patient safety, focusing on both environmental and
personal factors, along with the importance of assessing the patient's perspective and lifestyle. These
topics are essential for understanding safety in healthcare and will likely be tested on the ATI exam.
Study Notes: Chapter 27 – Patient Safety and Quality (Potter & Perry, Fundamentals of Nursing,
11th Edition)

Critical Thinking Model for Assessing Safety

● Key organizations:
○ AGS: American Geriatrics Society
○ ANA: American Nurses Association
○ BGS: British Geriatrics Society
○ TJC: The Joint Commission
● Clinical Judgment Measurement Model: Used to assess and ensure patient safety.
Nursing Process & Patient Safety
● Applying critical thinking helps in making clinical judgments that maintain or promote
patient safety.
Assessment Phase
● Thoroughly assess:
○ The patient (health status, environment)
○ Environmental factors (potential risks such as falls, fire, electrical, and chemical
safety)
○ Compare findings to expected standards for safe care.
Patient’s Perspective on Safety
● Patients have unique views on safety based on their personal experiences, culture, and
background.
○ Different perceptions: What’s considered safe by the nurse may differ from the
patient's perception.
○ Example: Ethnic minority patients may face increased stress or fear in unfamiliar
health care settings (hospitalization).
Key Elements of Patient-Centered Safety Assessment
● Patient’s perceptions of risk factors
● Patient’s values and beliefs about safety
● Patient’s concerns about being in a health care setting
● Patient’s knowledge on how to adapt to safety risks
● Patient’s past experiences with accidents
● Consult with family caregivers when necessary.

Perceptions of Safety
● Understanding safety:
○ What does it mean to feel safe?
○ Describe any changes to improve safety at work or at home.
Lifestyle Considerations
 ● Assistive devices: Does the patient use a wheelchair, walker, or cane? Ensure the patient
demonstrates safe use.
● Activities of daily living:
○ Difficulty with bathing, dressing, or toileting.
○ Meal preparation safety (e.g., using stove and appliances safely).
○ Laundry: How is it done? Location of appliances?
● Social activities: What types of social activities does the patient engage in?
● Driving: Does the patient drive? When and how far? Use of seat belts or helmets?
Medication History
● Medications: Ask about prescription, over-the-counter, and herbal medicines.
● Review: Has the doctor or pharmacist reviewed medications in the last year?
● Side effects: What side effects has the patient experienced?
History of Falls
● Past falls: Ask if the patient has ever fallen or tripped, or had any near misses.
● Cause of fall: What was the patient doing when the fall happened?
● Injury from fall: Any injury sustained? How did it happen?
● Symptoms before fall: Did the patient experience any symptoms before the fall?
Home Maintenance and Safety
● Home maintenance: Who does minor home repairs and snow removal or lawn mowing?
● Safety at home: Does the patient feel safe? Describe any environmental hazards.
● Emergency contacts: Who can the patient call for help during an emergency?
● Home modifications: Would the patient consider modifying their home for increased safety?

Health Care Environment

● Assessing hazards in a health care setting:
○ Placement of equipment and furniture that could impede ambulation.
○ Bed positioning for patient comfort and mobility.
○ Availability of assistive devices (e.g., gait belts).
○ Ensuring hand hygiene practices are followed by staff and visitors.
○ Access to nurse call systems.

Risk for Medical Errors

● Distractions in the workplace increase risk of errors (e.g., phone calls, alarms).
● Fatigue from long shifts can impair concentration and lead to errors.
● Two identifiers: Always verify patient identity using two identifiers (e.g., name and birthday).

Disasters & Emergency Preparedness

● Responding to community disasters: Hospitals must be prepared for influxes of patients
during emergencies like pandemics or bioterrorist attacks.
● Early signs of bioterrorism-related illnesses (e.g., nausea, vomiting, diarrhea) often mimic
general viral symptoms.
● Community education: The Federal Emergency Management Agency (FEMA) and
American Red Cross offer resources for disaster preparedness.

Key Terms for ATI Exam:

● Critical Thinking Model
● Patient-centered care
● Lifestyle safety (assistive devices, activities of daily living, social activities, driving)
● Medication safety
 ● History of falls
● Home safety and maintenance
● Health care environment hazards
● Medical errors
● Disaster preparedness
● Cultural competence in health care

Reflect Now – Home Risk Assessment:

● Go to the CDC Website (CDC Home and Recreational Safety PDF) and complete a home
risk assessment for someone who is 65 years or older.
● Focus: Identify ways to minimize safety risks in their home environment.

Patient’s Home Environment & Risk Assessment

● Environmental Factors: Access to supportive care and home health services depends on
the location and structure of the home. Ensure reliable utilities (e.g., electricity, water,
Internet) are present.
● Family Caregiver: Assess the willingness and ability of family caregivers to adapt the home
environment and assist in providing care.
● Hazard Assessment: Review the entire home (including outdoor spaces):
○ Check lighting (indoors and outdoors)
○ Inspect flooring and surfaces
○ Evaluate the presence of safety devices (side rails, safety bars, alarms)
○ Furniture placement: Ensure no barriers that could impede mobility or create
hazards.
○ Know where medications and cleaning supplies are stored.
○ Locks on doors and windows: Are they functional and secure?
● Food Safety: Assess the patient's knowledge of safe food handling, storage, and
preparation:
○ Check expiration dates on food items
○ Ensure freshness of food in the fridge
○ Teach proper cleaning of fruits and vegetables
● Environmental Comfort: Assess home systems:
○ Is the heating and cooling system functioning?
○ Are smoke detectors, carbon monoxide detectors, and fire extinguishers
present and in working order?
● Risk for Falls:
○ Assessment tools: Use risk assessment instruments to evaluate a patient’s fall risk.
○ Consider age, fall history, elimination habits, medications, mobility, and
cognition.
○ Family involvement: Family members can often provide additional insight into the
patient's fall history and mobility.
● Psychosocial & Economic Resources:
○ Caregiver support: Understand the willingness and ability of family members to
assist.
○ Economic resources: Can the patient afford necessary home modifications or
medications?

Analysis & Nursing Diagnosis

 ● Use critical thinking to analyze assessment data and identify patterns in findings.
Recognize risk factors like impaired mobility or visual impairment to create appropriate
interventions.
● Nursing Diagnosis Examples:
○ Risk for Fall
○ Impaired Mobility
○ Impaired Cognition: Confusion
○ Risk for Injury
○ Risk for Poisoning
○ Lack of Knowledge
In summary, the assessment process is crucial in identifying safety risks in both the healthcare setting
and home environments. By conducting comprehensive assessments and utilizing critical thinking, nurses
can address potential hazards and help reduce the risks of falls and injuries.
Study Notes: Fall Prevention and Patient Safety (Potter & Perry, Fundamentals of Nursing, 11th
Edition)

Fall Risk Screening

The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) Clinical Practice
Guideline provides a detailed approach for screening, evaluating, and managing fall risks in older adults.
Here’s how it is structured:
Screening Process:
1. Initial Questions: Ask the following to identify risk:
a. Two or more falls in the past 12 months?
b. Acute fall (recent fall)?
c. Difficulty walking or maintaining balance?
If the answer is yes to any of these, further assessment is required.
2. Gait and Balance Evaluation:
a. Gait abnormalities or unsteadiness noted? If so, further evaluation and
interventions should be implemented.
3. Evaluate for additional intervention if needed.

Multifactorial Fall Risk Assessment

If the person reports a fall or has risk factors, proceed with a comprehensive fall risk assessment:
1. Obtain relevant medical history including physical examination, cognitive and functional
assessment.
2. Assess fall risk factors such as:
a. History of falls (previous falls increase the likelihood of future falls).
b. Medications: Review if the patient is on any sedatives, blood pressure
medications, or others that may contribute to dizziness or drowsiness.
c. Gait, balance, and mobility issues.
d. Visual acuity: Ensure that vision problems (like cataracts) are addressed.
e. Neurological impairments: Conditions like stroke, Parkinson’s, etc., can increase
risk.
f. Muscle strength: Weak muscles increase the likelihood of falls.
g. Heart rate and rhythm: Abnormalities can impact balance and dizziness.
h. Postural hypotension: Assess for dizziness when standing up quickly.
i. Feet and footwear: Assess for proper footwear and check for issues like foot
deformities.
 j. Environmental hazards: Home and outdoor environments must be assessed for fall
risks (slippery floors, clutter, poor lighting).

Interventions for Fall Prevention

Once the risk factors have been identified, implement the following interventions:
1. Minimize medications that may increase fall risk.
2. Exercise programs: Provide an individually tailored exercise program to improve strength
and balance.
3. Treat vision impairment: Ensure glasses are up to date, or manage cataracts.
4. Manage postural hypotension: Encourage slow, deliberate movements when changing
positions (e.g., standing up slowly).
5. Manage heart rate and rhythm abnormalities.
6. Supplement vitamin D to support bone health and reduce fall risk.
7. Feet and footwear: Ensure proper shoes are worn and check for foot conditions.
8. Modify the home environment: Remove obstacles, use non-slip rugs, improve lighting, and
ensure that items are within reach.
9. Provide education: Teach patients and their families about fall prevention techniques.

Planning and Outcomes Identification

Critical Thinking is essential when planning interventions to prevent falls and enhance patient safety.
Here’s how the nurse uses critical thinking in the planning phase:
● Patient-Centered Interventions:
Interventions should be based on a patient’s unique situation—their medical conditions, level of
cognitive understanding, home environment, and available resources.
● Collaboration:
Engage health care teams and family caregivers to create a comprehensive fall prevention plan.
Collaboration ensures that interventions are holistic, addressing all aspects of safety.
● Utilize Professional Standards:
Use guidelines like Universal Fall Precautions or those from AGS/BGS to inform the care plan. These
standards help ensure safety measures are evidence-based.
● Environmental Assessment:
The nurse must observe and assess the home environment and health care setting for potential
hazards. For instance, checking for fall risks in a patient’s home or observing if safety measures (like grab
bars or side rails) are in place in a hospital.
● Delegation and Timing:
When caring for fall-risk patients, ensure that tasks are delegated appropriately. For example, if the
patient is on fall precautions, make sure that assistive personnel (e.g., nursing assistants) are helping
with tasks that might lead to a fall. Respond to patients’ needs promptly (e.g., assisting the patient to the
bathroom immediately to prevent them from trying to move alone).

Outcome Goals
The goal of all fall risk interventions is to reduce the risk of falls and maintain patient independence.
Key outcomes to aim for include:
● Increased patient mobility and strength.
● Reduced fall frequency or severity.
● Improved home safety through modifications.
● Enhanced patient and family education about fall risks and prevention.

Key Takeaways: Fall Prevention Algorithm (AGS/BGS)

 1. Screen for fall risk by asking the screening questions.
2. Evaluate gait, balance, and mobility.
3. Assess for multifactorial fall risk factors, such as medications, medical history, vision,
muscle strength, and environmental hazards.
4. Design individualized interventions based on the findings, such as medication
adjustments, exercise, vision correction, and home modifications.
5. Reassess periodically to evaluate progress and adjust the care plan as necessary.
6. Educate patients and caregivers to ensure they are aware of the risks and how to prevent
falls effectively.
By following the AGS/BGS guidelines, nurses can help older patients stay safe, prevent falls, and
promote overall well-being through personalized care plans.

Summary of Fall Risk Algorithm:

1. Screening: Assess whether the patient has had falls or balance difficulties.
2. Evaluate gait and balance.
3. Comprehensive risk assessment: Gather medical history, physical exam, and consider
multifactorial factors.
4. Intervention: Based on findings, address specific risks (e.g., exercise, medication review,
vision correction, home modifications).
5. Reassessment: Continuously monitor and adjust interventions as needed.
By using this approach, nurses are better equipped to ensure patient safety and effectively reduce fall
risks in older patients.
Study Notes: Fall Prevention and Patient Safety (Potter & Perry, Fundamentals of Nursing, 11th
Edition)

Outcomes and Collaborative Planning

Collaborating with the patient, family caregiver, and other healthcare team members is essential when
setting outcomes for patient safety during the planning process. Active patient participation in safety
planning improves adherence to the safety plan.
● When patients participate actively, they become more aware of potential hazards, which
increases their likelihood of following through with interventions and making the necessary
adjustments to their home and lifestyle to improve safety.
● Involve the patient and family caregivers in discussions about specific safety concerns
and strategies for reducing risks. This helps the patient and caregivers feel empowered,
and more likely to adhere to safety interventions.
Nursing Diagnostic Process for Fall Risk
Using a structured diagnostic process is key to identifying fall risks and planning for effective
interventions. Here’s how you might proceed with a Risk for Fall diagnosis.
Assessment Activities & Findings
1. Posture, Gait, Strength, and Balance:
a. Observation: Assess the patient's posture, range of motion, gait, strength, balance,
and body alignment.
b. Assessment Findings:
i. Decrease in left lower extremity strength.
ii. Patient drags left foot and has a weak left hand grasp while holding the
walker.
iii. Unsteady gait and impaired balance when standing.
2. Visual Acuity:
 a. Assessment: Assess the patient’s ability to see clearly, such as identifying near and
distant objects.
b. Assessment Findings:
i. Reports difficulty seeing at night.
ii. Blurred vision, unable to identify near objects without glasses.
3. Home Hazard Appraisal:
a. Assessment: Evaluate the patient's home environment for fall hazards.
b. Assessment Findings:
i. Poor lighting in the home.
ii. Excessive furniture in the living room.
iii. Unsecured rugs throughout the home.
iv. No grab bars in the bathroom.
Environmental and Experience-Based Standards
1. Standards of Care and Knowledge Base:
a. Recognize how health conditions can affect patient safety (e.g., visual impairment,
weakness).
b. Incorporate knowledge of the impact of medications, environment, and lifestyle on
safety.
c. Follow delegation principles and ensure that care tasks are delegated
appropriately.
d. Understand the time pressure involved in responding to immediate patient needs
and avoid delays.
2. Experience-Based Knowledge:
a. Use previous experiences caring for patients with similar needs to adapt and
improve safety interventions.
b. Knowledge of successful safety promotion interventions is crucial. Nurses should
rely on their own experience as well as evidence-based guidelines when planning
care.
3. Standards of Practice:
a. Follow professional standards of care, such as Universal Fall Precautions.
b. Adhere to clinical practice guidelines and agency policies related to safety.
c. Incorporate ethical standards and patient outcomes when developing a patient-
centered safety plan.
Critical Thinking Model for Planning Safety
The critical thinking model for planning patient safety involves several key steps to ensure
comprehensive and effective interventions:
1. Recognizing Cues:
a. Pay attention to the assessment findings (e.g., impaired gait, visual problems,
environmental hazards) to identify patterns that suggest fall risk.
2. Analyzing Cues:
a. Analyze these findings to determine whether any specific risk factors are contributing
to the patient’s fall risk. For example, muscle weakness, impaired balance, and
environmental hazards all contribute to fall risk.
3. Prioritizing Hypotheses:
a. Based on the analysis, prioritize the most critical factors contributing to the risk of
falls (e.g., weakness in lower extremities or poor lighting).
4. Generating Solutions:
a. Develop individualized solutions based on the patient’s specific needs (e.g.,
exercise programs to improve strength, vision correction, home modifications).
 5. Taking Action:
a. Implement safety interventions such as fall prevention strategies, home
modifications, and patient and caregiver education.
6. Evaluation:
a. Continuously assess the outcomes of interventions and adjust as necessary.
Reassess the patient’s environment and physical condition regularly to ensure the
care plan remains effective.

Critical Thinking in Patient Safety

Using critical thinking is essential to evaluate, plan, and implement effective safety interventions for
patients at risk for falls. The nurse must:
● Analyze patient assessment findings and identified risk factors.
● Prioritize interventions based on severity of the identified risks (e.g., more immediate risks
like poor vision or unsteady gait should be addressed first).
● Collaborate with the patient, family caregivers, and other members of the healthcare team
to design interventions that are personalized and feasible.
● Ensure timely and responsive care, as delays in assistance can increase the risk of falls.

Summary of Key Points:

1. Collaborative Planning: Actively involving the patient and caregivers ensures adherence to
safety plans and promotes patient awareness of hazards.
2. Nursing Diagnostic Process: Conduct a thorough assessment of posture, gait, vision, and
the home environment to identify fall risks.
3. Standards of Practice: Rely on professional standards of care and clinical guidelines to
guide decision-making and interventions.
4. Critical Thinking: A structured approach to assessing, analyzing, and planning ensures
that all aspects of patient safety are considered.
5. Outcome Evaluation: Continuously evaluate the effectiveness of interventions and adjust
plans as necessary to reduce fall risks and improve patient outcomes.
By applying these principles, nurses can help ensure that older patients remain safe in their homes and
reduce their risk of falls.
Nursing Care Plan: Risk for Fall

Assessment
Assessment Activities & Findings:
1. Home Hazard Assessment:
a. Kitchen table is cluttered with unopened mail and papers.
b. Throw rugs are on floors; bathroom and bedroom lighting is poor (40-watt bulbs).
c. Bathtub lacks grab bars.
2. Gait and Posture Observation:
a. Patient can bear weight on the right (dominant) leg.
b. Leans forward when holding walker, moves left leg slowly, drags left foot, weak left
hand grasp.
3. Medication Assessment:
a. Patient is taking antihypertensive, diuretic, calcium and vitamin D, and thyroid
medication.

Nursing Diagnosis: Risk for Fall

Planning
Expected Outcomes (NOC):
● Knowledge: Personal Safety
○ Patient and daughter will identify personal and environmental risks for falls within 1
week.
○ Patient and daughter will select prevention methods to avoid falls in the home at the
conclusion of the teaching session (2 weeks).
● Fall Prevention Behavior
○ Patient will not fall within 1 month.

Interventions (NIC)
1. Fall Prevention:
a. Action: Review findings from a home hazard assessment with the patient and her
daughter, and collaborate with an occupational therapist to propose changes such as
removal of throw rugs, placement of grab bars in the bathroom, and increased
lighting intensity in rooms (75-watt bulbs).
b. Rationale: Home hazard assessment identifies extrinsic fall risks, and modification
by occupational therapists can reduce falls in high-risk adults (Stark et al., 2017).
2. Education on Aging and Stroke Effects:
a. Action: Discuss normal aging changes, specific effects of recent stroke, and
associated risks for injury, as well as methods to reduce these risks.
b. Rationale: Education about hazards helps reduce the fear of falling (Olsen &
Bergland, 2014).
3. Physical Therapy Collaboration:
a. Action: Collaborate with physical therapist to begin exercises for strengthening
upper and lower extremities, and follow physical therapy guidelines for using the
walker.
b. Rationale: Correct use of assistive devices, like walkers, reduces fall risk. Health
care providers should emphasize walker use for injury prevention and training (Luz
et al., 2017).
4. Endurance and Assistive Device Evaluation:
a. Action: Consult with physical and occupational therapists to assess the need for
endurance training and assistive devices to address kyphosis, left-sided weakness,
and gait abnormalities.
b. Rationale: Multicomponent interventions (strength, balance, and endurance) improve
fall prevention and mobility in older adults (Cadore et al., 2013).

Evaluation
1. Evaluation Activity 1:
a. Ask the patient and daughter to identify fall risks and the planned changes in the
home.
b. Patient Response: Patient identifies previous falls and left-sided weakness as fall
risks, while the daughter points out bathroom hazards (lighting and lack of grab bars).
2. Evaluation Activity 2:
a. Ask the patient and daughter to describe the fall prevention strategies they have
planned for the home.
b. Patient Response: Patient and daughter agree to remove throw rugs, and the son
will help install lighting and grab bars in the bathroom.
3. Evaluation Activity 3:
 a. Reassess if patient has experienced a fall in the last month.
b. Patient Response: The patient has not experienced any falls.

Outcome Setting:
● Expected outcomes must be measurable and realistic, considering available resources.
○ For example: "Patient remains injury-free for 1 month," or "Patient removes
environmental hazards from the home within 1 month."
● Kylie sets a short-term outcome of "Patient will not fall in 1 month" to prioritize fall
prevention early in the recovery process after the stroke.

Prioritizing Care:
● Outcomes must be set based on the severity and immediacy of the risk. Given Mrs.
Cohen’s high fall risk due to left-sided weakness and the recent CVA, Kylie prioritizes fall
prevention in the first few weeks.
● After addressing fall prevention, Kylie plans to shift focus to other priorities such as
medication adherence and rehabilitation for strength and mobility.

Concept Map Example:

Primary health problem: Cerebrovascular accident with left-sided weakness and neglect.
Priority assessments:
● Mobility: Drags left foot, difficulty advancing walker, reduced strength in left hand.
● Coping strategies: Patient's emotional response to health changes.
● Home safety: Identifying trip hazards, poor lighting, lack of grab bars.

Nursing Diagnoses:
1. Impaired Mobility: Due to weakness and gait issues.
a. Interventions: Teach strengthening exercises, collaborate with physical therapist for
endurance training, and ensure safe pathways at home.
2. Health Seeking Behavior: The patient wants to regain strength and manage medications
properly.
a. Interventions: Engage patient in discussions about fall risks and the importance of
mobility aids and safety strategies.
3. Risk for Fall: Due to history of falls, age, left-sided weakness, impaired gait, and
environmental hazards.
a. Interventions: Focus on home safety, use of assistive devices, and medication
effects on balance.

Reflection and Conclusion:

By focusing on personal safety and fall prevention in the initial phase of the care plan, nurses can help
patients like Mrs. Cohen regain mobility and reduce their risk of falls, which is critical in their recovery
from a stroke. By following a structured approach, involving education, environmental modifications,
and collaboration with physical and occupational therapists, outcomes can be optimized, ensuring
the patient’s safety and well-being.
Concept Map for Ms. Cohen
Primary health problem: Cerebrovascular accident (CVA) with left-sided weakness and neglect.

Nursing Diagnoses and Priorities

Using clinical judgment, a nurse prioritizes diagnoses and interventions for patient care. The concept map
for Ms. Cohen, displayed in Figure 27.4, shows the interrelationship of multiple nursing diagnoses. The
primary focus is on safety, particularly regarding her mobility, gait, and balance issues resulting from the
stroke. Additional priorities emerge when a patient struggles to understand how a condition contributes to
safety risks. This is especially true when cognitive or emotional responses, like fear of falling, might
hinder active participation in safety measures.

Prioritizing Safety and Mobility

● Risk for Fall: This is a key priority diagnosis for Ms. Cohen due to the combination of left-
sided weakness, balance impairment, and environmental hazards.
○ Interventions: Focus on home hazard removal, physical therapy for gait training,
and education for the patient and family regarding stroke effects on mobility.
● Impaired Mobility: Given Ms. Cohen's left-sided weakness, it is crucial to help her regain
strength and mobility for safe ambulation.
○ Interventions: Engage in strengthening exercises, and provide assistance and
education on walker use.
● Health Seeking Behavior: Ms. Cohen's motivation to participate in rehabilitation and adhere
to safety measures will influence the success of the care plan.
○ Interventions: Encourage her to engage in rehabilitation, and help her
understand safety risks related to her condition.

Teamwork and Collaboration

Collaboration is essential when addressing the multiple aspects of fall risk and mobility issues. Physical
therapy (PT) and occupational therapy (OT) are key team members in Ms. Cohen's recovery.
1. Physical Therapist (PT):
a. Provides exercises to improve strength, endurance, and gait.
b. Home visits to evaluate walking ability and walker use.
2. Occupational Therapist (OT):
a. Recommends home modifications like grab bars, stairway railings, and slip-
resistant surfaces to reduce fall risks.
b. Assesses assistive devices for activities of daily living (ADLs).
Effective communication with all team members is vital. Nurses play a crucial role in keeping the team
updated on any changes in Ms. Cohen's status or concerns that arise.

Cultural Aspects of Care

A patient-centered care approach is critical, especially when working with patients from diverse cultural
backgrounds. Ms. Cohen’s vulnerability to injury could be exacerbated by the unfamiliar hospital
environment, especially if there are cultural differences in how care is approached.
1. Health Literacy: Nurses should assess the patient’s health literacy and tailor
communication to ensure that Ms. Cohen and her family understand the fall risks and safety
strategies.
2. Cultural Sensitivity in Communication: Be mindful of the patient's cultural beliefs and
preferences regarding safety measures. For example, if restraints are required, be aware of
cultural attitudes toward them. Some cultures may find them disrespectful, while others may
view them as a threat.
3. Collaboration with Family: Ensure that family members are included in discussions about
safety measures. For example, some cultures may prefer family members to stay with the
patient when restraints are needed, and this should be acknowledged and respected in care
planning.

ISBAR/SBAR Communication
Clear communication is crucial for coordinating care, especially when managing a high-risk patient.
Nurses should use structured communication models like ISBAR or SBAR when communicating about
fall risks and interventions with the healthcare team.
● I (Introduction) – Introduce the patient and key details.
● S (Situation) – Explain the current safety concerns (e.g., risk of falling).
● B (Background) – Include relevant medical history and the patient’s current condition.
● A (Assessment) – Provide a clinical judgment or status update (e.g., mobility, fall risks).
● R (Recommendation) – Propose actions or interventions (e.g., physical therapy, home
modifications).
● Readback – Confirm all information and recommendations.

Reflection on Care Approach

The prioritization of safety and mobility interventions is central to the care of Ms. Cohen. By
recognizing the interrelated nature of these issues and collaborating with the healthcare team, nurses can
provide comprehensive care to improve outcomes. Additionally, being sensitive to cultural aspects of
care ensures that safety measures are not only effective but also respectful of the patient's background,
which improves overall care adherence.

Conclusion
By incorporating concepts such as prioritizing patient safety, collaborating with healthcare
providers, and considering cultural differences, nurses can significantly enhance the quality of care
and reduce risks for patients like Ms. Cohen. This holistic approach helps ensure that fall prevention and
mobility rehabilitation are effective and aligned with the patient’s needs and preferences.
Building Competency in Patient-Centered Care
During an outpatient follow-up visit for a 78-year-old patient recovering from pneumonia, accompanied
by his 45-year-old daughter, it’s essential for the clinic nurse to assess the patient’s fall risk in the home
setting. This assessment will take into account several key factors:
Assessment Factors to Determine Fall Risk:
1. Mobility and Balance: The nurse should assess whether the patient has difficulty walking,
maintaining balance, or performing daily tasks. The patient’s ability to safely walk and move
around is a primary factor in determining fall risk.
2. History of Falls: If the patient has fallen recently or in the past, this increases the risk. The
nurse will ask questions about previous falls, their causes, and any injury sustained.
3. Medications: Review of the medications the patient is taking is essential. Some medications,
especially antihypertensives, sedatives, or diuretics, can increase the risk of falls due to
side effects like dizziness or lightheadedness.
4. Visual and Cognitive Function: Impaired vision or cognitive deficits can also increase fall
risk. The nurse will check whether the patient has difficulty seeing or concentrating, and
assess mental status (e.g., orientation, ability to process information).
5. Environmental Hazards: Assess the home environment to identify potential fall hazards
such as poor lighting, loose rugs, or lack of grab bars in bathrooms. In the clinic, the
nurse can ask questions about the patient's home setting to gather insight into potential
hazards.
6. Support Systems: The nurse should evaluate whether the patient has adequate social
support, such as a caregiver (in this case, the daughter) who can assist with mobility and
provide assistance at home. The presence of family members or caregivers can significantly
reduce fall risks.

Patient and Family Engagement

The clinic nurse should collaborate with the patient and the family caregiver (the daughter) to promote
patient safety. It’s important that the patient and family understand the resources available to enhance
safety, both in the home and within their community.
1. Community Resources: Nurses should help the patient and family identify local resources
(e.g., neighborhood safety programs, local police departments, or community check-in
services) to ensure ongoing support and safety.
2. Safety Modifications: Encourage the family to make necessary home modifications that
reduce fall risks, such as installing grab bars in the bathroom, improving lighting, and
removing hazards like throw rugs.

Implementation of Patient-Centered Care and Safety

QSEN (Quality and Safety Education for Nurses) outlines skills to ensure that nurses can implement
safe practices and promote patient safety. Among these skills, nurses should:
● Use technology and standardized practices that support safety and quality care.
● Utilize strategies such as checklists and forcing functions to ensure safety and reduce
errors.
● Communicate any concerns about hazards or potential risks to the patient, family, and
healthcare team.
Critical Thinking in Safety:
The nurse needs to apply clinical judgment by continuously evaluating the patient’s risk factors and
anticipating environmental hazards. This ongoing assessment helps guide interventions aimed at
reducing the likelihood of falls and other safety risks. Nurses must stay vigilant for potential hazards, even
in the outpatient setting, and intervene when necessary to promote safety.

Health Promotion and Injury Prevention

Health promotion involves creating a safe environment and encouraging practices that minimize injury
risks. Nurses can play a significant role by recommending health promotion strategies such as:
1. Passive Strategies: Public health initiatives like educational programs on fall prevention or
neighborhood safety can raise awareness. Legislative interventions, such as safety
regulations (e.g., building codes that require nonslip floors or stair rails), can help make
communities safer.
2. Active Strategies: Nurses can guide patients to take an active role in their own health by
engaging in exercises to improve balance and strength, following wellness programs, or
adopting safer behaviors like using walking aids or wearing non-slip shoes.

Cultural Competency in Community Health

When working in the community, nurses must be culturally competent. This means they need to build
trust with community members, understand the cultural context, and respect cultural beliefs while
promoting safety. In community-based settings, nurses can assess and recommend personalized safety
measures that fit each patient’s home, neighborhood, and work environment.
● Assess the patient’s cultural beliefs and how they may influence their approach to safety,
home modifications, or health behaviors.
● Offer recommendations that respect these beliefs while enhancing the patient's ability to live
in a safe environment.

Conclusion
Nurses play a vital role in patient-centered care by assessing fall risks, promoting health, and
advocating for environmental safety. By engaging the patient and their family caregiver in the fall
prevention process, encouraging the use of community resources, and implementing health
promotion strategies, nurses help ensure a safer environment for patients. Through effective teamwork
and collaboration, along with the use of evidence-based practices, nurses can help reduce the risk of
falls and enhance patient safety across all settings.
Developmental Interventions for Infant, Toddler, and Preschooler
As children grow and develop, they become increasingly curious and mobile, making it crucial for adults
to protect them from injury. Nurses play a key role in educating parents and caregivers about the potential
risks children face and offering guidance on how to promote safety at home. Evidence-based
interventions can effectively reduce the risk of injury and support child development.
Infant and Toddler Safety
For infants, toddlers, and preschoolers, the focus is primarily on preventing common accidents and
providing a safe environment for growth and exploration. Nurses working with parents can provide
important safety tips and interventions that reduce the risk of injury.
1. Sudden Infant Death Syndrome (SIDS) Prevention:
a. Keep soft objects, toys, crib bumpers, and loose bedding out of an infant’s
sleep area.
i. Rationale: These items can increase the risk of suffocation, strangulation,
or entrapment, which are leading causes of SIDS. Ensuring that no items
are obstructing the infant’s breathing space is essential to maintaining a
safe sleep environment.
b. Use a firm sleep surface, such as a mattress in a safety-approved crib covered
by a fitted sheet.
i. Rationale: A firm sleep surface reduces the risk of suffocation and ensures
the infant's safety while sleeping.
c. Prepare an infant’s sleep area next to where parents sleep.
i. Rationale: An infant should never sleep in an adult bed, couch, or chair
alone or with a parent or anyone else. Sleeping in close proximity to the
parent reduces the risk of SIDS and allows for easier monitoring of the
infant during sleep.
2. Falls and Accidents:
a. Secure furniture, electrical outlets, and choking hazards in the home.
i. Rationale: As toddlers begin to explore their environments, they are at risk
for falling or injuring themselves. Ensuring that furniture is secured and
sharp objects, choking hazards, and electrical outlets are covered can
prevent these accidents.
b. Encourage parents to use safety gates for stairs and childproof the home
environment.
i. Rationale: Preventing access to dangerous areas, such as stairs, can
reduce the risk of falls for young children who are still mastering balance
and coordination.
3. Burns and Scalds:
a. Teach parents to keep hot objects, liquids, and stoves out of reach of young
children.
i. Rationale: Toddlers are naturally curious and may reach for hot items,
leading to burns or scalds. Using back burners, safety locks, and keeping
hot liquids out of reach can help protect young children from injury.
4. Poisoning Prevention:
a. Store cleaning products, medications, and other hazardous substances in
locked cabinets out of a child’s reach.
 i. Rationale: Young children often put objects into their mouths, and
poisoning is a significant risk if toxic substances are left within reach.
Storing dangerous products safely can prevent accidental ingestion.

Vaccination Education and Safety

In addition to physical safety, nurses also play an essential role in ensuring children receive necessary
vaccinations. Immunizations are a critical part of pediatric care and can help prevent potentially life-
threatening diseases.
● Reminder/Recall Systems: Implementing strategies such as postcards, letters, telephone
calls, or combination methods can remind parents about scheduled vaccinations. This is
especially useful for populations that may have difficulty accessing care or are at risk of
missing vaccines due to logistical issues (e.g., transportation problems or limited access to
health care).
● Outreach, Case Management, and Home Visits: These services are effective for reaching
hard-to-reach populations, ensuring they receive vaccines on time and reducing the risk of
disease outbreaks within communities.
Addressing Vaccine Hesitancy:
Nurses should also be prepared to address vaccine hesitancy by providing education and fostering a
non-confrontational dialogue with parents. The American Academy of Pediatrics (AAP) recommends
these steps for working with vaccine-hesitant parents:
1. Listen to Parents’ Concerns: It’s important to acknowledge parents' concerns about
vaccines and provide them with accurate, evidence-based information in a respectful manner.
2. Partner with Parents in Decision Making: Engage parents in the decision-making process,
making sure they understand the benefits of vaccines and the potential risks.
3. Discuss Vaccine Safety: Nurses should provide clear information about the known benefits
of immunizations and discuss the possibility of adverse events, stressing that the risk of
serious side effects is extremely low compared to the lives saved through vaccination.
4. Emphasize Positive Outcomes: Highlight the lives saved by immunization and the
collective community protection that vaccines offer. Framing the conversation around the
positive impact of immunizations can help reduce anxiety and encourage cooperation.

Interventions for Toddler and Preschooler Safety

For toddlers and preschoolers, safety interventions can also extend to teaching safe play behaviors and
social safety:
● Supervised Play: Ensure that children play in safe, age-appropriate environments. Outdoor
play areas should be free from hazards like broken equipment or unsafe surfaces.
● Child Safety Education: Educating children on safety principles (e.g., looking both ways
before crossing the street, staying away from strangers) can help reduce accidents as they
grow older.

By implementing these developmental safety interventions, nurses help promote the well-being of
infants, toddlers, and preschoolers. Working with parents and caregivers to ensure a safe environment at
home, fostering communication about vaccination, and encouraging responsible play can all contribute to
reducing the risk of injury and promoting healthy childhood development.
Infant and Toddler Safety Interventions (Continued)
1. Immunizations and Regular Health Checkups:
a. Infants should be immunized according to recommended schedules.
 i. Rationale: Immunizations not only protect infants from preventable
diseases but also reduce the risk of sudden infant death syndrome (SIDS)
and other serious health conditions.
2. Pacifier Safety:
a. Do not attach pacifiers to string or ribbon and place them around a child’s
neck.
i. Rationale: Attaching a pacifier to a string or ribbon increases the risk of
choking. Pacifiers should be used safely without any strings or cords.
3. Formula Preparation and Storage:
a. Follow all instructions for preparing and storing formula.
i. Rationale: Proper formula preparation and storage prevent contamination
and ensure that the baby receives the correct nutrients. Undiluted formula
can cause fluid and electrolyte disturbances, while overly diluted formula
doesn't provide enough nutrition.
4. Toy Safety:
a. Use large, soft toys without small parts such as buttons.
i. Rationale: Small parts on toys can easily become dislodged and create a
choking hazard. Toys should be chosen carefully to ensure they are
appropriate for the child's age and developmental stage.
5. Crib and Playpen Safety:
a. Do not leave the mesh sides of playpens lowered.
i. Ensure crib slats are spaced less than 6 cm (2-3/8 inches) apart.
ii. Rationale: The risk of a child’s head becoming wedged between the crib
slats or in the lowered mesh side of a playpen could lead to asphyxiation.
Proper crib setup and maintenance are vital for infant safety.
6. Supervision During Activities:
a. Never leave crib sides down or infants unattended on changing tables or in
infant seats, swings, strollers, or high chairs.
i. Rationale: Infants can roll or move unexpectedly, potentially falling from
changing tables or other devices and sustaining serious injuries. Constant
supervision is essential during these activities.
7. Safe Use of Infant Seats and Swings:
a. Only use infant seats and swings according to the manufacturer’s directions.
i. Rationale: Using these devices correctly is essential. If a child becomes too
active or too big for these items, the risk of falling or tipping over increases.
8. Water Safety:
a. Never leave a child alone in the bathroom, tub, or near any water source (e.g.,
pool).
i. Rationale: Drowning is a leading cause of death in children. Constant
supervision around water significantly reduces this risk.
9. Home Safety (Baby-Proofing):
a. Remove small or sharp objects and toxic or poisonous substances, including
plants.
i. Install safety locks on floor-level cabinets.
ii. Rationale: Infants are naturally curious and explore by putting things in
their mouths. Removing hazardous objects and using safety locks can
prevent choking and poisoning accidents.
10. Plastic Bag Safety:
a. Remove plastic bags from the home.
 i. Rationale: Infants and toddlers may suffocate from plastic bags if left within
their reach. Keeping them out of the home reduces suffocation risks.
11. Electrical Safety:
a. Cover electrical outlets.
i. Rationale: Infants, particularly those crawling, may insert objects into
outlets, leading to electrical shocks. Outlet covers protect them from these
dangers.
12. Door Lock Safety:
a. Install keyless locks (e.g., deadbolts) on doors above a child’s reach.
i. Rationale: Keyless locks help prevent toddlers from wandering outside and
getting lost. They also allow quick exit in emergencies, like a fire.
13. Emergency Preparedness:
a. Caregivers should learn CPR and the Heimlich maneuver.
i. Rationale: These lifesaving skills ensure caregivers are prepared in the
event of an emergency, such as choking, and can significantly increase a
child’s chances of survival.

Preschooler Safety Interventions

1. Swimming Safety:
a. Teach children to swim at an early age, but always provide supervision near
water.
i. Rationale: Swimming is an important life skill that can save a child’s life in
an emergency, but it should always be supervised to prevent drowning
accidents.
2. Pedestrian Safety:
a. Teach children how to cross streets and walk in parking lots. Instruct them to
never run after a ball or toy.
i. Rationale: Young children are at risk for pedestrian accidents. Teaching
them safe street-crossing and parking lot behaviors can prevent injury.
3. Stranger Safety:
a. Teach children not to talk to, go with, or accept anything from strangers.
i. Rationale: Stranger danger is a real concern, and teaching children to
avoid strangers can reduce the risk of abduction or injury.
4. Basic Physical Safety Rules:
a. Teach children proper use of safety scissors, never running with an object in
their mouth or hand, and never attempting to use the stove or oven unassisted.
i. Rationale: Ensuring children know basic safety rules can reduce the
likelihood of injuries in everyday activities. For example, using scissors
properly and avoiding running with objects in their hands helps prevent
cuts and falls.

Summary of Key Safety Practices for Infants, Toddlers, and Preschoolers

● Immunization and health checkups are essential for preventing diseases and ensuring
proper development.
● Safe sleep practices, such as placing infants on a firm mattress and keeping soft objects out
of the crib, help reduce the risk of SIDS.
● Supervision during daily activities (e.g., bathing, feeding, playtime) is crucial to prevent
accidents like choking, drowning, or falls.
 ● Baby-proofing the home (e.g., securing furniture, using outlet covers, and installing safety
locks) is essential for infant safety.
● Child safety education for parents and caregivers, along with teaching children basic safety
rules, plays a significant role in injury prevention.
By implementing these strategies, parents, caregivers, and health professionals can help protect young
children from preventable accidents and create an environment where children can safely grow and
develop.
School-Age Child Safety Interventions
School-age children, typically between 6-12 years old, become more independent and active outside the
home. They engage with peers at school, in the community, and during extracurricular activities. At this
stage, safety education is crucial to ensure that children understand the risks associated with school and
play environments.
● Safety in School and Play:
○ Educate children about the importance of wearing seat belts and helmets when riding
in cars, bikes, or other vehicles.
○ Encourage safe behavior during sports or physical activities, including appropriate
protective equipment.
○ Ensure children know how to safely cross streets, obey traffic signals, and stay within
safe play areas.
Adolescent Safety Interventions
Adolescents (ages 12-18) are at increased risk for accidents and injuries, primarily due to peer pressure,
experimentation, and changing social dynamics. The adolescent's time spent away from home and their
increased independence add additional safety risks, particularly in the areas of alcohol and drug use,
driving, and mental health.
● Alcohol and Drug Use Prevention:
○ Educate adolescents about the dangers of alcohol and substance abuse,
emphasizing the risks of impaired judgment and accidents.
○ Encourage open communication with parents, teachers, and healthcare providers
about peer pressure and the importance of making informed decisions.
● Suicide Prevention:
○ Recognize warning signs of depression or suicidal tendencies, including withdrawal
from family or friends, drastic mood swings, or expressions of hopelessness.
○ Promote problem-solving skills and offer mental health resources for teens in crisis.
○ Help strengthen connections with family, friends, and community to provide support
systems.
● Safety While Driving:
○ Reinforce the importance of seatbelt use and not texting or using a phone while
driving.
○ Discuss the dangers of reckless driving, speeding, and driving under the influence of
alcohol or drugs.
Adult Safety Interventions
For young and middle-aged adults, safety risks are often linked to lifestyle factors and environmental
stresses. Factors such as high levels of work-related stress, poor diet, lack of physical activity, and
substance use increase the likelihood of accidents and health problems.
● Lifestyle Modifications for Safety:
○ Encourage adults to take regular breaks from stressful activities, and promote stress
management techniques such as deep breathing, yoga, or mindfulness.
○ Guide adults toward making healthier choices, such as quitting smoking, reducing
alcohol intake, and improving dietary habits.
 ○ Offer resources for stress management, including employee assistance programs or
counseling services.
● Exercise and Sleep:
○ Promote regular exercise to maintain physical and mental health, helping to reduce
stress and improve overall well-being.
○ Emphasize the importance of getting adequate rest and managing sleep disorders to
ensure alertness and reduce accident risks.
● Anger Management:
○ Educate adults on the importance of managing anger, particularly regarding "road
rage" and other impulsive actions that could lead to accidents.
Older Adult Safety Interventions
For older adults, safety interventions focus on preventing falls and other accidents while accommodating
the physiological changes that come with aging. These interventions aim to help older individuals
maintain their independence and quality of life.
● Fall Prevention:
○ Use the AGS (2011) fall prevention algorithm to guide nursing interventions aimed
at reducing the risk of falls. This includes checking home environments for hazards,
improving lighting, and making sure furniture is sturdy and well-arranged.
○ Provide resources to help older adults remain independent, such as local
transportation services and meal programs like Meals on Wheels.
● Driving Safety:
○ Educate older adults about safe driving practices, such as driving shorter distances
and using mirrors and blind spots carefully.
○ Discuss the importance of reducing distractions (e.g., keeping the radio volume low
and the window down if hearing is impaired).
○ Offer counseling for individuals struggling with the decision to stop driving, and
provide assistance in finding community transportation alternatives.
● Burn and Scald Prevention:
○ Prevent burns by reducing the temperature of hot water heaters. Set the water
heater to a safe temperature (below 120°F) to avoid scalding.
○ Label faucets and stove dials with color coding to help older adults easily
distinguish between hot and cold settings.
○ Monitor for confusion or memory problems that may lead to forgetting to turn off
stoves or water faucets, leading to burns.
● Environmental Safety:
○ Assist in home safety audits for older adults, ensuring that their living space is free
from hazards like slippery floors, cluttered walkways, or poorly lit areas.
○ Encourage regular physical activity to improve strength, balance, and flexibility,
which can reduce the risk of falls and injuries.
Conclusion
Each developmental stage, from infants to older adults, presents unique safety challenges. Nurses play a
pivotal role in educating patients and families about safety risks, providing preventative measures, and
promoting health practices that reduce the likelihood of accidents and injuries. By addressing the specific
needs of different age groups and being proactive in safety education, healthcare providers help to
ensure that individuals live safely and independently throughout their lives.
Pedestrian Safety for Older Adults and All Age Groups
Walking is a beloved activity for many older adults, but it can pose safety risks if precautions aren't taken,
especially at night or in high-traffic areas. Nurses can play a key role in educating older adults and other
age groups on strategies to reduce pedestrian accidents:
 ● Reflectors and Visibility:
○ Encourage the use of reflectors on clothing when walking at night, ensuring the
individual is visible to drivers.
● Safe Crossing:
○ Advise pedestrians to always cross at corners and use crosswalks instead of
crossing in the middle of the street, especially on busy roads.
○ Cross with the traffic light and never against it. This ensures that pedestrians are
following traffic patterns, which is safer.
○ Teach pedestrians to look left, right, and left again before entering the street or
crosswalk to check for approaching vehicles.
● Route Assessment for Hazards:
○ Encourage individuals to assess their walking routes for potential hazards, such
as uneven sidewalks, damaged walkways, or distractions like unrestrained dogs or
toys left in pathways. These obstacles can increase the risk of falls.
Environmental Interventions for Home Safety
A thorough assessment of the patient’s home environment is crucial to identify potential hazards that may
lead to accidents or injuries. Nurses can offer recommendations to address these risks and promote a
safer living space for older adults, or anyone with inherent risks for injury:
● Removing Environmental Hazards:
○ Ensure the home environment is free from clutter, loose rugs, or other tripping
hazards that may cause falls.
○ Assess lighting in all rooms, hallways, and stairways, ensuring it is adequate to
prevent accidents due to poor visibility.
● Bathroom Safety:
○ Install grab bars in bathrooms near the shower, bathtub, and toilet for added support
and to reduce fall risks.
○ Non-slip mats should be placed in the bathtub or shower to avoid slipping on wet
surfaces.
● Preventing Burn Risks:
○ Lower the thermostat on hot water heaters to avoid burns from hot water.
○ Ensure that stove knobs are clearly marked or color-coded for easier identification
and to prevent accidental burns.
● Kitchen Safety:
○ Keep sharp objects, cleaning chemicals, and hot cooking appliances out of reach
for those who might have trouble handling them due to cognitive or physical
impairments.

Developmental Interventions for Children and Adolescents

Preschoolers Safety Interventions
Preschool-age children are naturally curious and often engage in risky behavior out of exploration. Safety
education is essential at this stage to avoid preventable injuries:
● Poisoning Prevention:
○ Teach children not to eat things they find in the street or grass, such as mushrooms
or weeds, which could be poisonous.
● Appliance Safety:
○ Remove doors from unused refrigerators or freezers to prevent children from getting
trapped, which can lead to asphyxiation.
● Safe Play Areas:
 ○ Monitor play to ensure it occurs in safe, designated areas free from hazards like
traffic, toxic plants, or unsupervised water sources.
School-Age Children Safety Interventions
School-age children are at increased risk for injuries, especially during recreational activities and while
navigating traffic. Nurses should provide parents with the following guidance:
● Bicycle and Skateboard Safety:
○ Teach children how to ride bicycles and skateboards safely by using helmets and
following rules of the road to reduce injury risks.
● Sporting Safety:
○ Encourage children to learn proper techniques for sports and always wear
appropriate safety gear, including helmets, pads, and protective clothing.
● Supervision Around Electrical Equipment:
○ Educate children not to operate electrical equipment unsupervised to prevent
accidents or electrical mishaps.
● Firearm Safety:
○ Keep firearms locked in secure cabinets, and educate children about the dangers of
firearms to prevent accidental injuries or deaths.
Adolescent Safety Interventions
Adolescents face safety risks primarily due to peer pressure, risk-taking behaviors, and newfound
independence. Nurses can help mitigate these risks by providing educational interventions and resources
for both adolescents and their parents:
● Driver Education:
○ Encourage adolescents to enroll in driver education courses to reduce the risks of
motor vehicle accidents, one of the leading causes of injury for this age group.
● Substance Abuse Prevention:
○ Educate adolescents on the risks of alcohol, drugs, and smoking, and offer
resources or programs that help reduce peer pressure and support healthier lifestyle
choices.
● Supervised Socialization:
○ Promote socialization in safe environments, such as community programs or
school-sponsored activities, to allow adolescents to interact with peers under adult
supervision.
● Mentorship:
○ Encourage mentoring relationships between adults and adolescents to provide
positive role models who can influence healthy decision-making and reduce risky
behavior.
● Internet Safety:
○ Teach adolescents how to use the Internet safely, avoiding overuse and exposure to
harmful or inappropriate content. Encourage safe browsing habits and awareness of
online threats.
Conclusion
Safety education and environmental modifications play a critical role in reducing injury risks across
various age groups. From teaching pedestrian safety to children to preventing fall-related injuries in older
adults, nurses can make a significant impact on improving patient safety by providing appropriate
education and interventions. By fostering awareness of potential hazards and empowering individuals to
make safer choices, healthcare professionals contribute to better health outcomes for patients at all
stages of life.
Interventions to Promote Safety for Children and Adolescents (Continued)
Modified from Hockenberry M, Wilson D: Wong’s Nursing Care of Infants and Children, 11th ed., St
Louis, 2019, Elsevier.
Basic Needs and Home Safety
1. Oxygen Safety:
a. When administering oxygen in the home, ensure proper fire safety measures are
followed.
i. Post signs such as "No Smoking" and "Oxygen in Use" to alert family
members of the presence of oxygen.
ii. Do not use oxygen around electrical equipment or flammable substances.
iii. Oxygen tanks should be stored upright in carts or stands to prevent tipping
or falling over.
2. Fire Safety:
a. Space heaters must be used carefully in the home. Before using any space heater:
i. Check that the heater is listed by a recognized testing laboratory.
ii. Inspect the heater for damage such as cracked plugs or loose connections
before each use.
iii. Never leave space heaters unattended and turn them off when leaving a
room or going to sleep.
iv. Keep space heaters at least 3 feet away from anything that can burn,
including papers, clothing, or rugs.
v. Install smoke alarms on every floor of the home and outside all sleeping
areas.
vi. Ensure that carbon monoxide (CO) detectors are in place, particularly
when using fuel-burning appliances or space heaters.
3. Food Safety:
a. Instruct families on proper food handling:
i. Wash hands and food preparation surfaces frequently, and clean utensils
and cutting boards thoroughly.
ii. Prevent cross-contamination by keeping raw meat, poultry, seafood, and
their juices separate from other foods.
iii. Cook food to the proper temperature, refrigerate leftovers promptly, and
ensure the refrigerator is functioning properly (below 40°F).
iv. Store perishable foods properly to prevent spoilage and illness.
Fall Prevention in the Home
1. Home Modifications:
a. Remove obstacles such as furniture, piles of magazines, or boxes from frequently
traveled areas.
b. Ensure end tables are secure and have stable, straight legs. Nonessential items
should be stored in drawers to reduce clutter.
c. Remove small rugs or secure them with nonslip pads or skid-resistant adhesive
strips. Make sure carpeting on stairs is secured properly to prevent tripping hazards.
d. For individuals with a history of falling, recommend wearing an electronic safety
alert device that can notify emergency services if activated.
e. Observe the patient’s use of assistive devices (such as canes or walkers) to ensure
they are used correctly and are in good working order.
General Preventive Measures
1. Neighborhood Safety:
a. Educate patients on the importance of proper lighting and locks on windows and
doors to reduce the risk of injury or crime.
 b. Encourage individuals to contact local police or community organizations for advice
on neighborhood safety.

FOCUS ON OLDER ADULTS: Physiological Changes and Safety Implications

As individuals age, various physiological changes increase the risk of safety concerns. Key
considerations for patient safety among older adults include:
● Visual and Hearing Impairments: Decreased vision and hearing increase the risk for falls
and accidents. Regular eye and hearing exams are critical.
● Slowed Reaction Time and Reflexes: Aging leads to a slower response to stimuli, so older
adults must be provided with more time to react in emergency situations.
● Decreased Strength and Mobility: Limited flexibility, range of motion, and strength
contribute to fall risk.
● Memory Impairments: Cognitive changes can affect decision-making and the ability to
remember critical safety precautions.
The aging process, combined with a higher prevalence of chronic conditions, also leads to increased use
of medications, some of which can interact to increase fall risk.
Implications for Practice:
1. Family Caregiver Support:
a. Encourage family caregivers to assist older adults while allowing them to remain as
independent as possible.
b. Provide caregivers with resources on fall prevention (e.g., CDC's STEADI program)
and assistive devices like walkers and canes.
2. Health Promotion and Fall Prevention:
a. Encourage regular vision and hearing exams, as well as physical therapy to
improve strength, balance, and mobility.
b. Help older adults make home modifications, such as installing grab bars, non-slip
mats, and smoke alarms.
c. Provide education on safe driving, including the importance of restricted driving
hours or discontinuing driving if necessary.
d. Suggest supervised exercise or balance classes to improve physical stability and
reduce fall risks.
e. If necessary, establish a regular toileting schedule to prevent falls related to
nocturia.
3. Medication Management:
a. Review medications for potential interactions that increase the risk of falls.
b. Encourage the use of medication organizers to assist older adults in remembering
their medications and reduce the likelihood of missed doses.
By recognizing the impact of age-related physiological changes and providing appropriate interventions,
nurses can help reduce the risk of injury and improve the quality of life for older adults. These measures,
when implemented effectively, enhance the overall safety and independence of elderly patients.
Continued: Interventions to Promote Safety for Children and Adolescents

Neighborhood Safety and Crime Prevention

● Neighborhood Safety Classes: Encourage residents to participate in safety classes that
teach precautions to minimize the risk of becoming involved in a crime. Useful tips include:
○ Parking in well-lit areas or busy public spots.
○ Carrying a whistle attached to car keys for emergency situations.
○ Keeping car doors locked while driving.
○ Staying alert to avoid being followed by other vehicles while driving.
Home Fire Prevention and Safety
Accidental home fires are often caused by smoking in bed, improperly discarded cigarettes, grease fires,
and misuse of candles or space heaters. Electrical fires from faulty wiring or appliances are another
significant risk. To reduce these hazards:
● Quit Smoking or encourage smoking outside the home.
● Regularly inspect cooking equipment and appliances (e.g., irons and stoves).
● Ensure visual aids like large numbers or symbols are used on temperature control dials,
especially for patients with visual deficits.
● Smoke detectors should be installed in strategic positions throughout the home. Ensure
alarms can be heard by all household members in case of fire.
● Teach everyone, including children, the “stop, drop, and roll” technique in case their
clothing or skin catches fire.
Preventing Accidental Poisoning
● Children: Keep hazardous substances such as medications, cleaning fluids, and batteries
out of reach. Call the poison control center for guidance if a child is poisoned, rather than
trying home remedies.
● Adolescents and Adults: Substance poisoning often occurs due to suicide attempts or
drug experimentation.
● Older Adults: Be aware that older adults are at greater risk due to diminished eyesight and
impaired memory, which can lead to accidental ingestion of harmful substances or
overdoses.
Key Recommendations:
● Ensure medications are kept in original containers with large print labels.
● Suggest the use of medication organizers that are filled weekly by caregivers.
● Proper disposal of unused medications is critical to prevent poisoning.

Patient Teaching: Prevention of Electrical Hazards (Box 27.8)

Objective:
To educate patients on recognizing and eliminating electrical hazards in the home.
Teaching Strategies:
1. Grounding of Electrical Appliances: Ensure all electrical appliances and equipment are
properly grounded.
2. Identifying Hazards: Highlight common electrical hazards, such as:
a. Frayed cords
b. Damaged equipment
c. Overloaded outlets
3. Safety Guidelines:
a. Use extension cords only when necessary and secure them with electrical tape
along baseboards.
b. Avoid running wires under carpeting to prevent potential hazards.
c. Always grasp the plug, not the cord, when unplugging electrical devices.
d. Keep electrical items away from water to prevent shock hazards.
e. Do not operate unfamiliar equipment or appliances.
f. Disconnect electrical items before cleaning them.

Safety in Acute and Restorative Care Settings

In healthcare settings, safety is a priority to protect patients. Nurses implement various measures to
ensure patient safety, including:
 1. Fall Prevention: Implement strategies to reduce falls, such as ensuring a clutter-free
environment, assisting with mobility, and using assistive devices.
2. Prevention of Injuries: When using restraints and side rails, ensure proper techniques are
followed to prevent injury.
3. Procedure-Related Accidents: Take precautions to minimize the risk of injuries related to
medical procedures, fires, and electrical hazards in hospital settings.

Summary of Key Concepts:

● Encourage neighborhood safety and awareness to minimize crime.
● Implement fire safety measures, including smoke detectors and fire extinguishers.
● Prevent poisoning through safe storage and disposal of hazardous substances.
● Teach electrical safety in the home to avoid injuries related to electrical shocks.
● Prioritize fall prevention and injury reduction in healthcare settings, focusing on patient
mobility, use of restraints, and handling of medical equipment safely.
These comprehensive safety practices are vital in ensuring the well-being of patients and their families,
preventing accidents and injuries across different age groups and environments.
Evaluation Using Teach-Back for Patient/Family Caregiver Learning
Principles of Teach-Back:
● To ensure effective communication and comprehension, the nurse can use the teach-back
method. This allows the healthcare provider to verify that the patient and their caregiver have
understood key safety concepts, such as fire and electrical hazards in the home.
Teach-Back Example for Fire Hazards:
● Nurse: "I want to be sure I explained the fire hazards that I found in your home clearly. What
electrical hazards exist in your home right now, and what steps can you take to eliminate
them?"
● This allows the patient or caregiver to articulate the hazards they’ve learned about and
demonstrate understanding.
Teach-Back Example for Electrical Safety:
● Nurse: "What can you do in your home to prevent getting an electrical shock?"
● By asking this, the nurse can confirm the caregiver's understanding of electrical safety
principles.

Box 27.9: Correct Use of a Fire Extinguisher in the Home

Objective:
To ensure the patient can correctly use a fire extinguisher in the home in the event of a fire.
Teaching Strategies:
1. Choosing the Correct Location for an Extinguisher:
a. Place on each level of the home, near an exit, in clear view, away from stoves and
heating appliances, and above the reach of small children.
b. Common areas to store fire extinguishers include the kitchen, near the furnace, and
in the garage.
2. Read Instructions:
a. After purchasing a fire extinguisher, the patient should read the instructions and
review them periodically to refresh their memory on how to operate it properly.
3. Considerations Before Using a Fire Extinguisher:
a. Ensure all occupants have evacuated the house.
b. Call the fire department before attempting to fight the fire.
c. Attempt to extinguish only small, contained fires.
d. Ensure there is a clear exit route in case the fire escalates.
 e. Use the right type of fire extinguisher for the fire at hand (e.g., Class A, B, or C).
f. Be sure the patient knows how to use the extinguisher.
4. The PASS Mnemonic (to help remember the correct steps for using a fire extinguisher):
a. Pull the pin to unlock the handle.
b. Aim low at the base of the fire (not at the flames).
c. Squeeze the handles together.
d. Sweep the nozzle from side to side to cover the area of the fire.
By reviewing these instructions and ensuring that the patient can demonstrate or explain the PASS
method and proper use of a fire extinguisher, you confirm their preparedness to respond in case of a fire.
Evaluation Using Teach-Back for Patient/Family Caregiver Learning
Principles of Teach-Back:
To assess understanding and retention of key safety concepts, such as fire safety and poison prevention,
the teach-back method can be used. Here's how to evaluate patient and caregiver learning for fire
extinguisher usage and poison intervention:

Teach-Back Example for Fire Extinguisher Use:

● Nurse: "When would it be appropriate to use a fire extinguisher at home?"
● This question checks the patient's or caregiver's understanding of when it is safe to use a fire
extinguisher (e.g., small fires that are contained, and when all occupants are safely out of the
home).
Teach-Back Example for PASS Mnemonic:
● Nurse: "Can you explain for me what the mnemonic PASS means?"
● This allows the patient or caregiver to recall the steps for properly using a fire extinguisher:
○ Pull the pin to unlock the handle
○ Aim low at the base of the fire
○ Squeeze the handles together
○ Sweep the unit from side to side

Box 27.10: Intervening in Accidental Poisoning

If a poisoning incident occurs, it's important to act quickly, and family members or caregivers should be
educated on the proper response steps. Here's how to intervene:
1. If the person collapses, has a seizure, difficulty breathing, or cannot be awakened, call
9-1-1 immediately.
a. If CPR is necessary, perform it until emergency responders arrive.
2. If the person is conscious and has ingested something irritating or harmful:
a. Have the person drink a small amount of water or milk, but only if they are
conscious and able to swallow.
b. Always call Poison Control (1-800-222-1222) before attempting any intervention,
and follow their specific instructions.
3. For Skin or Eye Contact:
a. Irrigate the affected area with cool tap water for 15 to 20 minutes.
4. For Inhalation Exposure:
a. Move the person to fresh air as quickly as possible.
5. Do Not Induce Vomiting if certain substances have been ingested (e.g., lye, household
cleaners, or petroleum products). Instead, seek professional advice from Poison Control.
By following these guidelines, caregivers and family members can prevent further harm and increase the
chances of a better outcome in case of accidental poisoning.
Using the teach-back method helps ensure that patients and caregivers understand how to handle these
situations correctly and confidently.
BOX 27.11 EVIDENCE-BASED PRACTICE: Fall Prevention
PICOT Question:
Does a multifactorial fall-intervention program, compared to single interventions, reduce the
incidence of falls among hospitalized adult patients?
Evidence Summary:
Falls are the most common adverse event in hospitalized older adults (Slade et al., 2017). These falls are
linked to longer hospital stays and worse patient outcomes. Research shows that multifactorial
interventions—those that are comprehensive and address several risk factors—are significantly more
effective at preventing falls than single interventions. These multifactorial interventions typically include:
● Aerobic exercises
● Strength training
● Mobility strategies
● Medication management
● Patient and staff education
● Provision of effective assistive devices
● Environmental modifications (Slade et al., 2017)
In the community setting, falls also represent a significant issue, and evidence supports that both
multifactorial and individual exercise interventions are effective. Research consistently shows that
exercise programs focused on gait, balance, and functional training are particularly beneficial when
lasting 12 months, with the most effective frequency being three exercise sessions per week (Guirguis-
Blake et al., 2018).
Application to Nursing Practice:
● Promote early mobility in hospitalized patients. Collaborating with a physical therapist to
ensure the use of appropriate gait training and assistive devices can help prevent falls (see
Chapter 38).
● Implement Universal Fall Precautions for all hospitalized patients and tailor specific
interventions to address the unique fall risks of each patient. This could include:
○ Regular reassessments of fall risks
○ Adjustments to the environment or patient positioning as needed
● Hourly “purposeful rounding”: Nurses should engage in hourly rounds using a standard
checklist to assess and address the patient’s needs. This proactive strategy helps prevent
falls by anticipating patient needs, such as pain management or help with elimination (HRET,
2016; Daniels, 2016; Touhy and Jett, 2022).
● Use checklists that incorporate fall prevention strategies. These checklists have been shown
to improve adherence to interventions and reduce fall incidents, particularly during change-
of-shift handoffs, where they ensure all fall precautions are in place (Johnston and Magnan,
2019).
● In the community setting, evidence-based exercise programs, especially those led by
accredited exercise instructors, have shown effectiveness in reducing fall risks. One such
program is the CDC’s STEADI (Stopping Elderly Accidents, Deaths, and Injuries)
program, which provides a toolkit for fall prevention (CDC, 2020i; Touhy and Jett, 2022).
Patient-Centered Care for Fall Prevention:
A comprehensive, patient-centered fall prevention plan requires nurses to use critical thinking in the
development and implementation of tailored interventions. Understanding the patient's unique risks and
needs is crucial. For example:
 ● Postural hypotension: For patients with this condition, place the bed in the low position,
and have the patient dangle their feet for 3 to 5 minutes before ambulation to prevent
dizziness.
● Urinary urgency/incontinence: For patients with frequent urinary urgency, consider
providing a bedside commode rather than requiring the patient to walk unassisted to the
bathroom.
● Gait belts and safety equipment: For patients at risk of falls during ambulation, gait belts
and other safety devices should be used to assist in safe movement (see Chapter 38).
By using these evidence-based practices and a comprehensive approach, nurses can significantly reduce
the incidence of falls in both hospital and community settings, improving patient outcomes and safety.
Ensuring patient safety involves not only teaching proper use of assistive devices, but also making
necessary modifications to the environment. Here are key points to consider when helping patients use
assistive aids and reducing fall risks:
Assistive Aids (Canes, Crutches, Walkers):
1. Routine Checks:
a. Ensure that the rubber tips on canes, crutches, or walkers are in good condition.
b. Confirm that the devices are the correct height and being used properly by the
patient.
c. Regularly inspect the equipment to make sure it is not damaged and that it provides
adequate support.
2. Environmental Modifications:
a. Remove excess furniture or equipment that might obstruct the patient’s path.
b. Instruct the patient to wear rubber-soled shoes or slippers, which provide better grip
and balance when walking or transferring.
3. Additional Safety Features:
a. Safety bars near toilets, locks on beds and wheelchairs, and a nurse call system
are essential features that enhance safety in healthcare settings.
Wheelchair Safety:
1. Wheelchair-related Falls:
a. Older adults or patients with disabilities are at risk of falls and injury when using
wheelchairs.
b. Seat belts should be applied properly to prevent the patient from sliding down and
becoming at risk for choking.
c. Anti-tip bars, brakes, and side rails should be in place to prevent the patient from
being ejected from the wheelchair or sustaining injuries from collisions.
d. Front wheels that are too small or hard can cause the wheelchair to tip when
navigating uneven surfaces. Ensuring that the wheelchair is designed for safe use in
the home or facility is key.
2. Transporting Patients Safely:
a. Always ensure that all safety features are engaged before transporting the patient.
b. Tripping over footrests or leaning over the back of a wheelchair to adjust the wheel
lock can lead to falls or injury, so proper posture and handling are critical during
transfers.
3. Wheelchair Training:
a. Patients using wheelchairs regularly should receive training on proper posture,
handling, and maintenance to minimize fall risks and other injuries.
Teaching and Interventions:
Kylie’s approach with Mrs. Cohen demonstrates an excellent example of fall prevention and patient
education. By explaining the fall risks clearly, Kylie is partnering with the patient and caregiver (Meg) to
adapt the home environment and educate them about safety measures.
● Fall Risk Education: Kylie discusses Mrs. Cohen's fall risks, including her history of falls,
age, effects of her stroke, and side effects of her blood pressure medication, such as
dizziness upon standing.
● Slow and Steady Movements: Kylie advises Mrs. Cohen to stand slowly, take a moment to
assess how she feels before walking, and proceed only if she feels stable. This helps mitigate
dizziness caused by her medication.
● Strengthening and Gait Improvement: Kylie emphasizes that working with physical therapy
will help improve Mrs. Cohen’s gait and minimize the risk of dragging her foot, which is
another fall risk factor.
Restraints:
In some cases, restraints might be necessary for patients who are confused, agitated, or frequently
attempt to remove medical devices (e.g., IVs or catheters). However, the use of restraints should be
temporary and approached cautiously:
● Confused or Agitated Patients: When patients are unable to maintain their safety due to
confusion or agitation, physical restraints can provide short-term safety while minimizing
harm.
● Mobility Limitations and Care Dependency: In nursing home settings, patients with mobility
limitations or increased care needs may be more prone to requiring restraints.
As a nurse, it is crucial to balance safety with autonomy and to use restraints as a last resort, always
considering alternatives that allow for patient mobility and freedom as much as possible.
Key Takeaways:
● Ensure that assistive aids like walkers and wheelchairs are properly maintained and used.
● Modify the environment to remove obstacles and provide safety features like handrails and
locks.
● Educate patients and caregivers on fall prevention strategies, including slow movements and
proper body mechanics.
● Restraints should be used cautiously, only when absolutely necessary, and with careful
attention to patient safety and dignity.
Understanding Restraints in Healthcare Settings
Restraints are a serious and complex issue in healthcare, particularly because of the potential risks and
ethical concerns they bring. It's important to understand the definition, the regulations surrounding their
use, and the alternatives to ensure patient safety and dignity. Here's an overview:
Definition of Restraints:
● Physical Restraints: These include manual methods, physical devices, or equipment that
limit or completely prevent a patient's ability to move freely. This can involve restraints such
as wrist or ankle straps, or devices like bed rails that restrict movement.
○ Exclusions: Certain devices like orthopedically prescribed devices (e.g., braces),
protective helmets, and methods used for conducting examinations or preventing falls
(like a side rail) are not considered restraints.
● Chemical Restraints: Medications, such as anxiolytics (anti-anxiety medications) or
sedatives, can be used to manage a patient's behavior, but they should not be used as a
routine solution to a medical issue. These are also distinct from standard medical treatments.
Key Principles for Restraint Use:
● Temporary Measure: Restraints should only be used temporarily when necessary to ensure
patient safety. They should not be a long-term solution but rather a means of providing safety
 in specific situations, such as when a patient is at risk of self-harm or is disrupting medical
treatments.
● Regulations: Federal and state laws, especially those related to Medicare and Medicaid,
strictly regulate the use of restraints in nursing homes and other healthcare settings.
Restraints should only be applied when medically necessary and with informed consent
(unless it’s an emergency situation).
● Alternatives First: Before resorting to restraints, all possible alternatives should be explored.
This includes addressing the root cause of behavior (e.g., pain, confusion, agitation), using
non-restrictive measures (e.g., providing a calm environment, increased supervision), and
other interventions. Only the least restrictive form of restraint should be used.
When Are Restraints Used?
● Patients Who Are Confused or Disoriented: Patients with dementia or cognitive
impairments may wander or attempt to remove medical devices, requiring temporary use of
restraints.
● Risk of Injury: If a patient is at risk of falling or harming themselves by moving around
unsafely, restraints may be used to ensure their safety.
● Intervention Plan: Restraints should only be a part of a comprehensive, individualized care
plan, developed with the input of an interprofessional team. The goal is to minimize or
eliminate the need for restraints through other measures.
Risks and Complications of Restraints:
● Physical Complications:
○ Immobilization can lead to serious complications such as pressure injuries,
pneumonia, constipation, and incontinence.
○ In some cases, restraint use has been linked to restricted breathing and
circulation, leading to potentially fatal outcomes, such as asphyxia.
● Psychosocial Effects:
○ The use of restraints can lead to loss of self-esteem, humiliation, and agitation.
○ There is also a risk of emotional trauma and decreased quality of life for patients
who feel restricted.
Regulatory Standards for Safe Use:
● The Joint Commission (TJC) and Centers for Medicare & Medicaid Services (CMS)
enforce strict standards for the safe and limited use of restraints in healthcare settings.
● Efforts have been made to reduce restraint use through legislative measures and the
promotion of restraint-free environments.
Alternatives to Restraints:
To ensure patient safety while respecting their dignity, healthcare providers should use alternatives such
as:
● Increased supervision or frequent checks.
● Environmental modifications, such as reducing clutter or providing a safe walking path.
● Non-restrictive devices, such as soft mitts or positioning aids that do not fully restrict
movement.
● Behavioral interventions or pain management techniques to address the root cause of
agitation.

Key Takeaways:
1. Restraints should be used only when absolutely necessary and always as a temporary
solution to prevent harm.
2. Federal and state laws strictly regulate restraint use, especially in nursing homes,
ensuring they are only used when medically necessary.
 3. Alternatives to restraints should always be explored first, with restraint being the last resort.
4. Restraints carry significant risks, including physical injury, psychological harm, and even
death, so they should be used with great caution and under stringent guidelines.
Ultimately, the goal is to create a restraint-free environment whenever possible, utilizing appropriate
interventions and providing care that promotes the patient's dignity and well-being.
Restraint Use in Healthcare: Standards and Best Practices
The healthcare community has made significant strides in reducing and eliminating the use of physical
restraints, particularly those that were once common, such as jacket or vest restraints. Below is an
overview of current practices and guidelines regarding restraint use, alternatives, and the role of staff
training and patient involvement.

Elimination of the Jacket (Vest) Restraint:

● Many healthcare agencies have eliminated the use of the traditional jacket or vest
restraints due to the associated risks and ethical concerns. The focus has shifted to finding
less restrictive alternatives to ensure patient safety.
● The overall goal is to avoid restraints whenever possible, utilizing alternative methods to
prevent falls, injuries, or agitation.

Staff Training and Safe Use of Restraints:

● Comprehensive Training: Direct care staff must receive training in the healthcare
setting’s restraint and seclusion policies to ensure that they are knowledgeable about the
safe and appropriate use of restraints, if needed.
● Mechanical Restraint Devices: Staff involved in the use of mechanical restraints must be
trained specifically in the safe use of these devices to minimize the risk of injury or harm.
● Continuous Education: As guidelines and regulations evolve, ongoing education is critical to
maintaining high standards of care and ensuring the safety of both patients and staff.

Alternatives to Restraints:
1. Low Beds:
a. A low bed helps patients rise more easily and reduces the distance to the floor if a
fall occurs. This is especially helpful for patients at risk of falling or those attempting
to ambulate without assistance.
2. Electronic Bed/Chair Alarms:
a. These devices are effective in preventing falls and avoiding the use of physical
restraints. When a patient attempts to get out of bed or a chair, the alarm triggers,
alerting staff to the movement.
b. Types of alarms:
i. Knee-band alarms: Sound when the patient moves to a near-vertical
position.
ii. Infrared alarms: Placed on the headboard or bedframe, these detect
movement when the patient attempts to get out of bed and send an alarm.
3. Environmental Modifications:
a. Adjusting the environment to be safer and reducing risks, such as removing
obstacles or ensuring proper lighting, can reduce the need for restraints and support
patient mobility.

Involving the Patient and Family Caregiver:

 ● Collaboration: When restraints are required, involving the patient and their family
caregiver in the decision is crucial. This promotes understanding and cooperation while
reducing the feelings of humiliation or frustration.
● Education: It’s essential to explain the purpose of the restraint, how the patient will be
cared for while in restraints, and reassure them that the use of restraints is temporary and
aimed at protecting the patient from harm.

Legal and Policy Considerations:

1. Clinically Justified Use:
a. Restraints must be clinically justified, meaning they must be part of a patient’s
prescribed treatment plan to address specific medical concerns (e.g., preventing
removal of medical devices).
2. Provider Orders:
a. A healthcare provider’s order is required before using restraints, and this must be
based on a face-to-face assessment of the patient.
b. The order must be current (within 24 hours) and specify:
i. The type of restraint.
ii. The location of the restraint (e.g., wrists, ankles).
iii. The duration for which the restraint will be applied.
iv. The circumstances under which the restraint will be used (e.g., preventing
removal of medical equipment).
3. Monitoring and Documentation:
a. Proper monitoring and documentation are critical to ensure that restraints are
applied safely and that the patient’s well-being is prioritized throughout their use.
b. Agencies have specific policies in place for the monitoring of patients in restraints,
which should always be adhered to.

Key Takeaways:
● Restraints should only be used as a last resort, and alternatives like low beds, alarms,
and environmental modifications should always be considered first.
● Staff training in the safe use of restraints and familiarity with healthcare agency policies is
essential.
● Patient and family involvement in decisions regarding restraint use is important for
maintaining dignity and clarity about the purpose of the restraint.
● Legal standards, including provider orders and monitoring procedures, must be strictly
followed to ensure safe and ethical restraint use.
Ultimately, the goal is to create a safe and respectful environment where restraints are used minimally,
if at all, and patients receive the care they need to maintain their safety and dignity.
Restraint Use for Violent or Self-Destructive Behavior
For patients exhibiting violent or self-destructive behavior, restraint use is a critical but temporary
measure to prevent harm. However, strict guidelines and monitoring are required to ensure patient
safety and minimize harm.
Time Limits and Order Renewal for Restraints:
● Healthcare provider assessment is required within 60 minutes of applying restraints for
violent or self-destructive behavior.
● Restraint orders must be renewed periodically based on the patient’s age and the nature of
their behavior:
○ Adults (18+ years): Orders renewed every 4 hours.
○ Children (9–17 years): Orders renewed every 2 hours.
 ○ Children (younger than 9 years): Orders renewed every 1 hour.
● Restraint orders cannot be written as as-needed (prn); they must be renewed within the time
limits stated above, and are limited to a maximum of 24 consecutive hours.
Ongoing Assessment and Monitoring:
● Nurses are responsible for frequent and ongoing assessments of patients who are
restrained to monitor their physical and psychological well-being. These assessments should
include:
○ Vital signs
○ Skin integrity under the restraint
○ Nutrition and hydration
○ Circulation to extremities
○ Range of motion (ROM)
○ Hygiene
○ Elimination needs
○ Cognitive function and psychological status
● For violent patients, monitoring should occur every 15 minutes. For nonviolent patients,
monitoring should occur every 2 hours.
● Restraints should be removed periodically according to agency policy to allow for rest and
assessment.
● If available, use audio or video monitoring to continuously assess violent patients when
they are restrained.
Objectives for the Use of Restraints:
Restraints must meet one of the following objectives:
1. Reduce the risk of injury from falls.
2. Prevent interruption of necessary therapy, such as traction, IV infusions, NG tube feeding,
or Foley catheterization.
3. Prevent patients from removing life-support equipment (e.g., ventilators or feeding
tubes).
4. Reduce the risk of injury to others from the patient’s behavior.
Collaboration for Restraint-Free Environment:
● Collaboration with the healthcare team is essential in creating and maintaining a restraint-
free environment. The goal is always to discontinue restraints as soon as the patient’s
condition allows, focusing on the patient's dignity and autonomy.

Side Rails as a Restraint:

While side rails are commonly used for mobility and stability in bed, they are considered a form of
physical restraint if they limit a patient's movement or ability to exit the bed safely. Here's a
breakdown of the risks and guidelines associated with side rail use:
1. When Side Rails Can Be Beneficial:
a. Assist patients with mobility or stability while repositioning in bed or moving from
the bed to a chair.
b. Prevent falls for patients who are unable to exit the bed safely on their own.
2. Risks of Side Rails:
a. When raised, side rails can increase the risk of falls if patients try to climb over or
get caught between the rails.
b. Entrapment hazards can occur, especially in frail, elderly, or confused patients.
Patients can get caught or strangled if the spacing between the rails is too wide.
c. Patients may attempt to crawl over or fall from the bed if they have a strong will
to move independently, making side rails potentially dangerous.
 3. When Side Rails Are Not Considered a Restraint:
a. If a patient has a clear, safe route to exit the bed, and side rails are used for stability
or to assist in repositioning, they are not considered a restraint.
b. For example, raising only the two side rails at the top of the bed and leaving the
lower part of the bed open allows the patient to exit safely.
4. Guidelines for Safe Use of Side Rails:
a. The bed should be in the lowest position possible when side rails are raised to
minimize the distance to the floor if a fall occurs.
b. Always ensure that side rail bars are closely spaced to prevent entrapment of the
head, limbs, or other body parts between the rails.
c. Regularly check the condition of the rails to ensure they are secure and functioning
properly.

Key Takeaways:
● Restraints are a temporary and last resort measure. They should only be used after all
other alternatives have been exhausted.
● Frequent monitoring and assessment are critical to minimize harm, ensuring the safety and
well-being of the patient.
● Side rails should be used cautiously, considering mobility, responsiveness, and risk
factors such as age and cognitive status.
● The ultimate goal is to create a restraint-free environment, and collaboration with the
healthcare team is essential to make that possible.
By following these guidelines, healthcare providers can ensure that patient safety is prioritized while
reducing the risks associated with restraints and side rails.
Study Notes: Fire Safety, Electrical Hazards, Seizure Management

Fires in Healthcare Settings

● Smoking-related fires: Unauthorized smoking in beds or bathrooms is a significant risk.
● Institutional fires: Can be caused by electrical or anesthetic-related fires.
● Nursing Measures:
○ Prevent fires by complying with smoking policies and keeping combustible
materials away from heat sources.
○ Conduct annual fire drills as required by healthcare agencies.
● If a fire occurs:
○ Protect patients from immediate injury.
○ Report the exact location of the fire.
○ Contain the fire and extinguish it if possible.
○ Evacuating patients:
■ Move patients away from the fire, especially if on life support (use a bag-
valve mask).
■ Ambulatory patients: Direct to a safe area.
■ Non-ambulatory patients: Use stretchers, beds, or wheelchairs. Avoid
carrying patients to prevent further injury.
■ Fire department: Assist with evacuations.
● RACE mnemonic for fire intervention:
○ R - Rescue patients in immediate danger.
○ A - Activate the fire alarm.
○ C - Confine the fire (close doors, turn off oxygen/electrical equipment).
○ E - Extinguish the fire using an appropriate extinguisher.
 ● Fire Extinguisher Use:
○ Pull pin.
○ Aim at the base of the fire.
○ Squeeze handles.
○ Sweep from side to side.

Electrical Hazards
● Maintenance of electrical equipment:
○ Biomedical equipment (e.g., hospital beds, infusion pumps, ventilators) must be
inspected regularly by clinical engineering departments.
○ Use only properly grounded and functional equipment.
○ Check for safety inspection stickers to ensure equipment is safe to use.
● Precautions:
○ Remove faulty equipment, sparking devices, or those not in proper working order.
○ Report damaged equipment to appropriate hospital staff immediately.

Seizure Management
● Seizures: Result from hyperexcitation of neurons, leading to muscle contractions (tonicity
and clonicity), loss of consciousness, and falls.
● Signs and Symptoms:
○ Aura: Warning sign before a seizure, can involve bright light, smell, or taste.
○ Tonic-clonic seizure (Grand mal):
■ Lasts 2-5 minutes.
■ Includes loss of consciousness, tonicity, clonicity, and incontinence.
■ Shallow breathing and cyanosis may occur.
■ Postictal phase: Amnesia, confusion, deep sleep.
● Emergency Action:
○ Call 9-1-1 if:
■ Seizure lasts 5 minutes or longer.
■ Repeated seizures occur without consciousness between.
■ Breathing difficulties or choking is present.
● Seizure Precautions:
○ Minimize injury: Protect the patient from musculoskeletal or head injury by
keeping them safe during the seizure.
○ Seizure precautions should be followed for patients with a history of seizures to
reduce the risk of injury during an episode.

Key Terms to Remember for ATI Exam:

● RACE: Rescue, Activate, Confine, Extinguish.
● Aura: A warning sign before a seizure.
● Tonic-clonic (Grand mal) seizure: Generalized seizure with muscle rigidity and jerking.
● Seizure precautions: Measures taken to protect a patient with a history of seizures.
● Electrical safety: Importance of maintaining and inspecting biomedical equipment.
Study Notes: Seizure Management and Patient Safety

Seizure Management
● Seizure Overview:
○ A seizure is caused by hyperexcitation of neurons, leading to muscle
contractions, loss of consciousness, and potential falls.
 ○ Tonic-clonic seizures (Grand mal) involve tonicity (muscle rigidity) and clonicity
(muscle jerking).
● Emergency Actions During Seizure:
○ Stay with the person: Time the seizure and stay with the patient until fully awake
and alert.
○ Remain calm: Talk reassuringly to the person.
○ Check for medical ID: Look for any identification that indicates a seizure disorder or
relevant medical conditions.
○ Time the seizure: Helps determine if emergency help is needed. Most seizures last
a few minutes, but if prolonged (e.g., over 5 minutes), call emergency services.
● Safety Measures:
○ Keep the person safe:
■ Guide them away from sharp objects or any potential hazards.
■ Encourage people to step back to avoid crowding the person and
increasing confusion.
○ Do not give food, water, or pills until the person is fully awake and alert.
○ Position the person:
■ Turn them onto their side to help with ventilation and prevent aspiration.
■ If they’re at risk of falling, lay them down on the floor with something soft
under the head.
■ Turn their mouth toward the ground to allow any secretions to drain.
● Post-seizure Care:
○ Make them comfortable: Loosen tight clothing around the neck.
○ If the person is aware, help them sit down in a safe area.
○ Ensure privacy: Waking up in front of a crowd can be distressing.

Status Epilepticus
● Definition: Status epilepticus is a medical emergency characterized by prolonged or
repeated seizures without recovery in between, requiring immediate medical intervention
and intensive monitoring.

Seizure Precautions
● Nursing Interventions:
○ Protect from injury: Prevent the patient from striking objects or falling during the
seizure.
○ Positioning: Ensure adequate ventilation and oral secretion drainage by placing
the patient on their side.
○ Provide privacy: Respect patient privacy and dignity, especially during recovery.
○ Support: Offer emotional support to the patient following the seizure to help with
confusion or embarrassment.
● Box 27.14: Seizure Precautions:
○ Monitor for injury: Ensure a safe environment to minimize trauma during a seizure.
○ Positioning: Keep airway clear by turning the patient onto their side and placing a
soft item under the head.
○ Follow-up care: Observe and document the seizure episode accurately for medical
records.

Key Terms to Remember for ATI Exam:

● Tonic-clonic seizure (Grand mal): Seizure type with muscle rigidity and jerking.
 ● Status epilepticus: Prolonged or repeated seizures, a medical emergency.
● Seizure precautions: Interventions to protect a patient during and after a seizure, ensuring
safety and comfort.
Study Notes: Disasters, Workplace Violence, and Infection Control

Disaster Response and Emergency Management:

● Nurse's Role: Be prepared to manage an influx of patients during a disaster.
○ TJC (2020a) requires hospitals to have emergency-management plans that:
■ Identify potential emergency situations.
■ Estimate their probable impact.
■ Maintain sufficient supplies.
■ Have a response plan for staff actions and recovery.
● Bioterrorism:
○ Infection Control is essential during a biological attack.
○ For suspected or confirmed bioterrorism-related illnesses, follow Standard
Precautions (see Chapter 28).
○ Additional precautions: For diseases like smallpox or pneumonic plague, use
Airborne Precautions or Contact Isolation.
● COVID-19 Response:
○ CDC Recommendations (2020e) for managing patients with COVID-19:
■ Isolate symptomatic patients as soon as possible.
■ Set up separate triage areas; place suspected or confirmed COVID-19
patients in private rooms.
■ Airborne infection isolation rooms should be reserved for aerosol-
generating procedures.
■ Personal protective equipment (PPE): Use a respirator, gown, gloves,
and eye protection when entering the room of a suspected/confirmed
COVID-19 patient.

Preventing Workplace Violence:

● Workplace Violence Awareness:
○ Nurses must recognize and report violence in healthcare settings.
○ Underreporting of violence is common, leading to insufficient resources for
prevention.
● Patient Behaviors Predicting Violence:
○ Behaviors that predict patient violence (Jackson et al., 2014):
■ Increased speech volume.
■ Irritability.
■ Prolonged glaring.
■ Mumbling.
■ Abusive language towards caregivers (e.g., swearing, name-calling).
■ Pacing around the waiting area or bed.
● Causal Factors for Violence (Arnetz et al., 2015):
○ Patient behavior: Cognitive impairment, demanding to leave.
○ Patient care issues: Needles, pain/discomfort, physical transfers.
○ Situational events: Use of restraints, transitions in care, attempts to intervene or
redirect patients.
● Staff Behavior and Violence:
○ Staff actions can contribute to violent incidents:
 ■39% of statements in a study identified staff behavior as a contributing factor.
■35% of staff reported their own behavior contributing to the most severe
violent episodes.
● Nurse Awareness:
○ Recognizing warning signs early can help prevent violence.
○ Pay attention to the patient’s emotional state and act calmly.
○ Be mindful of your own tone and actions to avoid escalating a situation.

Key Terms to Remember for ATI Exam:

● TJC (The Joint Commission): Requires hospitals to have emergency-management plans.
● Standard Precautions: Infection control practices for managing bioterrorism-related
illnesses.
● Airborne Precautions: Used for diseases like smallpox, pneumonic plague, and COVID-19.
● PPE (Personal Protective Equipment): Necessary when caring for patients with contagious
diseases.
● Workplace Violence: Recognize early signs and prevent escalation, understanding both
patient and staff behaviors.
Study Notes: Seizure Protection, Workplace Violence, and Nurse Interventions

Seizure Protection Guidelines (Box 27.14):

● When a seizure begins:
○ Note the time of onset.
○ Stay with the patient and call for help.
○ Track the duration of the seizure.
○ Notify healthcare provider immediately.
● Positioning the Patient Safely:
○ If the patient is standing or sitting, ease them to the floor and protect their head by
cradling in your lap or placing a pad under their head.
○ Do not lift the patient from the floor during the seizure.
○ Clear the surrounding area of sharp or hard objects.
● In Bed:
○ Remove pillows and raise side rails for safety.
○ If possible, turn the patient onto their side, with the head slightly tilted forward.
● General Safety Tips:
○ Do not restrain the patient or force apart their clenched teeth.
○ Never place any objects in the mouth during a seizure, including fingers, medicine, or
tongue depressors. Bite-block or oral airway may be used in advance if tonic-clonic
seizures are anticipated.
○ Observe the seizure carefully, noting the sequence and timing of activity.
● Post-Seizure Care:
○ Reorient and reassure the patient as they regain consciousness.
○ Position the patient comfortably in bed with side rails up (one rail down for easy
exit).
○ Conduct a head-to-toe evaluation for injuries, including checking the mouth for
broken teeth or mucous membrane damage, as well as looking for bruising or joint
injuries.

Workplace Violence Prevention:

● Common Causes of Violence:
 ○ Half of the reasons for violent episodes are related to patient dissatisfaction with
service quality, staff professionalism, or unacceptable comments from staff
(Shafran-Tikva et al., 2017).
● Identifying Violent Patients:
○ Assessment tools are available to predict patients likely to act violently (see agency
procedure).
● Reducing Violence - Tips (CPI, 2021):
○ Be nonjudgmental and empathetic to the patient’s feelings; their issues are
important to them.
○ Respect personal space:
■ Stand 1½ to 3 feet away from an escalating patient.
■ Explain your actions before entering personal space.
○ Use nonthreatening nonverbal communication:
■ Keep tone, facial expressions, and movements neutral.
■ Do not overreact; stay calm, rational, and professional.
○ Focus on feelings:
■ Watch and listen for the patient’s real message. Redirect challenging
questions if necessary.
■ Restate requests to keep the conversation on track.
○ Set limits:
■ Use clear, simple limits when patients become disruptive.
■ Offer positive choices where possible.
○ Allow silence for reflection:
■ Give the patient time to think and process what’s happening.
● Self-Care for Nurses:
○ Workplace violence can be stressful and dangerous; ensure you use stress-
management approaches to take care of yourself away from work (see Chapter 37).

Key Terms for ATI Exam:

● Seizure Precautions: Nursing interventions to protect the patient during a seizure and
ensure their safety (e.g., time the seizure, position the patient, clear the area).
● Workplace Violence: Awareness and strategies for managing and preventing violence in
healthcare settings.
● CPI (Crisis Prevention Institute): Provides guidelines for reducing violence in healthcare,
such as maintaining empathy, respecting space, and setting limits.
● Bite-Block/Oral Airway: Devices used to protect the patient’s airway during a tonic-clonic
seizure if necessary.
● Postictal Phase: The phase after a seizure, where the patient may experience confusion,
amnesia, or deep sleep.
Study Notes: Reflective Practice, Patient Outcomes, and Evaluation in Patient Safety

Reflect Now: Responding to Patient Family Stress:

● Scenario: You are caring for a 10-year-old child diagnosed with acute lymphocytic leukemia.
The child is undergoing treatment but experiencing many side effects. The father is angry
about his child’s diagnosis and feels unsupported by family and friends. He begins yelling at
you when you walk into the room to administer medication, accusing you of not providing
appropriate care.
● How to Respond:
 ○ Remain calm: Responding with empathy and professionalism is key to defusing the
situation.
○ Acknowledge the father’s emotions: "I can see that you are really upset and
frustrated right now, and I understand that this is a very difficult time for your family."
○ Reassure and listen: "I am here to make sure your child gets the best care possible.
Can you tell me more about what’s bothering you? I want to help."
○ Explain your role and care plan: "Let me explain the treatment and the side effects
that may occur. I'm happy to answer any questions you have about the medication or
the process."
○ Offer support: "Is there someone I can contact to help with your concerns or provide
additional support to you and your family?"
● Role-Playing: Practice this approach with a peer to enhance your communication skills and
manage emotional family dynamics effectively.

Evaluation and Reflection in Patient-Centered Care:

● Patient-Centered Care:
○ Patient perspective: Always consider the patient’s view on safety and care.
Understand their concerns, limitations (physical, cognitive, or emotional), and
expectations of care.
○ Questions to ask:
■ "Are you satisfied with the changes you have chosen to make for your
home?"
■ "Do you feel safer because of the changes?"
■ "How do you feel now? Are you still afraid of falling?"
■ "In what way could we make you feel safer?"
● Involving Family:
○ Engage family members, especially those who assist in home care, in the evaluation
process to ensure holistic support and safety.

Patient Outcomes and Clinical Judgment:

● Evaluation Process:
○ Monitor responses: Track how the patient responds to the care delivered. Compare
the expected outcomes with the patient’s actual progress.
○ Clinical judgment: Reflect on the patient’s assessment and any changes in their
condition to determine if the nursing diagnosis has been resolved.
● Outcomes:
○ If outcomes are met, the nursing diagnosis is considered resolved, and interventions
were effective.
○ If outcomes are not met, reassess the situation to determine whether new safety
risks have emerged, or if existing risks persist.
● Reevaluating Safety:
○ For example, if a fall occurs, consider the following:
■ What factors led to the fall?
■ What makes the patient feel unsafe in their environment?
■ What changes or risks may have contributed to the fall?
● Family Involvement in Evaluation:
○ Engage the family in identifying safety risks: "What changes have you recently
experienced that you believe contribute to your risk for falling or lack of safety?"
 ○ Community Resources: Offer support by helping the patient and family connect with
community resources to improve safety.

Key Terms for ATI Exam:

● Patient-Centered Care: Involves considering the patient's perspective on safety and care
and involving the family in decisions.
● Clinical Judgment: Reflecting on patient assessments to evaluate the effectiveness of care
and determine whether outcomes are met.
● Patient Outcomes: Evaluating if the care provided has achieved the expected outcomes;
resolving nursing diagnoses based on patient progress.
● Safety Evaluation: Reassessing factors related to patient safety, such as falls or other
injuries, and adjusting interventions as necessary.
Study Notes: Patient Safety, Fall Prevention, and Evaluation

Reassessing Patient and Family Needs:

● Continual Reassessment: Nurses should consistently reassess the patient’s and family’s
needs for additional support services like home care, physical therapy, counseling, and
further teaching.
● Expected Outcomes for Safety:
○ A safe physical environment.
○ Patients should feel their expectations have been met and be knowledgeable about
safety factors and precautions.
○ The goal is to have the patient free from injury.

Case Example: Mrs. Cohen's Medication and Fall Risk:

● Initial Visit: Nurse Kylie assessed Mrs. Cohen’s knowledge of her medications and fall risks.
Mrs. Cohen understands that both medications lower her blood pressure and that one of
them increases her bathroom visits.
● Teaching and Reinforcement:
○ Review of Medications: Kylie confirmed the timing for the medications (morning)
and agreed to follow up on their success at the next visit.
○ Fall Risk Education: Kylie discussed the risks associated with Mrs. Cohen's age,
medications, and weakness from a stroke. They also discussed proper use of the
walker and making her home safer.
○ Confirming Understanding: Kylie reinforced learning by asking Mrs. Cohen to
explain the fall risks, and Mrs. Cohen successfully identified the key factors that
increase her risk.

Patient-Centered Evaluation:
● Assess Knowledge: Nurses need to assess whether the patient understands and can
correctly recall the safety-related information.
● Involve Family: As seen with Mrs. Cohen and her daughter Meg, family members can be
crucial in ensuring safety measures are implemented effectively at home.

Key Concepts and Skills:

1. Safety Knowledge and Clinical Judgment:
a. Impact of health conditions on patient safety.
b. Understanding the patient’s beliefs, attitudes, and knowledge of safety.
c. Anticipating the effects of medications, lifestyle, and environmental factors on safety.
 d. Identifying characteristics of safe vs unsafe behaviors and environments.
2. Time Pressure and Environment:
a. Nurses must manage tasks under time constraints and in complex settings (e.g.,
acute care vs home care).
b. Avoid delays in patient evaluation and prioritize the safety needs of patients.
3. Nursing Standards:
a. The ANA Standards and Scope of Nursing Practice guide patient care.
b. Nurses should base decisions on clinical practice guidelines and institutional
policies to ensure patient safety.

Critical Thinking Model for Safety Evaluation:

● Nurses should use a structured approach for evaluating safety outcomes:
○ Recognize Cues: Assess changes in patient behavior and condition.
○ Analyze Cues: Identify potential risks and contributing factors.
○ Prioritize Hypotheses: Determine which factors are most critical for the patient’s
safety.
○ Generate Solutions: Plan interventions that address the identified risks.
○ Take Action: Implement interventions and monitor their effectiveness.

Safety Guidelines for Nursing Skills:

● Fall Prevention:
○ Assessing Risk: Nurses should evaluate a patient’s risk for falls based on both
physiological (e.g., weakness, medication) and behavioral factors (e.g.,
disorientation, wandering).
○ Involve the Family: Educate the patient and their family on fall prevention strategies
and encourage their active participation in the safety plan.
○ Restraints: Always explore alternatives to restraints first, and use them only as a
last resort. Involve family members in this decision-making process.

Skill 27.1: Fall Prevention in Healthcare Settings:

● Delegation and Collaboration: While nurses must assess and communicate fall risks, tasks
such as implementing fall prevention strategies can be delegated to assistive personnel (AP).
○ Instructions for AP: Nurses should clearly explain:
■ The patient’s specific fall risks.
■ Environmental safety precautions to minimize fall risk.
■ Patient behaviors that might indicate increased fall risk (e.g., disorientation,
wandering).
● Equipment for Fall Prevention:
○ Fall risk assessment tools (Standardized and valid tools like HRET, 2016).
○ Safety equipment: Hospital beds with side rails, low beds, gait belts, seat belts for
wheelchairs, and optional devices like bed alarm pads or hip protectors.

Patient Safety Strategies:

● Prevention Protocols: Implement safety measures based on the patient's individual needs
and the environmental context.
● Patient Education: Continually educate the patient and their family on safety risks and
prevention strategies, including medication management, use of assistive devices (e.g.,
walkers), and environmental modifications to reduce falls.
Key Takeaways for Exam Preparation:
● Critical Thinking: Use clinical judgment to assess, prioritize, and take action on patient
safety.
● Fall Risk Prevention: Always assess risk factors for falls and implement appropriate safety
measures.
● Involve Patients and Families: Engage patients and their families in understanding and
adopting safety practices.
Fall Prevention: Steps and Rationale
Step 1: Patient Identification
● Action: Identify the patient using at least two identifiers, such as name and birthday or name
and medical record number, according to agency policy.
● Rationale: This ensures the correct patient is being treated, complies with The Joint
Commission standards, and improves patient safety (TJC, 2021a).
Step 2: Review Medical History
● Action: Review the patient's medical record for a history of falls and risks for injury (ABCs).
● Rationale: Identifying patients at high risk for falls, such as those over age 85 or with bone
disorders or coagulation issues, helps assess potential for serious injury like fractures or
internal bleeding (IHI, 2021).
Step 3: Assess Health Literacy
● Action: Assess patient and family caregiver health literacy.
● Rationale: Ensures the patient has the ability to process, understand, and communicate
health information, which is crucial for preventing falls (CDC, 2021b).
Step 4: Perform Hand Hygiene and Fall Risk Assessment
● Action: Perform hand hygiene and use a validated fall risk assessment tool to compute the
fall risk score.
● Rationale: Proper hand hygiene reduces infection transmission. A fall risk tool helps identify
intrinsic physiological factors that predispose patients to falls and is most effective when
tailored to specific patient populations (AHRQ, 2018).
Step 5: Comprehensive Assessment
● Action: Continue with an individualized assessment, considering the patient’s unique fall
risks.
● Rationale: This helps identify all factors that contribute to the patient's fall risk, ensuring a
thorough evaluation.
Step 6: Assess Mobility
● Action: Use tools like the Banner Mobility Assessment Tool (BMAT) or Timed Up and Go
(TUG) test to assess the patient's ability to ambulate.
● Rationale: Observing the patient's mobility directly provides more accurate information than
self-reporting. These tests evaluate balance, gait, and the ability to stand and walk, all critical
to fall risk assessment (Boynton et al., 2014; Matz, 2019; CDC, 2017c).
Step 7: Assess Pain
● Action: Assess the patient’s pain severity using a 0-10 scale.
● Rationale: Pain, especially in the lower extremities, can be a major contributor to fall risk, as
it can affect mobility and stability.
Step 8: Assess Fall History
● Action: Ask the patient or family caregiver about recent falls or injuries using the SPLATT
acronym (Symptoms, Previous fall, Location, Activity, Time, Trauma).
● Rationale: This helps identify patterns and causes of previous falls and provides critical
information for developing targeted fall prevention strategies (Touhy & Jett, 2022).
Step 9: Review Medications
 ● Action: Review medications, including over-the-counter and herbal products, for fall risks.
● Rationale: Some medications, especially those listed in the AGS Beers Criteria, can increase
the risk of falls due to their side effects, such as drowsiness or confusion (AGS, 2019).
Step 10: Assess for Polypharmacy
● Action: Assess whether the patient is using multiple medications (five or more) for the same
condition, or if medications are inappropriate for their condition.
● Rationale: Polypharmacy has been linked to a higher incidence of falls, particularly in older
adults, as interactions between medications can impair balance and cognition (Dhalwani et
al., 2017).
Step 11: Assess Fear of Falling
● Action: Assess for fear of falling, considering risk factors like age, gender, chronic illness,
and prior falls.
● Rationale: Fear of falling itself can lead to decreased activity and further functional decline,
making it an important factor to address in fall prevention (Park et al., 2017).
Step 12: Assess Condition of Assistive Devices
● Action: Check the condition of any assistive devices the patient is using (e.g., walker,
bedside commode).
● Rationale: Malfunctioning or poorly maintained equipment can increase the risk of falls.
Ensure all devices are in good working order.
Step 13: Patient-Centered Education
● Action: Use a patient-centered approach to assess what the patient already knows about fall
risks.
● Rationale: Involving the patient in the fall risk assessment and educating them on the
significance of their risk factors ensures they are informed and prepared to participate in fall
prevention strategies.
Step 14: Discuss Fall Prevention Goals
● Action: Discuss the patient’s goals or preferences for implementing fall prevention strategies.
● Rationale: Aligning the fall prevention plan with the patient’s preferences enhances their
engagement and adherence to the strategies (Chinai et al., 2018).
Step 15: Apply Fall Risk Identification
● Action: If the patient is identified as a fall risk, apply a color-coded wristband or other
markers (e.g., yellow socks).
● Rationale: Color-coded identifiers are a quick and visible reminder of the patient’s fall risk for
staff and visitors.
Step 16: Assess Wheelchair Use
● Action: If the patient uses a wheelchair, assess factors like comfort, fatigue, and
engagement.
● Rationale: Patients may attempt to exit their wheelchair without assistance if they are
uncomfortable or disengaged, increasing their risk of falls.

By following these comprehensive steps, healthcare providers can identify and mitigate fall risks,
improving patient safety and reducing the likelihood of injury.
Fall Prevention in Healthcare Settings: Expanded Steps

PLANNING
1. Provide Privacy and Comfort
a. Action: Ensure patient privacy and comfort during assessment and intervention.
b. Rationale: This maintains the patient's dignity and respect, fostering a sense of
security and cooperation.
 2. Perform Hand Hygiene and Prepare Equipment
a. Action: Perform hand hygiene and prepare all necessary equipment, ensuring
everything is functional.
b. Rationale: Reduces the risk of transmitting microorganisms, and having well-
functioning equipment ensures patient safety.
3. Explain Safety Measures to Patient
a. Action: Discuss fall prevention strategies specific to the patient’s risks, and address
fall prevention in the home. Optionally, have the patient sign an acknowledgment
form.
b. Rationale: Clear communication of purpose, benefits, and expectations encourages
patient participation and compliance (HRET, 2016).
4. Educate on Medication Side Effects
a. Action: Educate the patient and family caregivers about medication side effects that
increase fall risk.
b. Rationale: Many patients are unaware of the risks posed by certain medications,
which can contribute to falls (HRET, 2016).

IMPLEMENTATION
1. Conduct Hourly Purposeful Rounds
a. Action: Perform hourly rounds to assess pain, offer assistance with toileting, ensure
comfort, and assess personal items' placement. Provide pain relief as needed.
b. Rationale: Regular rounds have been shown to reduce falls and improve
communication among the care team. Proactively assisting with toileting and
addressing pain can prevent falls (Daniels, 2016; HRET, 2016).
2. Implement Early Mobility Protocols
a. Action: Follow protocols to ensure progressive increases in patient mobility, and
consider using accelerometers to monitor physical activity.
b. Rationale: Early mobility prevents deconditioning, which is a common fall risk for
hospitalized patients (Growdon et al., 2017; Gorman et al., 2014).
3. Universal Fall Precautions
a. Action:
i. Bed Position: Keep the bed in a low position and wheels locked; place a
non-slip mat at the exit side.
ii. Footwear: Encourage properly fitted, skid-proof footwear.
iii. Patient Orientation: Orient patients to their room and the call system.
b. Rationale: These measures minimize fall risks by making the environment safer,
ensuring easy access to the call system, and encouraging safe footwear use (AHRQ,
2018; HRET, 2016).
4. Safe Use of Side Rails
a. Action: Explain the purpose of side rails for patient safety, and check the agency
policy for proper side rail use.
b. Rationale: Side rails can provide support for repositioning but must be used correctly
to prevent injury or entrapment (FDA, 2017; TJC, 2020b).
5. Make Patient’s Environment Safe
a. Action:
i. Remove excess furniture and equipment, keep floors clear of clutter, and
clean spills immediately.
ii. Ensure adequate lighting and secure all cords.
iii. Place assistive devices in easy-to-reach locations.
 b. Rationale: Reducing obstacles and clutter reduces the risk of falls, while proper
lighting and accessible assistive devices increase safety (AHRQ, 2018).
6. Provide Comfort and Pain Management
a. Action: Offer analgesics as ordered, preferably around the clock, and ensure comfort
to reduce restlessness.
b. Rationale: Pain is a common reason patients attempt to leave their bed, and it can
increase fall risk (Patel et al., 2014).
7. Interventions for Moderate-to-High Risk Patients
a. Action:
i. Prioritize response to call lights for high-risk patients.
ii. Set an elimination schedule and use bedside commodes when necessary.
iii. Use sitters or restraints only when alternatives are exhausted.
b. Rationale: Prompt response to call lights, proactive toileting, and appropriate use of
sitters or restraints helps prevent patients from trying to get out of bed alone (Berry &
Kiel, 2021; HRET, 2016).
8. Safe Use of Wheelchairs
a. Action: Ensure that the wheelchair fits the patient properly and is used only for
transport.
b. Rationale: Correctly fitted chairs enhance comfort and prevent the patient from trying
to exit the chair (AHRQ, 2018).

EVALUATION
1. Ask Patient/Family to Identify Fall Risks
a. Action: Ask the patient and their caregiver to identify the fall risks for the patient.
b. Rationale: Demonstrates understanding and involvement in the fall prevention
process.
2. Discuss Home Fall Prevention
a. Action: Have the patient and family describe fall prevention interventions to
implement at home.
b. Rationale: Ensures that the patient is prepared to apply fall prevention measures in
their home, enhancing overall safety.
3. Evaluate Use of Assistive Devices
a. Action: Monitor the patient’s ability to use assistive devices (e.g., walker, commode)
throughout the day.
b. Rationale: Regular evaluation ensures that the devices are still appropriate and
functional.
4. Monitor Changes in Physical and Cognitive Status
a. Action: Evaluate any changes in the patient's motor, sensory, or cognitive status.
b. Rationale: Changes may indicate a need for adjustments to the care plan and could
indicate new or increased fall risks.
5. Evaluate Pain Control
a. Action: Use a pain scale to assess the patient's pain levels and determine if
interventions are effective.
b. Rationale: Pain can lead to falls if not adequately managed.
6. Teach-Back for Understanding
a. Action: Use the teach-back method to confirm that the patient and family understand
the reasons for fall risks and prevention strategies.
b. Rationale: This ensures that the information has been effectively communicated and
understood, promoting adherence to safety measures (AHRQ, 2020b).
By following these detailed steps in the planning, implementation, and evaluation phases, healthcare
providers can ensure that fall risks are thoroughly assessed, effective interventions are implemented, and
ongoing evaluation promotes patient safety and well-being.
The addition you've made continues to enhance the fall prevention and restraint protocols. Below is a
continuation from your entry, formatted for clarity, including rationale for actions and guidance on how to
manage unexpected outcomes:

STEPS RATIONALE
PLANNING (continued)
4. Obtain patient consent for use of restraint if required, based on legal and ethical standards.
● Consent ensures that patient rights are respected and that they or their family are informed
about the necessity and risks of using a restraint (CMS, 2020).
5. Position the patient appropriately for restraint application (e.g., comfortable and in a safe
position).
a. Proper positioning minimizes discomfort, pressure injuries, or injury from restraint
application.
IMPLEMENTATION
1. Apply the restraint according to manufacturer instructions, ensuring it is snug but not
restrictive.
a. Proper restraint application reduces the risk of harm and increases comfort.
Restraints should never be too tight to restrict circulation or breathing.
2. Monitor the patient closely while restrained, checking circulation, skin integrity, and comfort
every 15 minutes initially, then hourly.
a. Regular monitoring helps to prevent complications from prolonged restraint use, such
as pressure ulcers or circulatory issues.
3. Provide for basic needs (e.g., hydration, toileting, and repositioning) regularly to ensure
patient comfort.
a. Restraints can limit the patient’s ability to move freely, so addressing their basic
needs is essential to prevent discomfort or harm.
4. Document restraint use, including type, location, duration, and reason for use in the patient’s
record.
a. Accurate documentation is essential for legal and clinical accountability, ensuring that
restraint use aligns with protocols and is justified.
EVALUATION
1. Reassess patient every 2 hours for continued need for restraint, evaluating physical, mental,
and emotional status.
a. Ensures restraint use remains justifiable, reduces the risk of negative outcomes, and
follows the least restrictive approach.
2. Review patient’s response to restraint, including any signs of distress, and modify care plan
as necessary.
a. This step ensures patient safety, comfort, and well-being. Adjustments may include
alternative interventions if the restraint proves ineffective or harmful.
3. If restraint use is no longer necessary, promptly remove the restraint and reassess patient’s
ability to engage in activities of daily living (ADLs).
a. Removing the restraint as soon as possible promotes independence and reduces the
psychological impact of restraint.
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
1. Patient experiences skin breakdown or circulatory issues from restraint use
 Remove restraint immediately and assess for injury.
a.
Implement skin care measures (e.g., repositioning, applying skin barriers, etc.).
b.
Notify the healthcare provider and document findings.
c.
2. Patient exhibits worsening agitation or distress while restrained
a. Reassess restraint appropriateness, and consider alternative interventions (e.g.,
medication, calming environment, etc.).
b. Notify healthcare provider if necessary, and document patient’s emotional and
physical status.
3. Patient develops sudden physical injury or signs of distress
a. Discontinue restraint, assess for injuries, and notify healthcare provider.
b. Provide appropriate care for any injuries sustained, and document thoroughly.
4. Patient refuses to cooperate with the restraint
a. Communicate calmly and explain the reason for restraint.
b. Consider alternate approaches or a second healthcare provider's opinion if
resistance continues.
RECORDING AND REPORTING
1. Documenting restraint-related actions:
a. Document specific details in the medical record about the restraint order, application,
monitoring, and patient responses.
b. Record exact times of restraint application and removal, along with ongoing
observations.
c. Report any adverse outcomes or complications in accordance with facility protocols,
including safety event reports.
2. Hand-off communication:
a. When transferring patient care, clearly communicate any restraints in place, their
duration, and any modifications made to the restraint protocol.

This section now addresses detailed steps on the proper assessment, application, monitoring, and
evaluation of physical restraints, along with managing unexpected outcomes and ensuring thorough
documentation and communication throughout the process. The goal is to keep the patient safe,
informed, and treated with dignity while minimizing potential harm and ensuring legal and ethical
compliance.
Here's the continuation with the addition you requested, including further details on restraint types and
their rationale:

IMPLEMENTATION (continued)
1. Adjust bed to proper height and lower side rail on side of patient contact.
a. Allows you to reposition the patient during restraint application without injuring
yourself or the patient. Proper alignment prevents contracture formation when
restraints are in place.
2. Inspect area where restraint is to be placed.
a. Note if there is any nearby tubing or medical device. Assess the condition of the skin,
sensation, circulation, and range of joint motion.
b. Restraints sometimes compress and interfere with functioning of devices or tubes.
This assessment provides a baseline to monitor the patient’s response to restraint.
3. Pad skin and bony prominences (as necessary) that will be under restraint.
a. Reduces friction and pressure from the restraint on skin and underlying tissue,
preventing skin breakdown.
4. Apply the proper-size restraint.
 a. NOTE: Refer to manufacturer directions for proper application.
a. Mitten Restraint
b. The thumbless mitten device restrains the patient’s hands. Ensure the Velcro strap is
around the wrist and not the forearm.
c. Purpose: Prevents the patient from dislodging medical devices, removing dressings,
or scratching.
d. Criteria for Restraint: A mitten is considered a restraint if:
i. It is pinned or attached to the bed/bedding, or wrist restraints are used.
ii. The mitt is applied tightly, immobilizing the hands or fingers.
iii. The mitt is bulky, significantly reducing the patient’s ability to use their
hands.
iv. The mitt cannot be easily removed by the patient.
e. Clinical Judgment: Mittens can be considered a restraint alternative if they are
untethered and the patient can remove them independently.
b. Elbow Restraint (Freedom Splint)
f. This restraint consists of a padded fabric sleeve that wraps around the arm and is
secured with Velcro. It has a clamp that attaches to the patient's gown.
g. Purpose: Limits arm movement, preventing the patient from disrupting medical
devices near the face or neck. It doesn't prevent removal of abdominal or urinary
devices.
h. Note: Freedom sleeves restrict elbow bending, which may not prevent the patient
from removing IV lines.
c. Belt or Body Restraint
i. Position the patient sitting in the bed. Apply the belt over clothes, gown, or pajamas,
ensuring it’s positioned at the waist (not chest or abdomen).
j. Purpose: Restrains the patient's center of gravity, preventing them from rolling off
the bed or attempting to sit up unaided.
k. Important: If the belt moves over the chest or abdomen, it can interfere with
ventilation, so apply it snugly but carefully to avoid compromising breathing.
l. Clinical Judgment: This restraint is suitable for confused or impulsive patients who
attempt to exit the bed after repeated redirection.
d. Soft Extremity (Ankle or Wrist) Restraint
m. These restraints are made of soft, padded material and are wrapped around the wrist
or ankle with a Velcro strap.
n. Purpose: Appropriate for agitated patients who keep trying to remove necessary
medical devices.
o. Precaution: Restraint should be snug but not tight to prevent circulation problems.
p. Clinical Judgment: If the patient is in wrist or ankle restraints, they are at risk for
aspiration when lying supine. Position the patient laterally or with the head of the bed
elevated, rather than flat.
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
1. Skin irritation or breakdown at restraint site
a. Ensure frequent monitoring of skin, padding areas of contact with restraint, and
adjusting restraints as needed to prevent pressure.
b. Reassess the restraint type and size to ensure proper fit and comfort.
2. Patient develops increased agitation or distress
a. If restraint causes further agitation, remove the restraint (if appropriate) and attempt
less restrictive alternatives such as calming techniques, medication adjustments, or
environmental modifications.
 Restraint does not prevent removal of medical devices or dressings
3.
a. Consider an alternative restraint or technique, such as mittens or specialized
clothing, that more effectively prevents device removal.
4. Respiratory distress or discomfort due to restraint
a. Reposition the patient to ensure adequate ventilation, particularly with belt restraints.
Remove the restraint if necessary, and reassess the patient's clinical status.
RECORDING AND REPORTING
1. Document the use of restraint
a. Thoroughly record the type of restraint, duration, reasons for use, and the patient’s
response in their health record.
b. Include detailed information on skin condition and any discomfort or complications
experienced during restraint.
2. Ongoing assessment and communication
a. Continuously monitor the patient’s physical and psychological state, documenting any
adverse effects or changes in their condition.
b. Communicate restraint use and the patient's response during handoffs to ensure
continuity of care.

This section now includes a detailed explanation of how to apply different types of physical restraints, with
a focus on minimizing discomfort and ensuring patient safety. It also emphasizes the importance of
ongoing assessment, documentation, and communication to ensure the best possible care when
restraints are needed.
Here’s the continuation of the detailed steps and rationale for applying physical restraints, as well as
related safety and evaluation processes:

IMPLEMENTATION (continued)
5. Attach restraint straps to part of bedframe that moves when raising or lowering the
head of the bed.
a. Ensure that straps are secure and do not attach to side rails. Attach restraint to the
chair frame for patients in a chair or wheelchair, ensuring that the buckle is out of the
patient’s reach.
b. Rationale: Properly positioned straps prevent tightening or restricting circulation
when the bed is raised or lowered, enhancing patient safety and comfort.
6. Secure restraints on bedframe with quick-release buckle.
a. Do not tie straps in a knot. Ensure that the buckle is out of the patient’s reach.
b. Rationale: Quick-release buckles allow for rapid removal in emergencies,
contributing to patient safety in critical situations.
7. Double-check and insert two fingers under the secured restraint.
a. Assess proper placement of the restraint, including skin integrity, pulses, skin
temperature, color, and sensation of the restrained body part.
b. Place the bed in the lowest position after applying restraints.
c. Rationale: This step provides a baseline to monitor potential injury, while the bed
position helps to minimize the risk of injury should the patient attempt to get out of
bed.
8. Perform hand hygiene and remove restraint at least every 2 hours (or more frequently
per agency policy).
a. Reposition the patient, provide comfort and toileting measures, and evaluate the
patient’s condition. If the patient is agitated, violent, or noncompliant, remove one
restraint at a time and/or have staff assistance while removing restraints.
 b. Rationale: Releasing restraints periodically allows the patient to meet their basic
needs and ensures the restraint is necessary for continued use. Temporary, directly
supervised releases for patient care (e.g., toileting) are not considered a
discontinuation of the restraint.
c. Clinical Judgment: Restraints should not be ordered "as needed." If a patient needs
to be re-restrained after previously being released, a new order is required.
Violent/self-destructive patients should be monitored continuously while restraints are
off.
9. Place the nurse call system in an accessible location within the patient’s reach.
a. Rationale: This ensures the patient can call for assistance if needed and promotes
safety by reducing the risk of falls or other accidents.
10. Leave bed or chair with wheels locked.
a. Raise side rails (as appropriate) and lower the bed to the lowest position.
b. Rationale: Securing the bed or chair ensures stability if the patient attempts to get
out, and lowering the bed reduces injury risk in case of a fall.
11. Dispose of all contaminated supplies in appropriate receptacles.
a. Remove gloves and perform hand hygiene.
b. Rationale: This reduces the transmission of microorganisms and ensures proper
disposal of contaminated items to maintain a clean environment.

EVALUATION
1. Evaluate the patient’s response to restraints after application:
a. For non-violent patients: Assess signs of injury (e.g., circulation, range of motion,
vital signs, skin condition), behavior, and psychological status, and determine
readiness for discontinuation (frequency based on agency policy).
b. For violent/self-destructive patients: Evaluate the same signs every 15 minutes.
Perform visual checks if the patient is too agitated to approach.
c. Rationale: Frequent evaluations ensure that restraints are being used appropriately
and that injuries or discomfort are detected early. For non-violent patients, continuous
assessment may not be necessary, but checking every 15 minutes is crucial for
violent patients.
2. Evaluate the patient’s need for toileting, nutrition, fluids, hygiene, and other basic
needs.
a. Release the restraint at least every 2 hours.
b. Rationale: Addressing these needs prevents discomfort, maintains dignity, and
avoids physical complications associated with immobility, such as pressure injuries or
urinary retention.
3. Evaluate patient for any complications of immobility.
a. Rationale: Early detection of issues like skin irritation, respiratory distress, or
reduced mobility is critical to prevent more serious complications.
4. Renewal of restraints (per agency policy and CMS guidelines):
a. For non-violent patients: Restraints may be renewed based on the hospital's policy,
but they must be discontinued as soon as it's safe to do so.
b. For violent/self-destructive patients: Restraints can be renewed as follows:
i. 4 hours for adults (18 years or older)
ii. 2 hours for children and adolescents (9-17 years old)
iii. 1 hour for children under 9 years old
c. These orders may be renewed for a maximum of 24 consecutive hours.
 d. Rationale: Restraints for violent behavior require stricter renewal limits to ensure
they are not overused and the patient is evaluated at regular intervals for safety and
appropriateness.

This structured approach ensures the patient’s safety and well-being during restraint use, while also
adhering to best practices in monitoring and evaluating restraint effectiveness. Frequent assessments,
proper technique, and timely intervention can reduce the risk of complications and enhance patient
comfort.
Ensures that Restraint Application Continues to be Medically Appropriate
5. Examine IV catheters, urinary catheters, and drainage tubes.
a. Ensure that these devices are positioned correctly and that therapy remains
uninterrupted.
b. Rationale: Reinsertion of catheters or drainage tubes is uncomfortable and increases
the risk for infection or interrupts necessary therapy.
6. Use Teach-Back: “We’ve talked about the reason we’re using restraints on your father.
Tell me that reason. I want to be sure you understand.”
a. If the family caregiver cannot correctly teach back the information, revise your
explanation or develop a plan for further caregiver teaching.
b. Rationale: Teach-back is an evidence-based intervention that promotes patient
engagement, safety, adherence, and quality. The goal is to ensure patients and
caregivers fully understand the information provided. This approach also helps
improve communication and patient outcomes (AHRQ, 2020b).

Unexpected Outcomes and Related Interventions

1. Patient experiences impaired skin integrity:
a. Interventions:
i. Evaluate whether continued use of restraint is necessary and if alternatives
could be used.
ii. If restraint remains necessary, apply it correctly and provide adequate
padding.
iii. Check skin under restraint for abrasions and remove restraints more
frequently.
iv. Provide appropriate skin care and replace wet or soiled restraints.
b. Rationale: Skin integrity is critical to patient safety, and restraint application should
be regularly reassessed to minimize injury.
2. Patient becomes more confused or agitated:
a. Interventions:
i. Determine the cause of the behavior and address it, consulting with a
healthcare provider if necessary.
ii. Adjust the level of sensory stimulation based on the patient’s needs,
making sure it is meaningful.
iii. Reorient the patient as needed and consider restraint-free alternatives.
b. Rationale: Agitation and confusion may be symptoms of underlying causes such as
pain, discomfort, or anxiety. Adjusting the environment and care plan can help
alleviate distress.
3. Patient has neurovascular injury (e.g., cyanosis, pallor, coldness of skin, or complains
of tingling, pain, or numbness):
a. Interventions:
i. Remove the restraint immediately and stay with the patient.
 ii. Notify the healthcare provider and protect the affected extremity from
further injury.
b. Rationale: Neurovascular injuries are a serious complication and require immediate
action to prevent further harm to the patient.

Recording and Reporting

1. Record restraint alternatives used and patient response:
a. Document the patient’s behavior, level of orientation, and understanding of restraint
use, as well as any consent given by the family caregiver (if required).
b. Rationale: Thorough documentation helps ensure that restraint use is tracked,
patient needs are met, and compliance with policies is maintained.
2. Document the restraint details:
a. Record the placement, purpose, type, location of the restraint, skin condition, time
applied, ongoing assessment findings, and the time restraint ended.
b. Rationale: Accurate records are essential for tracking restraint use and ensuring
proper monitoring of the patient’s condition.
3. Report any injury from restraint to the registered nurse in charge and healthcare
provider immediately.
a. Rationale: Reporting ensures that injuries are managed promptly and that any
changes in the patient’s condition are communicated.
4. During hand-off reports, note the restraint’s location, type, and the most recent
assessment findings.
a. Rationale: Ensuring continuous communication during hand-off helps maintain
consistent patient care and highlights the importance of monitoring restraint use.

Key Points
● Clinical judgment involves understanding both the patient’s perspective on safety and the
risks posed by their physical conditions.
● Vulnerable populations (e.g., infants, children, older adults, those with chronic diseases)
are particularly at risk for safety alterations due to factors like limited healthcare access and
increased morbidity.
● Fall risk assessments should be performed on admission, after a change in condition, post-
fall, or during transfers to new healthcare settings. Validated tools (e.g., BMAT or TUG tests)
can help determine the patient’s need for assistance and evaluate mobility.
● Psychosocial factors impacting patient safety, such as health literacy, cultural background,
and perception of health, should always be assessed to make informed clinical judgments.
● Evidence-based alternatives to physical restraints include diversion activities, de-escalation
techniques, visual/auditory stimuli, and relaxation techniques, all of which should be
considered before restraint application.
● Review medical history (e.g., cognitive impairment, medications, underlying causes of
agitation) before using restraints to ensure that the decision is based on a full understanding
of the patient's condition.
● Continuous assessment is necessary for patients in restraints, ensuring that skin integrity,
circulation, and sensation are regularly evaluated to prevent complications and improve
patient outcomes.

By applying these measures and principles, nurses can enhance patient safety, ensure appropriate
restraint use, and prevent negative outcomes associated with physical restraints. Proper communication,
frequent reassessments, and vigilant monitoring are crucial in providing the best care.
Reflective Learning – Kylie’s Visit to Mrs. Cohen's Home:
1. What further assessment information in this situation is the most important and of immediate
concern for Kylie? (Recognize Cues)
● Immediate Concern: Kylie should assess Meg's current emotional state and stress levels in
relation to her caregiving role. Specifically, Meg has expressed concerns about her ability to
support her mother (worry about falling) and mentioned a lack of sleep. These are important
cues indicating caregiver stress and potential burnout, which could negatively affect both Meg
and Mrs. Cohen's well-being.
2. What family member conditions are consistent with this assessment information? (Analyze
Cues)
● Meg's stress and sleep deprivation are important conditions to consider. This suggests
caregiver fatigue, which can result from prolonged caregiving without proper rest or
emotional support. Meg’s concerns about her mother's safety (falling) also indicate
heightened anxiety and uncertainty in her caregiving role, which could impair her ability to
care for Mrs. Cohen effectively.
3. Which nursing diagnoses are most likely applicable in this caregiver situation? Which
diagnoses are the most serious or the highest priority? (Prioritize Diagnoses)
● High-Priority Diagnoses:
○ Caregiver Role Strain: This diagnosis is highly relevant due to Meg's emotional
distress, anxiety, and lack of sleep, all of which point to the strain of caregiving.
○ Sleep Deprivation: Meg has reported poor sleep, which is critical to address as it
impacts her ability to care for herself and Mrs. Cohen.
○ Risk for Injury (to Mrs. Cohen): This is a concern because of Meg’s worry about
falling, which indicates potential risks to Mrs. Cohen's safety, especially if Meg is
physically or emotionally exhausted.
4. What actions might Kylie take to achieve desired outcomes for Meg and would likely benefit
Mrs. Cohen as well? (Generate Solutions)
● Assess and Address Caregiver Fatigue: Kylie should suggest that Meg take breaks or
alternate caregiving duties with other family members if possible. Additionally, Kylie could
discuss respite care options to reduce Meg’s burden.
● Provide Resources for Sleep Improvement: Kylie might assess for environmental factors
(noise, light) that could disrupt Meg’s sleep and suggest relaxation techniques or proper sleep
hygiene.
● Safety Education and Support: Kylie could offer further training on how to assist Mrs.
Cohen with walking and preventing falls, ensuring Meg feels more confident in her caregiving
role.
5. Discuss three actions Kylie might implement to assist Mrs. Cohen. In what priority order should
they be implemented? Explain. (Take Action)
● Priority 1: Provide Safety Education for Meg: Kylie should first ensure that Meg
understands how to assist Mrs. Cohen in a way that minimizes the risk of falls (e.g., using
assistive devices, proper body mechanics). This addresses Meg’s immediate concern.
● Priority 2: Address Meg’s Caregiver Fatigue: Kylie should then offer emotional support to
Meg and suggest ways to manage caregiver stress, such as taking short breaks or seeking
respite care.
● Priority 3: Enhance Sleep Quality for Meg: Kylie should assist Meg in improving her sleep,
as lack of sleep could affect her physical and emotional health, impacting her caregiving
ability.
6. What evaluative measures would indicate that Kylie’s actions were effective? (Evaluate
Outcomes)
 ● For Meg: Improved emotional state (less stress/anxiety), better sleep, and increased
confidence in caregiving (expressed through reduced worry about falls).
● For Mrs. Cohen: Fewer falls or near-falls, improved strength and mobility due to physical
therapy, and overall safety while walking or being assisted.

Review Questions
1. You are caring for a patient in an ICU who has pulled out his own IV line. You have tried
restraint alternatives. Which of the following would you assess to determine appropriateness or
reason to physically restrain the patient? (Select all that apply.)
● Correct Answers:
○ Health care provider’s order
○ Patient’s current behavior
○ Current medications
● Rationale: You need to assess the patient’s behavior to understand the reason behind their
actions. A healthcare provider's order is required for restraints, and medications can influence
behavior or cognition.

2. You complete a fall risk assessment on your assigned patient, who is 45 years old and has a
history of cocaine use and liver failure. His laboratory results show an elevated prothrombin time.
You determine that the patient is at high risk for falling. Which of the following measures are
targeted to his fall risk status? (Select all that apply.)
● Correct Answers:
○ Using skid-proof footwear
○ Placing a low bed in room
○ Placing the nurse call system within patient’s reach
○ Using a bed exit alarm
● Rationale: These interventions address mobility challenges and fall risk, ensuring the patient
has a safe environment and the ability to call for assistance.

3. During a home health visit, a nurse observes a patient preparing lunch. Which of the following
are safe practices to follow in the safe preparation and storage of food? (Select all that apply.)
● Correct Answers:
2. Refrigerate leftovers as soon as possible.
4. Cook meats to the proper temperature.
5. Wash hands thoroughly before food preparation.
● Rationale: These are key food safety practices that reduce the risk of foodborne illness.

4. A nurse enters the hospital room of a patient who had a total knee replacement the day before
and is sitting in a chair. The nurse is preparing to return the patient to bed. Which of the following
pose potential safety risks? (Select all that apply.)
● Correct Answers:
3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
● Rationale: A high bed and lack of a gait belt increase the risk of falls and injury, especially
when transferring a patient after a recent surgery.

5. Match the patient fall risks on the left with the correct risk factor category on the right.
1. A 42-year-old patient who is recovering from anesthesia refuses assistance with
walking to the bathroom.
 a. Answer: A. Intrinsic risk
2. A 60-year-old patient with a history of falling in the last 6 months.
a. Answer: A. Intrinsic risk
3. A patient’s walking path has spilled fruit juice on the floor.
a. Answer: B. Extrinsic risk
4. A 68-year-old patient recovering from a colon resection uses an IV pole to walk.
a. Answer: A. Intrinsic risk
5. Patient is unable to identify own fall risks.
a. Answer: A. Intrinsic risk
6. The physical therapist has not yet fitted a 62-year-old patient for a prescribed walker.
a. Answer: B. Extrinsic risk
● Rationale: Intrinsic risks are related to the patient’s physical condition, while extrinsic risks
are environmental or equipment-related factors.

Let me know if you'd like further explanations or help with any other questions!