Famous Safety Precautions

• Assess skin integrity at least every 2 hours
• Remove restraints every 2 hours and provide ROM
• Tie restraints to the movable part of the bedframe (this always shows up on the NCLEX).
• Always use least restrictive alternative first

• No IVs, No BPs, & No Blood Draws on the arm with a mastectomy, a dialysis fistula/graft, an infected arm, or an arm with paralysis & weakness.
• Put a sign so people know! Use a wrist band.

• Any procedure with iodine dye/contrast, hold metformin 24 to 48 hours to prevent lactic acidosis.
• May start 48 hours after the procedure but only if kidney function is stable (good urine output, normal potassium, and creatinine/BUN wnl).

• Any eye surgery, move slowly and avoid bending over to prevent increased intracranial pressure and increased tension on eye suture lines. No bending forward!

•  May need one-on-one supervision for safety
• Put them close to the nursing station. Keep your enemies close and the confused closer.
• Remember that confused elderly clients may have pneumonia, UTIs, or any kind of infection. Confusion in the elderly: think infection!
• Delirium: Confusion and disorientation. Delirium is reversible (unlike alzheimer’s dementia). Find the cause and fix it. Most of the time may be due to an infection.

• Do not administer anticoagulants. No Fondaparinux, No Warfarin, No Heparin, No enoxaparin, No dalteparin (low molecular heparin) because of the risk of bleeding.

• Epiglottitis! Drooling!
• #1 intervention: Airway. Place in tripod position (bend forward with arms/hands on knees).
• No throat cultures to prevent airway obstruction
• No anxiety provoking interventions.  Wait to insert an IV.  Keep calm.
• Again, no visual inspection

• Blurry spot in the middle or loss of central field of vision. Peripheral vision is intact = macular degeneration. M Middle M Macular
• Small flashes of light = retinal detachment
• Inability to see things close up= presbyopia. Occurs with aging due to loss of elasticity of lense.  The elderly person is unable to adjust to near and far vision.
• Poor peripheral vision = Tunnel vision from optic nerve damage seen in glaucoma

• An IV infiltration is a priority concern, especially if it is a chemotherapy drug.  Infiltration can cause tissue necrosis. 
• Monitor for swelling, coolness, pain, skin changes, leakage, or decreased IV flow.

• ABC PRIORITY. Airway is always first. Priority problems: grunting, noisy breathing, neck surgery, facial burns, smoke inhalation, ventilator alarm or drooling.

• A client gains 2 lbs in 24 hours, notify HCP. 
• Weigh daily to catch exacerbations on time. Weigh at the same time. Before breakfast is the best time.
• Give diuretics: furosemide, bumetanide
• Left-sided heart failure think lung symptoms: dyspnea, cough, orthopnea.
• Right-sided heart failure, think the rest of the body such as hepatomegaly or edema.

To prevent ventilator-acquired pneumonia:

• Elevate HOB
• Oral care and aspiration of subglottic secretions
• Keep endotracheal cuff pressure > 20 mm Hg
• Oral antiseptics such as chlorhexidine mouthwash
• Sedation vacations

• Take a moment to think what is EXPECTED of the disease process and what is an UNEXPECTED finding that needs to be reported to the physician.
• Peritonitis: ↑ WBC IS expected
• An elevated BUN/creatinine is EXPECTED in renal failure.
• An elevated potassium is NEVER expected because high potassium can kill!

• Monitor for bleeding.
• Place on bleeding precautions.
• Question anticoagulants such as aspirin, enoxaparin, coumadin or heparin. 

• Never have a clean patient with a patient that requires isolation in the same room.
• Never have two patients with different organism in the same room.
• Same organism ok, even if in different places of the body.
• Everyone is on standard precautions.
• Never room in two clients with cystic fibrosis even if they have the same organism.  They may have different strains of bacteria.

• The corticosteroid inhalers are not rescue inhalers. Only short acting such as albuterol are used for rescue.  Pay attention to this because they will try to confuse you.  If a client is having an asthma attack, give them their albuterol!
• Rinse mouth well after using steroid inhaler (e.g., beclomethasone. Usually end with -sone) and do not swallow water to prevent oral candida.

• Wheezing, dyspnea, throat swelling are dangerous signs in any allergic reaction

• Give IV meds since they work faster.
• Not IM or SC in clients with burns. Only IM should be a tetanus shot.
• Burns: the priority is to give lactated ringers.  Hydration
• Burn clients are hypovolemic and at risk for renal failure. 
• Of course, we are talking about severe burns.

• Do not have one if you have metal: aneurysm clips, pacemaker, and retained metal in the body.
• A client with a pacemaker who is going to MRI is almost always the priority client!  Stop it!

• Always safety first. Protect from suicide/hurting others
• Set limits
• Establish trusting relationship
• Use least restrictive environment
• If a client has hallucinations, redirect them. If a client has delusions, distract them. 

• No live vaccines, no fresh fruits, no flowers, but the MOST important is handwashing.
• If you have an infection control question, always go for handwashing as the answer, especially if you are not sure.