CHAPTER 16: PROVISION OF A SAFE ENVIRONMENT

A fundamental concern of nurses, which extends from the bedside to the home to the
community, is preventing injuries and assisting the injured. Motor vehicle crashes, falls, drowning, fire
and burns, poisoning, inhalation and ingestion of foreign objects, and firearm use are major causes of
injury and death. Nurses need to be aware of what constitutes a safe environment for a particular
person or for a group of people in home and community settings. Injuries are often caused by human
conduct and can be prevented.

I. ENVIRONMENTAL SAFETY

A. FIRE SAFETY

In the event of fire, it is important that the staff members understand that the safety of the
clients are their number one priority. Remember the mnemonic RACE to prioritize in the event of a fire.

 Rescue clients who are in immediate danger.

 R is rescue clients in immediate danger. Rescue includes assisting those in need from
the fire area to an area of safety, which may be the closest fire zone away from the fire
or outside of the building.
 Activate the fire alarm.
 A is alarm (sound the alarm). Alarm or Alert may be as simple as telling a fellow worker
to call the fire department, activating a manual pull station, or sending out a code over
the public address system. Be sure the fire alarm system is operating properly. Make
certain that the system can detect fires, initiate the alarm and/or suppression systems,
and notify occupants, especially staff members.
 Confine the fire.
 C is confine the fire by closing all doors. Confining the fire can be a quick and simple
procedure resulting in saved occupant evacuation time and in locating the fire when fire
strikes. Suggest closing doors behind the last person leaving an area and closing every
door on the way out. Confining the fire limits the migration of heat and smoke as
residents are moved horizontally on the floor or out of the building.
 Extinguish the fire.
 E is extinguish. Extinguishment is an option for staff members who are competent in
using a fire extinguisher and are comfortable that building evacuation is underway and
they have a clear, unobstructed exit.
 Obtain the portable fire extinguishers must be provided in all healthcare facilities and
only used by properly trained staff members. Remind the group that fire extinguisher
use is an option only after the rescue, alarm/alert, and confinement are accomplished
and the fire department is on the way. To properly use the fire extinguisher, remember
the mnemonic PASS to prioritize in the use of a fire extinguisher.
 Pull the lockpin from its place;
 Aim the nozzle at the base of the flames;
  Squeeze the handles together; and
 Sweep from side to side at the base of the flames.

Here are some fire safety strategies to help you prepare for a fire emergency: Keep open
spaces free of clutter; clearly mark fire exits; know the locations of all fire alarms, exits, and
extinguishers. You can put out a fire by smothering it with a blanket, but if the nurse aiming the red can,
he must remember that different types of fires need different types of extinguishers. Using the wrong
fire extinguisher can make a fire worse. Know these types of extinguishers and where to find then in unit
or nursing environment. Type A which is use for wood, cloth, upholstery, paper, rubbish, plastic; type B
which is use for flammable liquids or gases, grease, tar, oil-based paint and; type C is for electrical
equipment.

As a nurse, you should also know the telephone number for reporting fires and know the fire
drill and evacuation plan of the agency. Designate an evacuation meet up location so you can account
for all patients and staff members. This will also help fire fighters inspect the building properly. Conduct
periodic fire drills to test and evaluate the efficiency, knowledge, and response of your staff members in
the event of a fire.

In the event of fire, never use the elevator in the event of a fire. The first is that fire can short-
circuit the elevator call button on the fire floor and therefore cause the elevator to stop at that floor.
Also, an elevator shaft provides a natural chimney. As such it can quickly fill with smoke. You don't want
to be trapped in a small metal box in a smoke chocked elevator shaft. If power is lost or is cut while you
are in the elevator then you are stuck there. Turn off oxygen and appliances in the vicinity of the fire.
Oxygen is frequently in use in hospitals and is highly flammable. When oxygen is in use, no open flames
or smoking are permitted in the area.

In the event of a fire, if a client is on life support, maintain respiratory status manually with an
Ambu bag (resuscitation bag) until the client is moved away from the threat of the fire and can be
placed back on life support. Ambulatory clients can be directed to walk by themselves to a safe area
and, in some cases, may be able to assist in moving clients in wheelchairs. Bedridden clients generally
are moved from the scene of a fire by stretcher, their bed, or wheelchair. If a client must be carried
from the area of a fire, appropriate transfer techniques need to be used, and if fire department
personnel are at the scene of the fire, they will help to evacuate clients.

B. ELECTRICAL SAFETY

Electrical equipment must be maintained in good working order and should be grounded;
otherwise, it presents a physical hazard.

 In the hospital, use a 3-pronged electrical cord. In a 3-pronged electrical cord, the third, longer
prong of the cord is the ground; the other 2 prongs carry the power to the piece of electrical
equipment. When you plug in a three-pronged plug, that third prong is providing an alternate
pathway for electricity in the event of a fault.
 Three-pronged grounded plug

 Check electrical cords and outlets for exposed, frayed, or damaged wires.
 Avoid overloading any circuit.
 Read warning labels on all equipment; never operate unfamiliar equipment.
 Use safety extension cords only when absolutely necessary, and tape them to the floor with
electrical tape.
 Never run electrical wiring under carpets because it can cause electrical fires.
 Never pull a plug by using the cord; always grasp the plug itself because operating the machine
with a damaged power cord may cause an electric shock or fire. It is dangerous to handle
the plug with wet hands. Doing this may result in receiving an electric shock.
 Never use electrical appliances near sinks, bathtubs, or other water sources.
 Always disconnect a plug from the outlet before cleaning equipment or appliances to prevent
electric shock.
 If a client receives an electrical shock, turn off the electricity before touching the client. During
defibrillator, do not touch the patient with hands, forearms or any portion of thy body. Neither
touches the metal frame of the cart or bed. Because it may pass the electricity to the health care
provider and will suffer from the volts and painful cramps from the amps.

C. RADIATION SAFETY

Curative yet potentially injurious, radiation plays a major role in diagnosing ailments and in
treating cancer. Radiation safety is also a hazard issue in certain areas of the hospital. Radiation injury
can occur from overexposure to radioactive materials used in diagnostic and therapeutic procedures.
Clients being examined using radiography or fluoroscopy generally receive minimal exposure and few
precautions are necessary. Nurses need to protect themselves, however, from radiation when some
clients are receiving radiation therapy. The following precautions should be taken to avoid serious
radiation exposure: The nurse should know the protocols and guidelines of the health care agency and
label potentially radioactive material. To reduce exposure to radiation, the nurse should do the
following: limit the time spent near sources of radiation; make the distance yourself as much as
possible from the radiation source and use a shielding device such as a lead apron whenever you must
be close to the source of radiation. Anyone caring for a patient undergoing radiation treatment should
monitor their own radiation exposure with a personal film (dosimeter) badge. The film badge is a
personal dosimeter used for monitoring cumulative radiation dose due to ionizing radiation. Place the
client who has a radiation implant in a private room and post appropriate notification that there is a
radiation hazard in the room to limit other people's exposure to the radiation. Never touch with bare
hands the dislodged radiation implants. The nurse should pick up the implant with long-handled
forceps and place it in a lead container. Lastly, keep all linens in the client’s room until the implant is
removed because linen also contains radiation and should be kept away from other people.

D. DISPOSAL OF INFECTIOUS WASTES

The handling and disposal of infectious/hazardous waste must adhere to very strict guidelines
set by the state and federal governments. If these materials aren’t handled appropriately and within all
legal rules and regulations, an institute can face serious fines. The following are some general guidelines
for handling infectious/hazardous wastes: Handle all infectious materials as a hazard. Hazardous
materials are defined as those things that are not biological but still remain hazardous to human beings
including patients and staff. Examples of hazardous materials are chemicals and radiation. Next, dispose
of waste in designated areas, using only proper containers for disposal and making sure that yellow
bags are used for yellow bag waste only. Ensure that infectious materials are labeled properly to make
sure that it is properly disposed. Needles (sharps) should not be recapped, bent, or broken because of
the risk of accidental injury (needle stick). Dispose of all sharps immediately after use in closed,
puncture-resistant disposal containers that are leak-proof and labeled or color-coded. Never remove the
cover from the sharps container or attempt to retrieve anything from it.

E. PHYSIOLOGICAL CHANGES IN THE OLDER CLIENT THAT INCREASE THE RISK OF ACCIDENTS

Common physiologic changes that affect safety include the musculoskeletal changes which the
strength and function of the older client’s muscle decreases; joints become less mobile and brittle and
postural changes and limited range of motion occur. Changes in nervous system includes: changes in
voluntary and autonomic reflexes become slower; decreased ability to respond to multiple stimuli
occurs and decreased sensitivity to touch occurs. There is an also sensory changes which includes
decreased vision and lens accommodation and cataracts develop; delayed transmission of hot and cold
impulses occurs and impaired hearing develops, with high-frequency tones less perceptible. Lastly, in
genitourinary changes include the increased nocturia and occurrences of incontinence may occur.

F. RISK FOR FALLS ASSESSMENT

People of any age can fall, but infants and older adults are particularly prone to falling and
causing serious injury. Falls are the leading cause of injuries among older adults. The nurse should assess
first if the client is risk for falling to prevent another injuries. It should be client-centered and include the
use of a fall risk scale per agency procedures. Include the client’s own perceptions of their risk factors
for falls and their method to adapt to these factors. Areas of concern may include gait stability, muscle
strength and coordination, balance, and vision. Assess for any previous accidents. Assess with the client
any concerns about their immediate environment, including stairs, use of throw rugs, grab bars, or a
raised toilet seat. Review the medications that the client is taking that could have a side or adverse
effect or side/adverse effects that could place the client at risk for a fall. Lastly, determine any scheduled
procedures that pose risks to the client.
G. MEASURES TO PREVENT FALLS

The nurse should take note the safety first of the client to prevent falls. At any age, people can
change their environments to reduce their risk of falling and breaking a bone. First is to assess the
client’s risk of falling. Carefully assess the client’s ability to ambulate and transfer. Provide walking aids
and assistance as required. Assign the client at risk for falling to a room near the nurses’ station. Alert
all health care providers to the patient’s risk for falling. Assess the client frequently to monitor the
status of the patient. On admission, orient clients to their surroundings and explain the call bell
system. Encourage the client to use the call bell to request assistance. Ensure that the bell is within easy
reach. Instruct the client to seek assistance when getting up. Use safety devices such as floor pads, and
bed or chair alarms that alert health care personnel of the person getting out of bed or a chair. Keep the
bed in the low position with side rails adjusted to a safe position (follow agency policy). Ensure to lock
all beds, wheelchairs, and stretchers so that clients can move in or out of bed easily. Keep clients’
personal items within their reach. Place bedside tables and overbed tables near the bed or chair so that
clients do not overreach and consequently lose their balance. Eliminate clutter and obstacles in the
client’s room. Provide adequate lighting so the client can see what is on his environment. Lastly, reduce
bathroom hazards. Maintain the client’s toileting schedule throughout the day. Encourage clients to use
grab bars mounted in toilet and bathing areas and railings along corridors

H. MEASURES TO PROMOTE SAFETY IN AMBULATION FOR THE CLIENT

In promoting safety in ambulation for the client, the gait belt may be used to keep the center of
gravity midline. A gait belt is an assistive device which can be used when assisting a client to ambulate or
to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help
with walking around. It is secured around the waist to allow a caregiver to grasp the belt to assist in
lifting or moving a person. To use the gait belt, place the belt on the client prior to ambulation. Encircle
the client’s waist with the belt. Hold on to the side or back of the belt so that the client does not lean to
1 side. Return the client to bed or a nearby chair if the client develops dizziness or becomes unsteady.
After moving the client, determine and document the client’s comfort (presence of anxiety, dizziness, or
pain), body alignment, tolerance of the activity (e.g., check pulse rate, blood pressure), ability to assist,
use of support devices, and safety precautions required (e.g., side rails).
 A. B.

A. Gait belt. B. Support patient by grabbing the hips area or gait belt

I. STEPS TO PREVENT INJURY TO THE HEALTH CARE WORKER

Body mechanics is the safe use of the body using the correct posture, bodily alignment, balance
and bodily movements to safely bend, carry, lift and move objects and people. Safe patient handling and
the application of the principles of body mechanics protect the patient and they also protect the nurse.

 Use available safety equipment.

 Position yourself appropriately.
 Face in the direction of the movement to prevent spinal twisting.
 Assume a broad stance to increase stability and provide balance.
 Keep the weight to be lifted as close to the body as possible.
 Lean your trunk forward, and flex your hips, knees, and ankles to lower your center of gravity,
increase stability, and ensure use of large muscle groups during movements.
 Tighten your gluteal, abdominal, leg, and arm muscles to prepare them for action and prevent
injury.
 Maintain the trunk erect and knees bent so that multiple muscle groups work together in a
coordinated manner.
 Proper body mechanics

J. RESTRAINTS (SAFETY DEVICES)

Restraints are protective devices used to limit the physical activity of the patient or to
immobilize the patient (or just an extremity). Documenting the use of restraints is an important nursing
requirement. Whereas the use of restraints was once fairly commonly, regulatory agencies pay very
close attention to their use today, therefore, restraint use must be limited and meet rigorous regulatory
requirements. The two types of restraints are: physical restraints which restrict patient movement
through the application of some kind of device and; chemical restraints which are medications
administered to inhibit specific behaviors in patients.

Examples of physical restraint

The agency policy should be checked when applying side rails. The use of side rails is not
considered a restraint when they are used to prevent a sedated client from falling out of bed. The client
must be able to exit the bed easily in case of an emergency when using side rails. Only the top 2 side
rails should be used. The bed must be kept the in the lowest position when using side rails.

The nurse should try everything in her professional arsenal before she resort to restraining a
patient. Some alternatives to restraining patients are: explaining everything to the client and family and
encouraging family and friends to stay with the patient. If the patient needs supervision, you may
suggest that the family arrange for sitters; assigning confused and disoriented patients to rooms near
the nurses’ station and orienting the patient and family to their surroundings; provide appropriate visual
and auditory stimuli, such as a night light, clocks, calendars, television, and a radio, to the client;
instituting exercise and waling schedules as the client’s condition allow while placing familiar items such
as family pictures near the client’s bedside. These personal items help clients become oriented to their
surroundings and; maintaining toileting routines and eliminating treatments that may be unnecessary as
soon as possible.

If the patient does require restraints, you must document the reasons for their use in detail
and frequently. Documentation for a patient to restraints should include the following information: the
reason for the restraint; the method of restraint; date and specific time of application; duration that the
restraint was applied, or the duration of the use of a chemical restraint; the client’s response to
restraints; record of release from restraints with periodic exercise and circulatory, neurovascular, and
skin assessments; assessment of continued need for restraint and; evaluation of the client’s response to
restraints. If the nurse did not document it, the nurse did not do it. It is important to document the
preceding information when using restraints.

The nurse just can’t put restraints on a patient who is getting on their nerves – the nurse should have to
follow some strict protocol, and have valid reasons for suggesting the use of restraints. Some of the
legal requirements in restraining the patient include the following: if restraints are necessary, a
physician’s order must state the type of restraint called for, identity the specific behaviors for which the
restraints will be used, and limit the time frame for their use; physicians’ orders for restraint should be
renewed within the time frame established by agency policy; restraints cannot be ordered “PRN” or “as
needed”; permission to use restraints should be granted by the patient and family if restraints are
necessary; restraints can’t be secured to the side rails, the nurse should use an easy slip-knot to secure
the device to the patient’s chair or bed frame; skin integrity and neurovascular and circulatory status
must be checked and documented every 30 minutes; the restraint must be removed at least two hours
to permit muscle exercise and promote circulation. This activity must be documented as well and; the
need for restraint must be continually assessed and documented.

K. POISONS

Inadequate supervision and improper storage of many household toxic substances are the major
reasons for poisoning in children. Implementing poison prevention for children is focused on teaching
parents to “childproof” the environment, including disposing of unused medications properly.
Adolescent and adult poisonings are usually caused by insect or snake bites and drugs used for
recreation or in suicide attempts. Implementing poison prevention in these age groups focuses on
providing information and counseling. Poisoning in older adults usually results from accidental ingestion
of a toxic substance (e.g., due to failing eyesight) or an overdose of a prescribed medication (e.g., due to
impaired memory). Implementing poison prevention with older adults focuses on safeguarding the
environment and monitoring the underlying problems.
 A poison is any substance that impairs health or destroys life when ingested, inhaled, or
otherwise absorbed by the body. There are specific antidotes or treatments are available only for some
types of poisons. The capacity of body tissue to recover from a poison determines the reversibility of the
effect. Poison can impair the respiratory, circulatory, central nervous, hepatic, gastrointestinal, and
renal systems of the body. A Poison Control Center phone number should be visible on the telephone in
homes with small children; in all cases of suspected poisoning, the number should be called
immediately.

To prevent poisoning, lock potentially toxic agents, including drugs and cleaning agents, in a
cupboard, or attach special plastic hooks to the insides of cabinet doors to keep them securely closed.
Unlatching these hooks requires firmer thumb pressure than small children can usually exert. Do not let
children watch you open the latches. Kids learn fast! Avoid storing toxic liquids or solids in food
containers, such as soft drink bottles, peanut butter jars, or milk cartons. Do not remove container
labels or reuse empty containers to store different substances. Laws mandate that the labels of all
poisons specify antidotes. Do not rely on cooking to destroy toxic chemicals in plants. Never use
anything prepared from nature as a medicine or “tea.” Teach children never to eat any part of an
unknown plant or mushroom and not to put leaves, stems, bark, seeds, nuts, or berries from any plant
into their mouths. Place poison warning stickers designed for children on containers of bleach, lye,
kerosene, solvent, and other toxic substances. Do not refer to medicine as candy or pretend false
enjoyment when taking medications in front of children; allow them to see the necessity of the
medicine without glamorizing it. Read and follow label directions on all products before using them.
Keep syrup of ipecac on hand at all times. Syrup of ipecac is a nonprescription emetic available in
single-dose 15-mL vials in all drugstores. Use it only after advice from the local poison control center or
the family primary care provider. Do not keep poisonous plants in the home, and avoid planting
poisonous plants in the yard. The cooperative extension agency in your county can provide a list of
poisonous plants. Display the phone number of the poison control center near or on all telephones in
the home so that it is available to babysitters, family, and friends.

The interventions that nurse should do when the client is poisoned: Remove any obvious
materials from the mouth, eyes, or body area immediately; identify the type and amount of substance
ingested; call the Poison Control Center before attempting an intervention; if the victim vomits or
vomiting is induced, save the vomitus if requested to do so, and deliver it to the Poison Control Center;
if instructed by the Poison Control Center to take the person to the emergency department, call an
ambulance; never induce vomiting following ingestion of lye, household cleaners, grease, or petroleum
products; never induce vomiting in an unconscious victim. The Poison Control Center should be called
first before attempting an intervention.

II. HEALTH CARE–ASSOCIATED (NOSOCOMIAL) INFECTIONS

Two of nursing’s primary functions are to prevent patients from getting infections and to keep
infections from spreading to other patients. An infection is an invasion of the body by pathogens that
multiply and produce injurious effects. An infectious disease that may be transmitted from one person
to another is a communicable disease. Nosocomial infections also referred to as hospital-acquired
infections, are acquired in a hospital or other healthcare facility and weren’t present or incubating at the
time the patient was admitted.

Illness impairs the body’s normal defense mechanisms, and a hospital environment provides
exposure to a variety of organisms that a patient hasn’t been exposed to in the past. Therefore, the
patient hasn’t developed resistance to these organisms. Healthcare personnel who fail to practice hasn’t
who fail to practice proper hand-washing procedures or fail to change gloves between client contact can
transmit infections. Most healthcare agencies have dispensers containing an alcohol based solution for
hand ribs mounted at the entrance to each client’s room as well as a stock of gloves usually available
outside and inside a patient’s room for healthcare workers to use. To reduce the risk of nosocomial
infections, the healthcare provider must: comply with either the current CDC hand hygiene guidelines
or the current WHO hand hygiene guidelines. Following the best practices identified in these guidelines
helps insure standardized, proven approaches to hand hygiene. Implement evidence-based practices to
prevent HAIs due to multidrug-resistant organisms (MDROs) in acute care hospitals. Each health care
agency needs to determine which practices are most appropriate for its unique client population and
circumstances that lead to prevalence of particular MDROs. Implement evidence-based practices to
prevent central line–associated bloodstream infections. Note: This requirement covers short- and long-
term central venous catheters and peripherally inserted central catheter (PICC) lines and; Implement
evidence-based practices for preventing surgical site infections. Preventing both central line and
surgical site infections require ongoing education of health care providers and clients/families. Protocols
exist which describe methods for preparing, maintaining, and monitoring aseptic entry sites.

III. STANDARD PRECAUTIONS

Standard precautions are used in the care of all hospitalized persons regardless of their
diagnosis or possible infection status. Nurses must practice standard precautions with all clients in any
setting, regardless of the diagnosis or presumed infectiveness. Standard precautions include hand
washing and the use of gloves, masks, eye protection, and gowns, when appropriate, for client contact.
They apply to blood, all body fluids, secretions, and excretions except sweat (whether or not blood is
present or visible), nonintact skin, and mucous membranes.

The nurse should reduce risk of transmission of microorganisms from recognized and
unrecognized sources.

 Perform proper hand hygiene after contact with blood, body fluids, secretions, excretions, and
contaminated objects whether or not gloves are worn.
 Perform proper hand hygiene immediately after removing gloves.
 Use a nonantimicrobial product for routine hand hygiene.
 Use an antimicrobial agent or an antiseptic agent for the control of specific outbreaks of
infection.
 Wear clean gloves when touching blood, body fluids, secretions, excretions, and contaminated
items (i.e., soiled gowns).
 Clean gloves

 Clean gloves can be unsterile unless their use is intended to prevent the entrance of
microorganisms into the body.
 Remove gloves before touching noncontaminated items and surfaces.
 Perform proper hand hygiene immediately after removing gloves.
 Wear a mask, eye protection, or a face shield if splashes or sprays of blood, body fluids,
secretions, or excretions can be expected.

Mask Eye protection Face shield

 Wear a clean, nonsterile, water-resistant gown if client care is likely to result in splashes or
sprays of blood, body fluids, secretions, or excretions. The gown is intended to protect clothing.
 Remove a soiled gown carefully to avoid the transfer of microorganisms to others (i.e.,
clients or other health care workers).
 Cleanse hands after removing gown.
 Handle client care equipment that is soiled with blood, body fluids, secretions, or excretions
carefully to prevent the transfer of microorganisms to others and to the environment.
 Make sure reusable equipment is cleaned and reprocessed correctly.
 Dispose of single-use equipment correctly.
  Handle all soiled linen as little as possible. Do not shake it. Bundle it up with the clean side out
and dirty side in, and hold away from self so that the nurse’s uniform or clothing is not
contaminated.
 Place used needles and other “sharps” directly into puncture-resistant containers as soon as
their use is completed. Do not attempt to recap needles or place sharps back in their sheaths
using two hands; use the one handed scoop technique or other safety device. Using two hands
can result in a needle stick puncture injury if the nurse accidentally misses the cover.
 Clean spills of blood or body fluids with a solution of bleach and water (diluted 1:10) or agency-
approved disinfectant.

IV. TRANSMISSION-BASED PRECAUTIONS

Transmission-based precautions are used in addition to standard precautions for clients with
known or suspected infections that are spread in one of three ways: by airborne or droplet transmission,
or by contact. The three types of transmission-based precautions may be used alone or in combination
but always in addition to standard precautions.

Airborne precautions are used for clients known to have or suspected of having serious illnesses
transmitted by airborne droplet nuclei smaller than 5 microns. Examples of such illnesses include
measles (rubeola), varicella (including disseminated zoster), and tuberculosis. The CDC has prepared
special guidelines for preventing the transmission of tuberculosis. The most current information may be
found on the CDC Division of Tuberculosis Elimination website.

Use standard precautions as well as the following:

 Place client in an airborne infection isolation room (AIIR). An AIIR is a private room that has
negative air pressure, 6 to 12 air changes per hour, and either discharge of air to the outside or a
filtration system for the room air.
 If a private room is not available, place client with another client who is infected with the same
microorganism.
 Wear a respiratory device (N95 respirator) when entering the room of a client who is known or
suspected of having primary tuberculosis.
 Susceptible people should not enter the room of a client who has rubeola (measles) or varicella
(chickenpox). If they must enter, they should wear a respirator mask.
 Limit movement of client outside the room to essential purposes. Place a surgical mask on the
client during transport.

Droplet precautions are used for clients known or suspected to have serious illnesses
transmitted by particle droplets larger than 5 microns. Examples of such illnesses are diphtheria
(pharyngeal); mycoplasma pneumonia; pertussis; mumps; rubella; streptococcal pharyngitis,
pneumonia, or scarlet fever in infants and young children; and pneumonic plague.

Use standard precautions as well as the following:

  Place client in private room.
 If a private room is not available, place client with another client who is infected with the same
microorganism.
 Wear a mask if working within 1 m (3 ft) of the client.
 Limit movement of client outside the room to essential purposes. Place a surgical mask on the
client while outside the room.

Contact precautions are used for clients known or suspected to have serious illnesses easily
transmitted by direct client contact or by contact with items in the client’s environment. According to
the CDC, such illnesses include gastrointestinal, respiratory, skin, or wound infections or colonization
with multidrugresistant bacteria; specific enteric infections such as C. difficile and enterohemorrhagic E.
coli O157:H7, Shigella, and hepatitis A, for diapered or incontinent clients; respiratory syncytial virus,
parainfluenza virus, or enteroviral infections in infants and young children; and highly contagious skin
infections such as herpes simplex virus, impetigo, pediculosis, and scabies.

Use standard precautions as well as the following:

 Place client in private room.

 If a private room is not available, place client with another client who is infected with the same
microorganism.
 Wear gloves as described in standard precautions.
 Change gloves after contact with infectious material.
 Remove gloves before leaving client’s room.
 Cleanse hands immediately after removing gloves. Use an antimicrobial agent. Note: If
the client is infected with C. difficile, do not use an alcohol-based hand rub because it is
not effective on these spores. Use soap and water.
 After hand hygiene, do not touch possibly contaminated surfaces or items in the room.
 Wear a gown (see standard precautions) when entering a room if there is a possibility of contact
with infected surfaces or items, or if the client is incontinent, or has diarrhea, a colostomy, or
wound drainage not contained by a dressing.
 Remove gown in the client’s room.
 Make sure uniform does not contact possible contaminated surfaces.
 Limit movement of client outside the room.
 Dedicate the use of noncritical client care equipment to a single client or to clients with the
same infecting microorganisms.

V. EMERGENCY RESPONSE PLAN AND DISASTERS

As a emergency nurse, you should know the emergency response plan of the agency. There are
two types of emergency response: Internal disasters are those that occur within the health care facility
and; External disasters occur in the community, and victims are brought to the health care facility for
care. When the health care facility is notified of a disaster, the nurse should follow the guidelines
specified in the emergency response plan of the facility.
VI. BIOLOGICAL WARFARE AGENTS

Nurses are considered frontline health care providers. As a result, they need education and
training to be able to assess and detect potential bioterrorism attacks. The biologic agents that have
been identified by the CDC as being of highest concern include anthrax, botulism, plague, viral
hemorrhagic fevers, smallpox, and tularemia.

Anthrax is caused by spore-forming bacterium—Bacillus anthracis and can be contracted

through the digestive system, abrasions in the skin, or inhalation through the lungs. Anthrax is
transmitted by direct contact with bacteria and spores; spores are dormant encapsulated bacteria that
become active when they enter a living host (no person-to-person spread). The infection is carried to
the lymph nodes and then spreads to the rest of the body by way of the blood and lymph; high levels of
toxins lead to shock and death. In the lungs, anthrax can cause buildup of fluid, tissue decay, and death
(fatal if untreated).

It is transmitted through direct skin contact with spores (most common); inhalation of
aerosolized spores (rare); and consumption of undercooked or raw meat products or dairy products
from infected animals (rare).

The symptoms of cutaneous anthrax are: localized itching followed by a lesion that turns
vesicular and subsequent development of black eschar (scab) within 7 to 10 days of initial lesion and;
fever, flulike symptoms, nonproductive cough, sore throat.

A blood test is available to detect anthrax (detects and amplifies Bacillus anthracis DNA if
present in the blood sample). Anthrax is usually treated with antibiotics such as ciprofloxacin,
doxycycline, or penicillin. The vaccine for anthrax has limited availability.

Smallpox is caused by variola virus and it is transmitted in air droplets and by handling
contaminated materials and is highly contagious. Droplet nuclei expelled from the mouth of an infected
person or by aerosol. Contaminated clothing or bed linen could also spread the disease. Humans are the
only natural host of variola.
 Symptoms begin 7 to 17 days after exposure and include fever, back pain, vomiting, malaise,
and headache. Papules develop 2 days after symptoms develop and progress to pustular vesicles that
are abundant on the face and extremities initially. A rash then appears—first on the tongue and in the
mouth. These red spots develop into sores that break open and spread large amounts of the virus into
the mouth and throat. The person is highly contagious at this point. The rash then spreads to the entire
body. By the third day of the rash, the rash becomes raised bumps, which fill with thick, opaque fluid
and have a depression in the center. The bumps become pustules, which begin to form a crust and then
scab. The scabs fall off, leaving pitted scars. The person is contagious until all the scabs have fallen off.

A vaccine is available to those at risk for exposure to smallpox.

Botulism is a serious paralytic illness caused by a nerve toxin produced by the bacterium
Clostridium botulinum (death can occur within 24 hours). Its spores are found in the soil and can spread
through the air or food (improperly canned food) when the person ingests preformed toxin or via a
contaminated wound. Botulism cannot be spread from person to person.

Symptoms include abdominal cramps, diarrhea, nausea and vomiting, double vision, blurred
vision, drooping eyelids, difficulty swallowing or speaking, dry mouth, and muscle weakness.
Neurological symptoms begin 12 to 36 hours after ingestion of food-borne botulism and 24 to 72 hours
after inhalation and can progress to paralysis of the arms, legs, trunk, or respiratory muscles
(mechanical ventilation is necessary).

If diagnosed early, food-borne and wound botulism can be treated with an antitoxin that blocks
the action of toxin circulating in the blood. Other treatments include induction of vomiting, enemas, and
penicillin. No vaccine is available.

Plague it is a bacterium found in rodents and their fleas—Yersinia pestis. Forms of plague
include bubonic (most common), pneumonic, and septicemic (most deadly). Bubonic plague is
transmitted through the bite of an infected flea or exposure that is carrying the plague bacterium, by
the ingestion of contaminated meat, or by handling an animal infected with the bacteria. Bubonic
plague is not transmitted person to person. Pneumonic plague is caused by an aerosol attack
(bioweapon). Pneumonic plague can be transmitted person to person.

Red spots on skin that later turn black (hence the name is black death)

Symptoms of pneumonic plague usually begin within 1 to 3 days are fever, weakness, rapidly
developing pneumonia with dyspnea, chest pain, cough, lymph node swelling and sometimes bloody or
watery sputum. The disease rapidly progresses to dyspnea, stridor, and cyanosis; death occurs from
respiratory failure, shock, and bleeding.

Antibiotics are effective only if administered immediately; the usual medications of choice
include streptomycin or gentamicin. A vaccine is available.

Tularemia also called deer fly fever or rabbit fever is an infectious disease of animals caused by
the bacillus Francisella tularensis. The transmission is not known to be spread from person to person. It
is spread in different ways: being bitten by an infected tick, deer-fly, or other insect; handling infected
animal carcasses; eating or drinking contaminated food or water and; breathing in/inhaling the F.
tularensis.
 Symptoms include sudden fever, chills, headache, diarrhea, muscle aches, joint pain, dry cough,
and progressive weakness. If F. tularensis was used as a bioweapon and made airborne for exposure by
inhalation, the infected people would experience severe respiratory illness, including life-threatening
pneumonia and systemic infection.

Treatment is with antibiotics. Recovery produces lifelong immunity (a vaccine is available).

Hemorrhagic fever is caused by several viruses, including Marburg, Lassa, Junin, and Ebola.
Ebola and yellow fever are two examples. Viruses of most VHFs reside in an animal reservoir host or
arthropod host (e.g., rodents are hosts and ticks and mosquitoes can be vectors). However, the hosts of
some VHFs (e.g., Ebola and Marburg) are unknown.

Humans are not natural reservoirs for VHFs. People are infected when they come in contact with
infected hosts. However, with some VHFs, after the accidental transmission from the host, humans can
transmit the virus to one another.

After an incubation period of 5 to 10 days: abrupt onset of fever, myalgia, headache, nausea and
vomiting, abdominal pain, diarrhea, chest pain. A rash on the trunk develops approximately 5 days after
onset. Bleeding (e.g., petechiae, bruises, and hemorrhages) occurs as disease progresses.

Ebola Virus Disease (EVD) is previously known as Ebola hemorrhagic fever. It is caused by
infection with a virus of the family Filoviridae, genus Ebolavirus. Ebola is first discovered in 1976 in the
Democratic Republic of the Congo and outbreaks have appeared in Africa. The natural reservoir host of
Ebolavirus remains unknown. It is believed that the virus is animal borne and that bats are the most
likely reservoir.

Ebola is spread of the virus is through contact with objects (such as clothes, bedding, needles,
syringes/sharps, or medical equipment) that have been contaminated with the virus. Symptoms similar
to hemorrhagic fever may appear from 2 to 21 days after exposure.

The nurse needs a further assessment. The nurse ask the client if he or she traveled to an area
with EVD such as Guinea, Liberia, or Sierra Leone within the last 21 days or if he or she has had contact
with someone with EVD and had any of the following symptoms: fever at home or a current
temperature of38 °C (100.4 °F) or greater; severe headache; muscle pain; weakness; fatigue; diarrhea;
vomiting; abdominal pain and; unexplained bleeding or bruising.

If the assessment indicates possible infection with EVD, the client needs to be isolated in a
private room with a private bathroom or a covered bedside commode with the door closed. Health care
workers need to wear the proper PPE. The number of health care workers entering the room should be
limited and a log of everyone who enters and leaves the room should be kept. Only necessary tests and
procedures should be performed, and aerosol-generating procedures should be avoided.

Currently, there is no specific medical treatment for Ebola hemorrhagic fever according to the
CDC. The CDC recommends the following medical treatments for Ebola-infected patients: Providing
intravenous fluids (IV) and balancing electrolytes (body salts) Maintaining oxygen status and blood
pressure.

VII. CHEMICAL WARFARE AGENTS

Nerve agents differ in their water solubility and volatility. The relative differences in these
properties influence an agent’s potential as a biological hazard. For example, more volatile compounds
are readily inhaled. In general, nerve agents enter the body via the respiratory tract; however, some
agents that are easily dissolved by organic solvents rather than water may be absorbed through the skin.
Understanding these properties will help nurses evaluate signs and symptoms and initiate appropriate
decontamination procedures and emergency care. Atropine and pralidoxime chloride (2-PAM Cl) are
antidotes for nerve agent toxicity; however, 2-PAM Cl must be administered within minutes to a few
hours (depending on the agent) following exposure to be effective.

Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. It is a clear,
colorless, and tasteless liquid that has no odor in its pure form. However, sarin can evaporate into a
vapor (gas) and spread into the environment. It enters the body through the eyes and skin and acts by
paralyzing the respiratory muscles.
 Phosgene is a colorless gas normally used in chemical manufacturing that if inhaled at high
concentrations for a long enough period will lead to severe respiratory distress, pulmonary edema, and
death. It smells like moldy hay, is also an irritant but six times more deadly than chlorine gas. It is a
major industrial chemical used to make plastics and pesticides. At room temperature (70°F), phosgene is
a poisonous gas. With cooling and pressure, phosgene gas can be converted into a liquid so that it can
be shipped and stored.

Mustard gas is yellow to brown and has a garlic-like odor that irritates the eyes and causes skin
burns and blisters. Hours after exposure a victim’s eyes become bloodshot, begin to water, and become
increasingly painful, with some victims suffering temporary blindness. Worse, skin begins to blister,
particularly in moist areas, such as the armpits and genitals. As the blisters pop, they often become
infected.

Ionizing radiation is radiation that carries sufficient energy to detach electrons from atoms or
molecules, thereby ionizing them. Exposure can occur from external radiation or internal absorption.
Symptoms depend on the amount of exposure to the radiation and range from nausea and vomiting,
diarrhea, fever, electrolyte imbalances, and neurological and cardiovascular impairment to leukopenia,
purpura, hemorrhage, and death.

VIII. NURSE’S ROLE IN EXPOSURE TO WARFARE AGENTS

The nurse should be aware that, initially, a bioterrorism attack may resemble a naturally
occurring outbreak of an infectious disease. Nurses and other health care workers must be prepared to
assess and determine what type of event occurred, the number of clients who may be affected, and how
and when clients will be expected to arrive at the health care agency. It is essential to determine any
changes in the microorganism that may increase its virulence or make it resistant to conventional
antibiotics or vaccines.