OXYGEN

It is important in nursing practice to be aware of factors in a patient’s environment that decrease the amount of available oxygen. A common environmental hazard in the home is an improperly functioning heating system. A furnace that is not properly vented or a car left running inside a closed garage may introduce carbon monoxide into the environment. Carbon monoxide is a colourless, odourless, poisonous gas produced by the incomplete combustion of carbon-containing fuels. Carbon monoxide binds strongly to haemoglobin, preventing the formation of oxyhaemoglobin and thus reducing the amount of oxygen delivered to the tissues (see Chapter 40). Low concentrations can cause nausea, dizziness, headache, fatigue and confusion. Higher concentrations can be fatal (National Safety Council, 2009a). Seasonal inspections and cleaning of heating systems and appliances should be done in private homes as well as in institutions.

Oxygen is indicated in the healthcare setting for many critical conditions and its use can prevent serious life-threatening complications resulting from hypoxaemia. However, there is a risk of serious injury and even death if it is not administered and managed appropriately. Oxygen is considered a drug when used other than in an emergency situation, and should be prescribed by a doctor. Common risks associated with oxygen use in the healthcare setting include incorrectly prescribed oxygen, patients on oxygen therapy not monitored properly, administration problems and faulty and/or missing equipment. Therefore, oxygen safety in healthcare settings includes the establishment of clinical practice guidelines such as the following:

To minimise risk, close monitoring and assessment of oxygen therapy at regular intervals, assessment and monitoring of the patient’s oxygen saturation (SpO₂) and partial carbon dioxide pressure (pCO₂) regularly, medical, nursing and allied health staff briefing, and awareness that therapeutic procedures and handling may increase the patient’s oxygen consumption and lead to increasing hypoxaemia is required to be communicated to all clinical staff (Royal Children’s Hospital Melbourne, 2012).

NUTRITION

Meeting nutritional needs adequately and safely requires environmental controls and knowledge. In the home, a person needs a refrigerator with a freezer compartment to keep perishable foods fresh. A clean water supply is needed for drinking and to wash fresh produce and dishes. Provisions for garbage collection are necessary to maintain sanitary conditions.

Foods that are inadequately prepared or stored, or that are subject to unsanitary conditions, increase a person’s risk of infections and food poisoning. Bacterial infections result from eating food contaminated by bacteria such as Escherichia coli or Salmonella, Shigella or Listeria organisms. Food poisoning is caused by ingestion of bacterial toxins produced in food; staphylococcal and clostridial bacteria are the most common causes. Although most food-borne diseases are caused by bacterial contamination, transmission of hepatitis A can occur from ingestion of food or water contaminated with HAV (hepatitis A virus). Hepatitis A contamination occurs when there has been faecal contamination of food, water or milk (Food Safety Information Council, 2003).

For illnesses caused by bacterial contamination, the onset of symptoms may be very rapid or may take a week or longer to appear. The onset of symptoms for hepatitis A ranges from 15 to 50 days (Fiore, 2004). In general, assessments for suspected food infections or poisoning encompass obtaining a patient’s history, including a detailed dietary assessment for the past week; conducting an examination of gastrointestinal (GI) and central nervous system (CNS) function; observing for a fever; and analysing cultures of faeces and vomitus. Suspected food and water sources are also studied. Preventive measures include thorough handwashing before handling food, adequate cooking and proper storage and refrigeration of perishable foods.

Food standards in Australia are covered by a range of legislations (Food Standards Australia and New Zealand, 2012). This authority oversees all aspects of food production, manufacture, distribution, labelling and retailing. It is also responsible for the recall of substandard food products.

TEMPERATURE AND HUMIDITY

The comfort zone for environmental temperature varies among individuals, but the usual comfort range is between 18°C and 24°C. Temperature extremes that occur during the winter and summer affect not only comfort and productivity, but also safety.

Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Frostbite occurs when a surface area of the skin freezes as a result of exposure to extremely cold temperatures. Hypothermia occurs when the core body temperature is 35°C or below. Older adults, the young, people with cardiovascular conditions, people who have ingested drugs or alcohol to excess and the homeless are at high risk of hypothermia. A faint, irregular heart rate, slow and shallow respirations, pallor and shivering may be observed. Death may ensue if the condition is not corrected.

Exposure to extreme heat can result in heatstroke or heat exhaustion. Chronically ill people, older adults and infants are at greatest risk of injury from extreme heat. Heat exhaustion is manifested by diaphoresis, hypotension, changes in mental status, muscle cramps and nausea. Heatstroke is a life-threatening condition with severe changes in mental status, including coma; characteristics of hyperthermia include hot, dry skin and rectal temperatures in excess of 40.5°C.

The relative humidity of the air in the environment may affect health and safety. Relative humidity is the amount of water vapour in the air compared with the maximum amount of water vapour that the air could contain at the same temperature. The comfort zone for humidity varies from person to person, but most people are comfortable when the humidity is between 60% and 70%.

When the relative humidity is high, the skin’s moisture evaporates slowly. Thus, during hot, humid weather, people feel uncomfortably hot and sticky. If the relative humidity is low, the skin’s moisture evaporates quickly. This is why, when the temperature is 30°C, people feel more comfortable if the relative humidity is 30% than if it is 85%.

Increasing the environmental humidity can have therapeutic benefits. Children and adults with upper respiratory tract infections may experience some improvement in their symptoms when a humidifier is placed in the room while they sleep. Increasing the relative humidity of inhaled air liquefies secretions and improves breathing. It is important to follow the manufacturer’s directions regarding the cleaning and maintenance of home humidifiers, to reduce the contamination of the water.

LIGHTING

Adequate lighting reduces physical hazards by illuminating areas in which people move and work. Outside the home, there should be adequate lighting on all walkways. Outdoor lighting also helps protect the home and its inhabitants from crime. Well-lit garages, paths and doorways discourage intruders from entering the premises or hiding in shadows.

Inside the house, halls, staircases and individual rooms should be adequately lit so that residents can safely carry out the activities of daily living (ADLs). Night-lights in dark halls, bathrooms and the rooms of children and older adults help reduce the risk of falls. A night-light in a guest room can help orient an overnight guest who needs to get up in the middle of the night. Artificial lighting should be soft and non-glaring, as sensitivity to glare increases with ageing (Ebersole and others, 2008).

OBSTACLES

Injuries in the home often result from people tripping over or coming into contact with common household objects, including doormats, small rugs on the stairs and floor, wet spots on the floor and clutter on bedside tables, shelves, the top of the refrigerator and bookshelves. The risk of falling over obstacles is present for all age groups; however, it is greatest for older adults. Falls are usually a result of a combination of intrinsic risk factors (e.g. illness, drug therapy or alcohol use) and extrinsic or environmental factors. In some cases an obstacle or extrinsic factor may be the only cause of a fall. Intrinsic factors may be difficult to modify or eliminate, but extrinsic ones are usually not.

To reduce the risk of injury, all obstacles should be removed from halls and other heavily travelled areas. Necessary objects such as clocks, glasses, tissues or medications should remain on bedside tables within reach of adults (but out of the reach of children in the home). Care should also be taken to ensure that small tables are secure and have stable, straight legs. Non-essential items should be placed in drawers to eliminate clutter. If small rugs are used, they should be secured with a non-slip pad or skid-resistant adhesive strips. Any carpeting on the stairs should be secured with carpet tacks.

Obstacles encountered in the healthcare setting may also act as potential risks caused by the same sorts of hazards as those found in the home, such as wet spots on floors, cluttered overbed tables and bedside lockers, misplaced chairs and hospital equipment such as lifting machines and other large pieces of medical equipment. As in the home, to reduce the risk of injury, such obstacles should be removed from heavily trafficked patient areas.

BATHROOM HAZARDS

Accidents such as falls, burns and poisoning often occur in the bathroom. Falls in the bathroom can be reduced through the use of secure, easily seen grab-bars and handrails and non-slip adhesive tape on the bottom of the bath. Lowering the thermostat setting on the water heater reduces the risk of scalding. In the medicine cabinet, medications should be clearly marked and kept out of the reach of children. Child-resistant caps should be on all medication containers when there are children living in the home or visiting. Medication not in use or out of date should be discarded by returning it to the local chemist/pharmacist.

SECURITY

Home fires are not a major cause of death and injury in Australia (fewer than 100 per year), and with the campaign to encourage the use of smoke detectors, the figures seem to be moving downwards. The most common causes of death are falling asleep while an ignition source is burning, children playing with a heat source, and faulty or malfunctioning appliances or equipment (Australian Bureau of Statistics, 2000). Smoke detectors (Figure 15-1) should be installed strategically throughout the home, and suitable fire extinguishers should be installed near the kitchen and any workshop areas. Doors should not be deadlocked from the inside while the premises are occupied.

FIGURE 15-1 Smoke and fire detector.

Image: iStockphoto/Tomasz Domagala.

Older homes should be inspected for lead. Although lead has not been used in house paint or plumbing materials for many decades, older homes continue to contain high lead levels. Soil and water systems may also be contaminated. Poisoning may occur from swallowing or inhaling lead. Children under the age of 6 years and pregnant women are at the greatest risk of poisoning (National Safety Council, 2009b).

Asbestos has commonly been used in construction materials for insulation and as a fire retardant. Although many asbestos-containing products are no longer available, it can be found in many older homes. The widespread use of asbestos as a construction material has created occupational hazards for builders (of developing cancers) and environmental hazards (if the asbestos sheet is unsealed or broken) for homeowners and renovators (US Environmental Protection Agency, 2007).

Precautions need to be taken to ensure security to homes from intruders. When assessing their home for safety, individuals should evaluate doors and windows for the presence and quality of locks. They should be encouraged to join Neighbourhood Watch and work closely with law enforcement personnel to reduce crime in their neighbourhoods.

TRANSMISSION OF PATHOGENS

A pathogen is a microorganism capable of producing an illness. One of the most effective ways of limiting the transmission of pathogens is the medical aseptic practice of hand-washing (see Chapter 29). Healthcare workers, consumers and patients must be instructed in the proper hand-washing technique and encouraged to use it frequently in the home and hospital.

The transmission of disease from person to person can also be reduced, and in some cases prevented, by immunisation. Immunisation is the process by which resistance to an infectious disease is produced or augmented. Active immunity is acquired by injecting a small amount of attenuated (weakened) or dead organisms or modified toxins from the organism (toxoids) into the body. Passive immunity occurs when antibodies produced by other persons or animals can be introduced into a person’s bloodstream for protection against a pathogen.

The human immunodeficiency virus (HIV)—the pathogen that causes acquired immune deficiency syndrome (AIDS)—and the hepatitis B and C viruses are transmitted through blood and other body fluids. Drug abusers who share syringes and needles have an increased risk of acquiring these viruses. Safe sexual practices, including the correct use of condoms and engaging in monogamous relationships, reduce the risk of these diseases, as well as that of other sexually transmitted infections (STIs). The first needle exchange program in Australia was piloted in Sydney in 1986, and there are now over 3000 programs set up across the country. Since the inception of needle exchange programs in New South Wales, fewer than 20 new reported cases of HIV infection are attributed to injection with infected needles. The World Health Organization considers the provision of sterile needles and syringes to be fundamental to any HIV and hepatitis B and C prevention program (NSW Health, 2006). When caring for all patients, regardless of their known health history, nurses should always use standard precautions to protect themselves from contact with blood and body fluids (see Chapter 29).

The transmission of disease is also controlled by adequate disposal of human waste through proper construction and repair of sewers and drains. Insect and rodent control plays a vital role in reducing the transmission of disease.

POLLUTION

A healthy environment is free of pollution. A pollutant is a harmful chemical or waste material discharged into the water, soil or air. People commonly think of pollution only in terms of air, land or water pollution, but excessive noise can also be a form of pollution that presents health risks.

Air pollution is the contamination of the atmosphere with a harmful chemical. Prolonged exposure to air pollution increases the risk of pulmonary disease. In urban areas, industrial waste and vehicle exhaust are common contributors to air pollution. Cigarette smoking is now banned in public buildings, and smoking inside the house should also be discouraged.

Land pollution of soil can be caused by improper disposal of radioactive and bioactive waste products (e.g. dioxin).

Water pollution is the contamination of the ocean, lakes, rivers and streams, usually by industrial pollutants. Water treatment facilities filter harmful contaminants from the water, but these systems may contain flaws. If water becomes contaminated, the public is notified to boil water used for drinking and cooking. Flooding often causes damage to water treatment stations and also requires the boiling of drinking and cooking water.

Noise pollution occurs when the noise level in an environment becomes uncomfortable to inhabitants. Noise levels are measured in units of sound intensity called decibels. Tolerance of noise varies from individual to individual, and is influenced by health status. Irreversible hearing loss may result from constant exposure to high sound intensity. People working in environments with high noise levels need to wear protective devices to reduce hearing loss (Figure 15-2). Adolescents should limit their exposure to intense noise such as that found at rock concerts.

FIGURE 15-2 Protective device to reduce hearing loss.

Image: iStockphoto/videnovic.

A healthcare facility can also be polluted by noise. The sounds of machines, people talking and intercoms and paging systems can create increased noise levels. Even when the noise level is not high enough to affect hearing acuity, it may produce a syndrome called sensory overload. Sensory overload is a marked increase in the intensity of auditory and visual stimuli. It disrupts processing of information, and the patient no longer perceives the environment in a meaningful way.

PROCEDURE-RELATED ACCIDENTS

Procedure-related accidents occur during therapy. They can include medication and fluid administration errors, improper application of external devices and incidents related to improper performance of procedures (e.g. Foley catheter insertion).

Many procedure-related incidents can be prevented by adherence to accurate nursing principles and practice. For example, strictly following the procedure for administering medications will prevent medication errors. Proper administration of intravenous (IV) fluids prevents fluid overload or deficit. The potential for infection is reduced when the principles of asepsis are used for sterile dressing changes or any invasive procedure. Finally, correct use of body mechanics, equipment and transfer techniques reduces the risk of injuries when moving and lifting patients (Worksafe, 2000).

EQUIPMENT-RELATED INCIDENTS

Equipment-related incidents result from the malfunction, disrepair or misuse of equipment or from an electrical hazard. To avoid injury, nurses should not operate monitoring or therapy equipment without instruction.

A checklist should be used to assess potential electrical hazards to reduce the risk of electrical fires, electrocution or injury from faulty equipment (see Box 15-2). In healthcare settings, the engineering staff make regular safety checks of equipment.

INFANT, TODDLER AND PRESCHOOLER

Infants, toddlers and preschoolers depend on adults to protect them from injury. Growing children are curious and completely trusting of their environment and do not perceive themselves to be in danger. Nurses are often in a position to educate parents or guardians about reducing risks of injuries to young children (see Chapter 20). Nurses and midwives working in antenatal and postpartum settings can easily incorporate safety into the care plan of the family. Community health nurses can assess the home and show parents how to promote safety in their homes (Table 15-1 and Figures 15-7 and 15-8).

TABLE 15-1 PROMOTING SAFETY FOR CHILDREN AND ADOLESCENTS

Modified from Hockenberry MJ and others 2010 Wong’s nursing care of infants and children, ed 9. St Louis, Mosby.

FIGURE 15-7 Safety covers for electrical outlets.

Image: iStockphoto/Luis Camargo.

FIGURE 15-8 Correctly fitted baby capsule. Children who are incorrectly restrained in a vehicle have a significantly higher risk of serious injury than those who are correctly restrained.

Reproduced with permission of VicRoads.

SCHOOL-AGE CHILD

School-age children increasingly explore their environment (see Chapter 20). They have friends outside their immediate neighbourhood, and they become more active in school, church and sporting activities. School-age children need specific teaching regarding safety in school and at play (see Figure 15-3). See Table 15-1 for nursing interventions to help guide parents in providing for the safety of school-age children.

ADOLESCENT

Risks to the safety of adolescents involve many factors outside the home environment, particularly their almost constant involvement with members of their peer group (see Chapter 20). Adults serve as role models for adolescents and, through example, expectations and education can help adolescents minimise risks to their safety. This age group has a high incidence of suicide because of feelings of decreased self-worth and hopelessness. The nurse must be aware of the risks posed at this time and be prepared to teach adolescents and their parents measures to prevent accidents and injury (see Table 15-1).

ADULT

Risks to young and middle-aged adults often result from lifestyle factors such as child-rearing, high stress levels, inadequate nutrition, excessive alcohol intake, and substance abuse (see Chapter 21). In today’s fast-paced society there also appears to be more expression of anger, which can quickly precipitate accidents (e.g. road rage). Adults need to have the opportunity to discuss the choices they have made in their lifestyle and the types of threats to safety that exist. Given information about threats to their wellbeing, adults may make necessary modifications to their lifestyle. Useful resources are stress management centres (see Chapter 42) and health promotion activities, which can be found in many community service programs and hospitals. In addition, neighbourhood centres, community clinics and outpatient clinics are equipped to help adults modify lifestyle habits that present risks to health (e.g. smoking, overeating, lack of exercise and alcoholism).

OLDER ADULT

Nursing interventions for older adults are designed to reduce the risk of falls and other accidents and to compensate for the physiological changes of ageing. Most injuries to older adults involve falls, car accidents and burns (Australian Bureau of Statistics, 2006). Advancing age and the concurrent physiological changes in vision, hearing, mobility, reflexes, circulation and the ability to make quick judgments all predispose older adults to falls (see Chapter 22). Certain disease states common to older adults, such as arthritis or cerebrovascular accidents, increase the chance of injury. In addition, the effects of many medications given to older adults, such as sedatives, diuretics and laxatives, make falls more likely.

Older adults are more likely to have car accidents because of:

A decline in these skills may account for the most common types of accidents, including right-of-way and turning accidents. The nurse can advise patients regarding safe driving tips (e.g. driving shorter distances or only in daylight, using side and rear-view mirrors carefully and looking behind them towards their ‘blind spot’ before changing lanes). If any sensory loss is detected, the nurse may refer the patient to a specialist for appropriate advice on safe driving. Eventually, counselling may be necessary to help patients make the decision about when to stop driving. At that time, the nurse should help locate resources in the community that provide transport.

Burns and scalds are also more apt to occur with older people because they may forget and leave hot water running or become confused when turning the dials on a stove or other heating appliance. Nursing measures for preventing burns are designed to minimise the risk from impaired vision. Hot water taps and dials can be colour-coded to make it easier for the person to know what has been turned on. Recommending a reduction in temperature of the water heater can also be very beneficial.

Older adults love to walk. Pedestrian accidents can be reduced for older adults and for all other age groups by persuading people to wear reflectors on garments when walking at night; to walk where there are footpaths; to stand on the footpath and not in the street when waiting to cross a street; to always cross at corners or pedestrian crossings and not in the middle of the block (particularly if the street is a major one); to cross with the traffic light and not against it; and to look right, left and right again before crossing the street.

GENERAL PREVENTIVE MEASURES

Nurses can contribute to a safer environment by helping the patient meet basic needs related to oxygen, nutrition, temperature and humidity. To ensure that oxygen availability is not threatened, the nurse might recommend that the patient has a gas heater periodically inspected for proper functioning. To achieve a comfortable level of humidity in the home, the patient might use a humidifier or, in the case of patients with upper respiratory tract infections, a room humidifier where they sleep. The nurse can teach basic techniques of food handling (e.g. hand-washing, checking for spoilage) and preparation (e.g. keeping food refrigerated before serving) so that nutritional needs are met safely. Education for older adults or people who enjoy outdoor activities should include ways to prevent and treat hypothermia, heatstroke and heat exhaustion (see Chapter 22).

Adequate lighting and security measures in and around the home, including the use of night-lights, exterior lighting, and locks on windows and doors, enable people to reduce the risk of injury from crime. The local police department and community organisations often have safety classes available for residents to learn how to take precautions to minimise the chance of becoming involved in a crime. For example, some useful tips include always parking the car near a bright light or busy public area, carrying a whistle attached to the car keys and checking to see if anyone follows the car.

To prevent the transmission of pathogens, nurses can teach aseptic practices. Medical asepsis, which includes hand-washing and environmental cleanliness, reduces the transfer of organisms (see Chapter 29). Patients and family members need to learn thorough hand-washing and when to use it (e.g. before and after caring for a family member, before food preparation, before preparing a medication for a family member and after contacting any body fluids). When patients require dressing changes or the use of syringes and needles, families should be shown how to properly dispose of contaminated items.

SPECIFIC SAFETY CONCERNS

The nurse takes measures to help patients avoid falls, injuries from use of restraints and side rails, fires, poisoning and electrical hazards. Special precautions are necessary to prevent injury in patients susceptible to seizures. Radiation injuries are also a specific safety concern.

FALLS

Modifications in the home and healthcare environment can easily reduce the risk of falls (Table 15-2). A heavy or debilitated patient in a bed or wheelchair or on a toilet should be properly supported and secured. Side rails are necessary unless a patient is able to freely and easily walk independently. Safety bars on toilets, wheel locks on beds and wheelchairs and call bells are additional safety features in healthcare settings (Figures 15-9 and 15-10). Excess furniture and equipment should be removed, and a weakened patient should wear rubber-soled shoes or slippers for walking or transferring. The nurse should also encourage the removal of clutter from halls, stairs and traffic areas. When patients use aids such as walking sticks, crutches or walkers, it is important to routinely check the condition of rubber tips and the integrity of the aid.

TABLE 15-2 MEASURES TO PREVENT FALLS BY OLDER ADULTS

MEASURE	RATIONALE
STAIRS
Install treads with uniform depth of 22.5 cm and 22.5 cm risers (vertical face of steps)	If stairs are of uniform size, older adults do not have to continually adjust vision
Install uniform-textured or plain-coloured surfaces on each tread, and mark edge of tread with contrasting colour	Uniform textures or colour help to decrease vertigo. Marking edge of tread provides obvious visual clue to end of stair
Ensure proper lighting of each tread. Block sun or lightbulb glare with translucent shades or screen, or use lower wattage bulbs	Older adults’ vision is unable to adjust quickly to changes in lighting
Ensure adequate headroom so that users do not have to duck to negotiate stairs	Sudden changes in head position may result in dizziness
Remove protruding objects from staircase walls	Decreased peripheral vision may prevent person from seeing object
Maintain outdoor walkways and stairs in good condition and free of holes, cracks and splinters	Decreased visual acuity can prevent person from seeing any structural defect
HANDRAILS
Install smooth but slip-resistant handrail at least 5 cm from wall	5 cm distance allows person to grasp handrail firmly for support
Secure handrail firmly so that user’s weight is supported, especially at bottom and top of stairway	Older adults have greatest risk of falling at top and bottom of stairs, because centre of gravity is being shifted and balance is unstable
Install grab-rails in bathroom near toilet and bath tub	This enables person to have support while rising from sitting to standing position
FLOOR COVERINGS
Ensure that patients wear properly fitting shoes or slippers with non-skid surface	Reduces chances of slipping
Secure all carpets, mats and tiles; place non-skid backing under small rugs	Sudden slip may cause dizziness and inability to regain balance
ORIENTATION
Place disoriented patients in room near nurses’ station	Provides for more frequent observation on the part of nursing staff
Maintain close supervision of confused patients	Confused patients often attempt to wander out of bed or room

FIGURE 15-9 Safety bar by toilet.

Image: iStockphoto/Rob Byron.

FIGURE 15-10 Safety locks on wheelchair.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

RESTRAINTS

A physical restraint is a device used to immobilise a patient or extremity and to restrict the freedom of movement of, or normal access to, a person’s body. Restraints were commonly used in the past to limit the activity of patients who were confused, combative or at high risk of falling when unattended. However, recent changes in legislation now place more-stringent governance on their use. Assessment and adherence to strict criteria is required before restraints can be applied. An overbed table placed in front of a patient who has difficulty rising from a chair is an example of a restraint. Typical extremity restraints include belts or soft-cloth ties.

Whenever a patient is restrained, there is a natural tendency for the patient to try to remove the restraint. When this occurs, patient injury is common. Complications of physical restraints include nerve and ischaemic injuries, asphyxiation and death (Joanna Briggs Institute, 2002). Patients who are restrained are more likely to fall, have longer hospital stays, acquire a nosocomial infection and die in hospital. The immobility imposed by restraining a patient can lead to pressure ulcer formation, hypostatic pneumonia, constipation, urinary and faecal incontinence and urinary retention (see Chapter 33). Loss of self-esteem, humiliation, fear and anger can also result.

Because of the risk of injury from restraints, the Aged Care Act 1997 restricts the use of restraints in residential aged-care facilities and extended-care facilities in Australia. In addition, the Australian Council on Healthcare Standards sets standards for the safe use of restraints in inpatient settings (see Online resources). The Department of Health and Ageing (2004) provides guidelines which allow nursing and medical staff to effectively evaluate the need for restraints and the safe and legal utilisation of them. If the use of restraints must be part of the patient’s medical treatment, alternative interventions must be tried first (Box 15-7), other healthcare disciplines must be consulted and supporting documentation must be provided.

BOX 15-7 ALTERNATIVES TO RESTRAINTS

• Orient patients and families to surroundings; explain all procedures and treatments to them.

• Encourage family and friends to stay, or use sitters for patients who need supervision.

• Allocate staff familiar to the patient/resident.

• Assign confused or disoriented patients to rooms in high-traffic areas.

• Increase observation and supervision of at-risk patients.

• Provide appropriate visual and auditory stimuli (e.g. family pictures, clock, radio).

• Eliminate bothersome treatments as soon as possible. For example, discontinue tube feedings and begin oral feedings as quickly as allowed by the patient’s condition.

• Use relaxation techniques (e.g. massage).

• Institute exercise schedules as allowed by the patient’s condition.

• Maintain toileting routines.

• Offer frequent change of position while in bed and seated.

• Consult with physiotherapists and occupational therapists to enhance patients’ abilities to carry out activities of daily living.

• Evaluate all medications patients are receiving to determine whether the medication is having the desired therapeutic effect.

• Conduct ongoing assessment and evaluation of patients’ care and their ongoing response to care.

• Lower bed height to suit individual requirements.

Adapted from Department of Health and Ageing (DoHA) 2004 Decision making tool: responding to issues of restraint in aged care. Canberra, DoHA. Online. Available at www.health.gov.au/internet/main/publishing.nsf/Content/AE6A3DEC50534D27CA256F4700752CFF/$File/decisiontool04.pdf 19 May 2012. Used by permission of the Australian Government.

The use of restraints involves a psychological adjustment for the patient and family. If restraints must be used, the nurse helps family members and patients by explaining their purpose and the precautions taken to avoid injury.

Residential aged-care facilities must obtain informed consent from family members before using restraints. For legal purposes, the nurse must know agency policy and procedures for appropriate use and monitoring of restraints. Institutions require a doctor’s order that states the type of restraint, specific patient behaviours for which restraints are to be used and a limited timeframe. These orders should be renewed within a specific time according to the agency’s policy (usually 24 hours). Restraints are not to be ordered prn (as needed). Assessment of patients who are restrained must be ongoing. Proper documentation, including the behaviours that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g. circulation to hand) and the evaluation of the patient response is essential. Patients periodically have their restraints removed, at which time the nurse does an assessment to determine whether the restraints continue to be needed.

Skill 15-1 includes guidelines for the proper use and application of restraints. Use of restraints must meet the following objectives:

• reduce the risk of patient injury from falls

• prevent interruption of therapy such as traction, IV infusions, nasogastric tube feeding or Foley catheterisation

• prevent the confused or combative patient from removing life-support equipment

• reduce the risk of injury to others by the patient.

SKILL 15-1 APPLYING RESTRAINTS

DELEGATION CONSIDERATIONS

Use of restraints is an intervention with elements that can be delegated and elements that cannot be delegated.

Elements that cannot be delegated because they require the problem-solving and knowledge-application abilities of professional nurses include the following:

• assessment of safety needs

• selection of appropriate interventions

• evaluation of effectiveness of restraint

• ongoing assessment to prevent complications of restraint use.

Elements that can be delegated to nurse assistants include the following:

• Instruct care provider to inform the nurse if any skin excoriation is present under or around restraint location.

• Instruct care provider in proper way to remove and reapply restraint to provide skin care and allow supervised movement.

EQUIPMENT

• Proper restraint

• Padding

STEPS		RATIONALE
1. Assess whether patient needs a restraint.		Restraints are used when other measures have failed to prevent interruption of therapy such as traction, IV infusions or nasogastric tube feedings; to prevent a confused or combative patient from self-injury by falling out of bed or a wheelchair; to prevent a patient from removing a Foley catheter, surgical drain or life support equipment; and to reduce risk of injury to others by the patient.
2. Review agency policies regarding restraints. Check doctor’s order for purpose of restraint and type and duration of restraint.		A doctor’s order is necessary to apply restraints and should be renewed every 24 hours. The least restrictive type of restraint should be ordered. Because restraints limit the patient’s ability to move freely, the nurse must make clinical judgments appropriate to the patient’s condition and agency policy. If the nurse restrains a patient in an emergency situation, a doctor’s order should be obtained as soon as possible.
Critical decision point: Jacket or vest restraints are not covered in this text—many healthcare agencies prohibit their use because of their association with fatal injuries
3. Review manufacturer’s instructions before entering patient’s room.		The nurse should be familiar with all devices used for patient care and protection. Incorrect application of a restraining device may result in patient injury or death.
4. Inspect area where restraint is to be placed. Assess condition of skin underlying area on which restraint is to be applied.		Restraints may compress and interfere with functioning of devices or tubes. Provides baseline assessment data regarding skin integrity. Provides nursing personnel with an objective measure for subsequent skin assessment.
5. Explain to patient and family the need for the restraint, and try to obtain consent.		Helps minimise patient anxiety during application of the device and helps minimise family concern during maintenance of restraint.
6. Place patient in proper body alignment.		Proper body alignment should be maintained to prevent contractures and neurovascular injury.
7. Pad skin and bony prominences before applying restraints.		Padding reduces friction and pressure to skin and underlying tissue.
8. Apply appropriate restraint, making sure it is not over an IV line or other device (e.g. dialysis shunt).		IV lines and other therapeutic devices may become occluded.
	A. Belt restraint: Device that secures patient to bed or stretcher. Avoid placing belt too tightly across patient’s chest or abdomen (see illustration).	Restrains centre of gravity and prevents patient from rolling off stretcher or sitting up while on stretcher or from falling out of bed. Tight application may interfere with ventilation.
Step 8A Left, Apply belt restraint with patient sitting. Right, Properly applied belt restraint allows patient to turn in bed. From Sorrentino SA 2011 Mosby’s textbook for long-term care nursing assistant, ed 6. St Louis, Mosby.
B. Extremity (ankle or wrist) restraint: Restraint designed to immobilise one or all extremities. Commercially available limb restraints are composed of sheepskin with foam padding (see illustration).		Maintains immobilisation of extremity to protect patient from injury from fall or accidental removal of therapeutic device (e.g. IV tube or Foley catheter).
Step 8B Securing an extremity restraint. Check restraint for constriction by inserting two fingers under restraint.
C. Mitten restraint: Thumbless mitten device to restrain patient’s hands (see illustration).		Prevents patients from dislodging invasive equipment, removing dressings or scratching, yet allows greater movement than a wrist restraint.
Step 8C Mitten restraint. (Courtesy Posey Company, Arcadia, Calif.)
D. Elbow restraint: Piece of fabric with slots in which tongue blades are placed so that elbow joint remains rigid (see illustration).		Used with infants and children to prevent elbow flexion (e.g. when an IV line is in place).
		Step 8D Freedom elbow restraint. (Courtesy Posey Company, Arcadia, Calif.)
E. Mummy restraint: Blanket or sheet that is opened on bed or cot with one corner folded towards centre. Child is placed on blanket with shoulders at fold and with feet towards opposite corner (see illustration, 1). With child’s right arm straight down or secured against body, right side of blanket is pulled firmly across right shoulder and chest and secured beneath left side of body (see illustration, 2). Left arm is placed straight against body or secured, and left side of blanket is brought across shoulder and chest and locked beneath child’s body on right side (see illustration, 3). Lower corner is folded and brought over body and tucked or fastened securely with safety pins (see illustration, 4).		Maintains short-term restraint of small child or infant for examination or treatment involving head and neck. Effectively controls movement of torso and extremities.
		Step 8E Applying Mummy restraint
9. Secure restraints with a quick-release tie (see illustration).		Allows for quick release in an emergency.
10. Attach restraints to bed frame, which moves when the head of bed is raised or lowered (see illustration).		Patient may be injured if restraint is secured to side rail and it is lowered.
Critical decision point: Do not attach to side rails.
Step 9 Always use a quick-release tie to secure restraints. (Courtesy Posey Company, Arcadia, Calif.)		Step 10 Attaching restraint to bed frame.
11. Insert two fingers under the secured restraint (see illustration for Step 8B).		A tight restraint may cause constriction and impede circulation. Checking for constriction prevents neurovascular injury.
12. Every 30 minutes, proper placement of restraint and skin integrity, pulses, temperature, colour and sensation of restrained body part should be assessed.		Frequent assessment prevents complications, such as suffocation, skin breakdown and impaired circulation.
13. Restraints should be removed for 30 minutes every 2 hours. If patient is violent and non-compliant, remove one restraint at a time and/or have staff assistance while removing restraints. Patient should not be left unattended at this time.		Provides opportunity to change patient’s position and perform full range of motion (ROM).
14. Secure call bell or intercom system within reach.		Allows patient, family or caregiver to obtain assistance quickly.
15. Leave bed or chair with wheels locked. Bed should be in lowest position.		Locked wheels prevent bed or chair from moving if patient attempts to get out. If patient falls when bed is in lowest position, the chances of injury are reduced.
16. Inspect patient for any injury, including all hazards of immobility, while restraints are in use.		Patient should be free of injury and not exhibit any signs of immobility complications. Use of restraints should be seen as a temporary measure and discontinued as soon as possible (Stolley, 1995).
17. Observe IV catheters and urinary catheters to ensure that they are positioned correctly and that therapy remains uninterrupted.
18. Provide appropriate sensory stimulation and reorient patient as needed.		Use of restraints can further increase disorientation.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
Recording and reporting	Home care considerations
• Record patient behaviours that place patient at risk of injury, type of restraint applied, time restraints were applied and patient’s behaviour after restraints were applied. • Document specific assessments related to ventilation, skin integrity, musculoskeletal system and peripheral vascular integrity. • Describe patient’s response when restraints were removed. • Describe alternatives to restraints that were used and patient’s response.	• Plan care with family. • Instruct family (or other caregiver) in use of alternatives to restraints (see Box 15-6). • If physical restraints are necessary, instruct family (or other caregiver) in proper application and observation of possible complications related to restraint use. Also inform caregiver whom to contact if any abnormal findings occur. • A patient who needs to be restrained in bed should have a hospital bed and will require constant supervision in the home.

In keeping with current trends towards health promotion, improved assessment techniques and modifications of the environment are offered as alternatives to restraints. Fall prevention products available in Australia include the Secure Care Products Chair Tender and Bed Tender systems, which set off an alarm when the resident’s weight is removed from the chair or bed (there is also an optional incontinence sensor). For mobile residents who may wander, a range of monitoring systems is available, including the Dementia Care System, the Secure Care Products Wandering Resident I.D. and SmartLoc systems. The devices allow a zone of free movement. When the safe zone is exceeded, an alarm sounds. The alarm can be designed to signal at the central nurses’ station so that staff are alerted quickly when a patient is up and out of bed (Figure 15-11).

FIGURE 15-11 Patient wearing an Ambularm device.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Restraints are not limited to physical restraints and can include chemical restraint, aversive treatment and environmental restraint. Chemical restraint is the intentional use of medication to control a patient’s behaviour where there is no medical condition being treated, for example sedation. Aversive treatment is the use of unpleasant voice tone, commands or threats used in an attempt to alter undesired behaviours. It also includes the withholding of basic human needs such as food, clothing or warmth. Environmental restraint occurs when a person is confined to an area or restricted from accessing an area that is usually available to them. These types of restraints carry their own set of risks, and strict guidelines must be followed (Department of Health and Ageing, 2004).

SIDE RAILS

Side rails may help to increase a patient’s mobility and/or stability when in bed or when moving from bed to chair. Side rails also help prevent the unconscious patient from falling out of bed or from a stretcher (Figure 15-12). When side rails restrict a person’s mobility, they may be considered a restraint. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed may try to climb over the side rail or out at the foot of the bed. Such attempts usually result in a fall. Nursing interventions to reduce a patient’s confusion should first focus on the cause of the confusion. Often nurses mistake a patient’s attempt to explore the environment or to self-toilet as confusion. A focused comprehensive assessment is essential. Whenever side rails are used, the bed should be maintained in the lowest position possible.

FIGURE 15-12 Side rails in the up position on a stretcher.

Image: Shutterstock/REDAV.

FIRES

A fire is always possible in the home or hospital. Accidental home fires typically result from smoking in bed, placing cigarettes in garbage bins, grease fires or electrical fires resulting from faulty wiring or appliances. Institutional fires typically result from an electrical or anaesthetic-related fire, since few institutions now allow patients to smoke in their rooms (Box 15-8).

BOX 15-8 FIRE INTERVENTION GUIDELINES FOR NURSES WORKING IN AGENCIES

• Keep the phone number for reporting fires visible on the telephone at all times.

• Know the agency’s fire drill and evacuation plan.

• Know the location of all fire alarms, exits and extinguishers.

• Use the mnemonic RACE to set priorities in case of fire:

R. Rescue and remove all patients in immediate danger.

A. Activate the alarm. Always do this before attempting to extinguish even a minor fire.

C. Confine the fire by closing doors and windows and turning off oxygen and electrical equipment.

E. Extinguish the fire using an extinguisher (see Box 15-9).

The interventions described here are directed towards fires occurring in healthcare agencies, but the same principles apply to fires in the home (Box 15-9). All nurses in Australia are mandated to know the agency’s policies and procedures regarding fire and evacuation as a part of the Commonwealth Occupational Health and Safety and Safety, Rehabilitation and Compensation legislation (Commonwealth of Australia, 2006).

BOX 15-9 CLIENT TEACHING FOR CORRECT USE OF AN ALL-PURPOSE FIRE EXTINGUISHER IN THE HOME

OBJECTIVES

• Client will correctly place the extinguisher in the home.

• Client will describe when it is appropriate to use a home fire extinguisher.

• Client will demonstrate the correct technique when using a fire extinguisher.

• Client will state when fire extinguishers need to be replaced.

TEACHING STRATEGIES

• Discuss correct placement of the extinguisher. It is recommended that one be placed 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. The instructions should be read when the extinguisher is purchased and kept available for periodic review.

• Describe the steps to take before using the extinguisher. Attempt to fight the fire only when all occupants have left the home, the fire department has been called, the fire is confined to a small area, there is an exit route readily available, the extinguisher is the right type for the fire and the client knows how to use the extinguisher.

• Instruct the client to memorise the mnemonic PASS: Pull the pin to unlock handle, Aim low at the base of the fire, Squeeze the top handle or lever and Sweep the unit from side to side (see Figure 15-13).

EVALUATION

• Client can correctly place an extinguisher in the home.

• Client correctly lists the steps to take before attempting to use an extinguisher.

• Client demonstrates correct use of the extinguisher while reciting the instructions with the mnemonic PASS (see Figure 15-13).

Modified from National Safety Council (NSC) 2009 Home fire prevention and preparedness, factsheet. Itasca, IL, NSC. Online. Available at www.nsc.org/news_resources/Resources/Documents/Home_Fire_Prevention_and_Preparedness.pdf 21 Feb 2012.

Homes should be equipped with smoke and fire alarms. It is important to have a plan of action in the event of fire. Adults, and even young children, should be familiar with the phrase ‘stop, drop and roll’, which describes the actions to be followed when clothing and skin are burning.

If a fire occurs in a healthcare agency, the nurse protects patients from immediate injury, reports the exact location of the fire, and contains the fire and extinguishes it if possible. All personnel are mobilised to evacuate patients. Patients who are close to the fire, regardless of its size, are at risk of injury and should be moved to another area. If a patient is receiving oxygen but not life support, the nurse discontinues the oxygen, which is combustible and can fuel an existing fire. If the patient is on life support, the nurse may need to maintain the patient’s respiratory status manually with an Ambu-bag (see Chapter 40) until the patient is moved away from the fire. Mobile patients can be directed to walk by themselves to a safe area, and in some cases may be able to help move patients in wheelchairs. Bedridden patients are generally moved from the scene of a fire by stretcher, their bed or a wheelchair. If none of these methods is appropriate, patients must be carried from the area. If a patient must be carried, the nurse should be careful not to overextend physical limits for lifting, because injury to the nurse can result in further injury to the patient. If fire department personnel are on the scene, they can help evacuate patients.

After a fire has been reported and patients are out of danger, nurses and other personnel must take measures to contain or put out the fire, such as closing doors and windows, placing wet towels along the base of doors, turning off oxygen and electrical equipment and using a fire extinguisher. There are different types of fire extinguishers—dry powder, carbon dioxide, pressurised water and foam. Nurses should familiarise themselves with the use and purposes of each type; for example, most extinguishers are used upright but some must be inverted for use. Fire extinguishers must be inspected and replenished according to the schedule attached to each canister. (The correct use of an extinguisher is discussed in Box 15-9 and demonstrated in Figure 15-13.)

FIGURE 15-13 Correct use of a fire extinguisher: A, Pull the pin. B, Aim at the base of the fire. C, Squeeze the handles. Sweep from side to side to coat the area evenly.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

The best intervention is to prevent fires. Nursing measures include complying with the agency’s smoking policies and keeping combustible materials away from heat sources. Some agencies have fire doors that are held open by magnets and close automatically when a fire alarm sounds. It is important to keep equipment away from these doors.

POISONING

A poison is any substance that impairs health or destroys life when ingested, inhaled or otherwise absorbed by the body. Specific antidotes or treatments are available for only some types of poisons. The capacity of body tissue to recover from the poison determines the reversibility of the effect. Poisons can impair the respiratory, circulatory, central nervous, hepatic, gastrointestinal and renal systems of the body.

The toddler, preschooler, young school-age child and older adult must be protected from accidental poisoning. Using child-resistant caps, placing medications and cleaning fluids and powders out of the reach of children, leaving potentially poisonous materials in their original containers and removing poisonous plants from the home can prevent accidental ingestion of poisonous materials. Poisoning can result from swallowing miniature button or disc batteries commonly found in games, hearing aids, calculators and watches. In older adults, diminished eyesight and impaired memory may result in accidental ingestion of poisonous substances or in accidental overdose of prescribed medications. To prevent medication errors on the part of patients in the home, the nurse should recommend the use of medication organisers that are filled once a week by the patient and/or family. These organisers have the day and time on each box, so the patient knows when and what to take at any given time (Figure 15-14). This is particularly useful for patients who may forget whether they have taken their medications.

FIGURE 15-14 One type of medication organiser.

Image: iStockphoto/alblec.

Guidelines for intervening in accidental poisoning should be adhered to. The Poisons Information Centre phone number (13 11 26 in all states of Australia; 0800 764 766 or 0800 POISON in New Zealand) should be visible on the telephone itself in homes with young children. In all cases of suspected poisoning, this number should be called immediately (Box 15-10).

BOX 15-10 PROCEDURAL GUIDELINES FOR INTERVENTIONS IN ACCIDENTAL POISONING

1. Assess for airway patency, breathing and circulation (ABCs) in all patients in whom accidental poisoning is suspected.

2. Remove any visible materials from areas such as the mouth and eyes to terminate exposure.

3. Identify the type and amount of substance ingested, if possible. This may help to determine the antidote.

4. In Australia, telephone the Poisons Information Centre on 13 11 26 before attempting treatment. In New Zealand, telephone 0800 POISON (0800 764 766) before attempting treatment.

5. Do not induce vomiting unless instructed to do so.

6. If directed, save vomitus for laboratory analysis, which may assist with further treatment.

7. Position the victim with the head to the side to prevent aspiration of vomitus and help keep the airway open.

8. Never induce vomiting in an unconscious victim or in a patient experiencing convulsions, since aspiration may occur.

9. Never induce vomiting if any of the following substances have been ingested: acids, household cleaners, grease or petroleum products or furniture polish. Vomiting may exacerbate internal burns.

10. If instructed to take the victim to the emergency department, call an ambulance. Emergency equipment may be needed en route.

ELECTRICAL HAZARDS

Electrical equipment must be maintained in good working order and should be earthed, whether in the home or healthcare setting. In Australia and New Zealand, the third (longer) prong in an electrical plug is the earth (Figure 15-15). Theoretically, the earth prong carries any stray electrical current back to the earth; hence its name. The other two prongs carry the power to the piece of electrical equipment. Improperly earthed or malfunctioning electrical equipment increases the risk of electrical injury and fire, and therefore all electrical equipment should have a safety and quality seal and/or should be checked by an electrician, whether in the home or a healthcare setting. Educating both the patient and the family and healthcare staff can reduce the risk of electrical hazards in the home and healthcare environment (Box 15-11).

FIGURE 15-15 Three-pronged earthed plug.

Used with permission of HPM.

BOX 15-11 CLIENT TEACHING FOR PREVENTION OF ELECTRICAL HAZARDS

OBJECTIVE

• Client will recognise electrical hazards in the home and eliminate them.

TEACHING STRATEGIES

• Discuss earthing appliances and other equipment.

• Provide examples of common hazards: frayed cords, damaged equipment and overloaded outlets.

• Discuss guidelines to prevent electrical shocks:

– Use extension cords only when necessary and use electrical tape to secure the cord to the floor where it will not be stepped on.

– Do not run wires under carpeting.

– Grasp the plug, not the cord, when unplugging items.

– Keep electrical items away from water.

– Do not operate unfamiliar equipment.

– Disconnect items before cleaning.

EVALUATION

• Have client list electrical hazards existing in the home.

• Review steps the client will take to eliminate these hazards.

• Check the home after the client has had an opportunity to eliminate hazards.

Should a patient receive an electrical shock in the healthcare setting, the nurse should immediately turn off and disconnect the appliance if safe to do so, then determine whether the patient has a pulse. If the patient has no pulse, cardiopulmonary resuscitation (CPR) should be initiated and emergency personnel should be notified (see Chapter 40). If the patient has a pulse and remains alert and oriented, the nurse should quickly obtain vital signs and assess the skin for signs of thermal injury. The patient’s doctor must be notified.

If an electrical shock occurs in the home, the nurse follows the same procedure but has the patient go to the emergency department and then notifies the patient’s doctor.

SEIZURES

Patients who have experienced some form of neurological injury or metabolic disturbance are at risk of a seizure. A seizure involves a hyper-excitation of neurons in the brain, leading to a sudden, violent, involuntary series of contractions of a group of muscles. The patient often loses consciousness. Seizure precautions encompass all nursing interventions to protect the patient from traumatic injury, positioning for adequate ventilation and drainage of oral secretions, and providing privacy and support following the seizure (Skill 15-2).

SKILL 15-2 SEIZURE PRECAUTIONS

DELEGATION CONSIDERATIONS

Interventions for a patient who is experiencing a seizure cannot be delegated. The nurse must constantly assess the patient’s airway patency, adequacy of breathing and circulatory status. Clinical judgments must be made quickly, using the elements of critical thinking. Nurse assistants can remain with the nurse during a seizure, to obtain needed supplies and notify other personnel at the nurse’s request.

EQUIPMENT

• Oral airway

• Padding for side rails and headboard

• Suction machine, oral suction equipment

• Clean disposable gloves

STEPS	RATIONALE
1. Assess seizure history, noting frequency of seizures, presence of aura and sequence of events, if known. Assess for medical and surgical conditions that may lead to seizures or exacerbate existing seizure condition. Assess medication history.	This enables the nurse to anticipate onset of seizure activity. Seizure medications must be taken as prescribed and not stopped suddenly, as this may precipitate seizure activity.
2. Inspect patient’s environment (in a healthcare agency or in the home) for potential safety hazards if a seizure occurs.	Patient’s bed should be in its lowest position, with side rails padded and patient positioned in side-lying position when possible (see illustration).
Step 2 Position of patient following seizure and when on seizure precautions.
3. For patients with a history of seizures, an airway (see illustration), suction apparatus, clean gloves and pillows should be visible in the hospital setting for immediate use.	This ensures prompt, organised intervention.
	Step 3 Examples of airways.
4. When a seizure begins, position patient safely. If patient is standing or sitting at time of seizure, guide patient to floor and protect head by cradling in nurse’s lap or placing a pillow under head. Clear surrounding area of furniture. If patient is in bed, raise side rails, add padding and put bed in low position.	Protects patient from traumatic injury, especially head injury.
5. Provide privacy.	Embarrassment is common after a seizure, especially if the seizure was witnessed by others.
6. If possible, turn patient on side, with head flexed slightly forwards.	Prevents tongue and dentures from blocking the airway and promotes drainage of secretions, thus reducing risk of aspiration.
7. Do not restrain patient. Loosen clothing.	Prevents musculoskeletal injury.
8. Do not place any objects in patient’s mouth.
Critical decision point: Injury may result from forcible insertion of a hard object. Soft objects may break or come apart and be aspirated. Placing objects in the patient’s mouth could result in tooth loss, lacerations, stimulation of the gag reflex with vomiting and aspiration and respiratory distress (Roth and others, 2011).
9. Stay with patient, observing the sequence and timing of seizure activity.	Continued observation is necessary to ensure adequate ventilation during and following seizure activity. Accurate, specific observations will assist in documentation, diagnosis and treatment of the seizure disorder.
10. After the seizure is over, explain what happened and answer patient’s questions.	Informing patients of the type of seizure activity experienced will help them participate knowledgeably in their care.
Status epilepticus
11. For a patient experiencing status epilepticus, put on clean gloves and insert a Guedel airway (see illustration for Step 3) when the jaw is relaxed between seizure activity. Do not place fingers near or in patient’s mouth.	Prevents transmission of infection. Patient is in continual seizure state and requires oral airway to ensure airway patency.
12. Access oxygen and suction equipment. Prepare for IV insertion.	In this emergency patient requires adequate airway and IV access.
13. Use pillows/pads to protect patient from injuring self.	Traumatic injury will be avoided.
Recording and reporting	Home care considerations
• Record the timing of seizure activity and sequence of events. Record presence of aura (if any), level of consciousness, posture, colour, movements of extremities, incontinence and patterns of sleep following the seizure. • Document patient’s response and expected or unexpected outcomes.	• Communicate with patient and family to identify precipitating factors. • Teach family to care for the patient during a seizure. • Provide family with guidelines to detect status epilepticus. • Until a seizure condition is well controlled (usually for at least 1 year), the patient should not have a bath in a bathtub or engage in activities such as swimming unless a knowledgeable family member is present. Driving may also be restricted during this time. • Patient should wear a medical alert bracelet or tag and have an ID card noting the presence of a seizure disorder and listing the medications taken. • Referral to a support group may be indicated (see The EpiCentre website http://137.172.248.46/epilepsy.htm).

During a seizure a patient’s jaw muscles can become tense. It has been found that significant injury to the patient’s oral cavity is rare, even during the most violent seizures. Injury may instead occur from a caregiver forcing an object into the patient’s mouth and from the teeth biting down on a hard object. Soft objects may break in the mouth during a seizure and be aspirated, so avoid inserting objects into the mouth. The exception is in the case of status epilepticus, a medical emergency whereby a person has continual seizures without interruption. An adequate airway is maintained with an oral airway. Patients experiencing a seizure are never restrained but are placed on seizure precautions and need to be adequately protected from traumatic injury.