Editing Fundamentals of Nursing (section)

== Safety and infection prevention in basic care ==

'''Falls.''' Screen every patient with a validated tool such as the Morse Fall Scale or the Hendrich II Fall Risk Model. Interventions include the bed in the lowest position with wheels locked, the call light and personal items within reach, nonskid footwear, adequate lighting including night lighting, prompt response to call lights, hourly rounding addressing the four Ps (pain, position, personal needs or potty, and possessions), and toileting on a schedule for high risk patients. Four raised side rails are considered a restraint. If a patient begins to fall while you are assisting, do not try to hold them upright. Ease the patient to the floor while protecting the head, staying with the patient, and calling for help. After any fall, assess before moving the patient, notify the provider, complete an incident report, and document the objective findings in the medical record without referencing the incident report.

'''Restraints.''' Restraints are a last resort after less restrictive alternatives have failed. They require a provider order that specifies the type, the reason, and the duration, and they may never be ordered as needed. For nonviolent, nonbehavioral use, the order is generally renewed every 24 hours. For violent or self destructive behavior, orders are limited to 4 hours for adults, 2 hours for ages 9 to 17, and 1 hour for children under 9, with a face to face evaluation within 1 hour. Apply the least restrictive device, secure ties to the movable bed frame and never to the side rails, use a quick release knot, and assess circulation, sensation, motion, and skin every 15 to 30 minutes per policy, with release for range of motion, repositioning, toileting, and fluids at least every 2 hours.

'''Infection prevention.''' Hand hygiene is the single most effective measure. Use soap and water when hands are visibly soiled, after using the restroom, and when caring for a patient with ''Clostridioides difficile'' or another spore forming organism, because alcohol based rubs do not kill spores. Follow standard precautions for every patient, and add contact, droplet, or airborne precautions as indicated. Airborne precautions require an N95 or higher respirator and a negative pressure room. Maintain surgical asepsis for sterile procedures: keep sterile items above waist level and within sight, consider a one inch border of the sterile field contaminated, do not turn your back on the field, and treat any wet field as contaminated.

'''Aspiration prevention.''' Sit the patient fully upright for meals, allow rest before eating, avoid rushing, use small bites and a chin tuck when swallowing if recommended, avoid straws for patients with dysphagia unless specified, check for pocketing of food in the cheeks, and keep the patient upright for at least 30 to 60 minutes after eating. Refer any patient with coughing, choking, a wet or gurgly voice, or drooling to a swallowing evaluation.