Factors Affecting Safety

People’s ability to protect themselves from injury is affected by such factors as age and
development, lifestyle, mobility and health status, sensory–perceptual alterations, cognitive awareness,
emotional state, ability to communicate, safety awareness, and environmental factors. Nurses need to
assess each of these factors when they plan care or help clients learn to protect themselves.

Age and Development

The age-dependent cognitive, psychological, language, and physical changes that occur across
the lifespan influence an individual’s ability to identify, anticipate, prevent, and recover from a range of
health risks. Consider the following examples: Toddlers and preschool-age children are attracted to
bodies of water but generally lack the ability to sense danger. This, compounded by the fact that a top-
heavy physique makes them more prone to falling into the water, places them at high risk for drowning.
Very young children can easily sustain burns if exposed to very hot water (greater than 49°C), as their
dermis is thin. The adolescent, whose thoughts usually include the personal fable, may believe that he
or she is immune to adverse outcomes when engaging in risky behaviour. In older adults, the
combination of reduced reflex activity and diminished sensory acuity can lead to increased risk of falling.

Lifestyle

Lifestyle factors that place people at risk include unsafe work environments; living in
neighbourhoods with high crime rates; access to firearms; abuse of alcohol and illicit drugs, which may
be contaminated by harmful additives; and lack of income to buy safety equipment (e.g., car seat).

Mobility and Health Status

People with impaired mobility related to paralysis, muscle weakness, or poor balance or
coordination are at increased risk of injury. People with paraplegia may be unable to move even when
they perceive discomfort, and those with peripheral neuropathy (an unfortunate yet relatively frequent
complication of diabetes mellitus) may not even perceive discomfort and thus sustain injury or skin
breakdown. People with hemiplegia and those with leg casts often have poor balance and fall easily.
Clients weakened by illness or surgery may not be fully aware of their limitations, which places them at
risk for falls or other injury.

Sensory–Perceptual Alterations

Accurate sensory perception of environmental stimuli is vital to safety. People with impaired
perception of touch, hearing, taste, smell, and vision are highly susceptible to injury. A person who does
not see well may trip over an object; a person with hearing impairment will not hear a siren in traffic;
and people with anosmia (impaired olfactory sense) may not smell burning food or the odour of a gas
leak.
 Cognitive Awareness

Awareness is the ability to perceive environmental stimuli and physical reactions and to respond
appropriately through thought and action. Clients with impaired awareness include people lacking sleep,
unconscious or semiconscious persons, disoriented people who may not understand where they are or
what to do to protect themselves, people who imagine nonexistent stimuli, and people whose judgment
is altered by disease or medications (e.g., opioids, tranquilizers, hypnotics, and sedatives).

Emotional State

Extreme emotional states can alter the ability to perceive environmental hazards. Stressful
situations can reduce a person’s level of concentration, cause errors of judgment, and decrease
awareness of external stimuli. People with depression may think and react to environmental stimuli
more slowly than usual or may be considering suicide (a leading form of intentional injury).

Ability to Communicate

Individuals with diminished ability to receive and convey information are at risk for injury. They
include people with aphasia (loss or impairment of the power to use or understand words, usually
resulting from brain damage), people with language barriers, and those unable to read. For example, the
person unable to interpret the sign “No smoking: oxygen in use” could cause a fire or an explosion.

Safety Awareness

Information about water safety, car safety, fire prevention, and the many age-specific hazards
and their preventive measures is crucial to safety. Clients in unfamiliar environments (e.g., hospital) or
dealing with new treatments (e.g., oxygen therapy, hot packs) frequently need specific safety
information.

Environmental Factors

Depending on the client’s situation, the nurse may need to assess the environment of the home,
workplace, or community. While clients generally seek out the health care setting to improve their
health, client safety may also be adversely affected by the health care setting environment, including
health care in the home.

Home A safe home requires, among many things, wellmaintained floors and carpets, a nonskid
bathtub or shower surface, strategically placed and functioning smoke alarms and carbon monoxide
detectors, and fire escape routes that residents are aware of. Outdoor areas, such as swimming pools,
need to be safely secured and maintained. Adequate lighting, both inside and out, will minimize the
potential for unintentional injury. Families living on farms are exposed to particular risks, as their homes
are also workplaces, where heavy equipment, large vehicles, open water, and animals are often present.

Workplace A range of chemical, biological, physical, ergonomic, and psychosocial hazards exist
in the workplace. Workers exposed to temperature extremes, those who lack adequate training on the
use of mechanical equipment, or those who are the victims of sexual harassment or discrimination in
the workplace are all at risk for ill health. Young, new workers, and migrant or immigrant workers are
employed in disproportionate numbers in physically demanding or hazardous jobs, which places them at
higher risk for workplace injuries and illnesses (Canadian Centre for Occupational Health and Safety,
2015). The work environment of the nurse includes risks to safety, such as exposure to microbial agents,
musculoskeletal injury related to moving patients, and potentially aggressive clients.

Community Adequate street lighting; safe water and sewage treatment; restrictions on
pollution, including smoke-free environments; and regulation of consumer products and sanitation in
food buying and handling all contribute to a healthy, hazard-free community. A safe and secure
community strives to be free of excess noise, crime, traffic congestion, poor-quality housing, or
unprotected creeks and landfills. Communities rely on coordinated local, provincial, and national
emergency preparedness and response resources when the safety of communities at large is at risk,
such as in the event of natural events and disasters (e.g., floods, forest fires, earthquakes, fires, and
highly dangerous infectious diseases) and accidents or criminal and terrorist acts involving explosives,
chemicals, radioactive substances or biological materials.

Health Care Setting, Including Home Care Safety issues within the Canadian health care setting
have come to the forefront since the release of the Canadian Adverse Events Study (Baker et al., 2004)
indicating that a high number of hospitalized patients (1 in 13) can experience adverse events, including
death, with many of these events deemed preventable. With reports of numerous patients (1 in 10)
harmed while receiving hospital care, the World Health Organization (WHO) has declared patient safety
a serious global public health issue (WHO, 2014).

Safety problems in the health care setting can arise from acts of omission (failure to institute the
appropriate therapeutic intervention), such as lack of assessment to predict risk of falls or lack of
discharge teaching, or acts of commission (incorrect diagnosis or treatment, or poor performance), such
as errors in medication dosage, wrong-site surgery, restraint-related injuries or death, burns, mistaken
identity, and health care-associated infection. Multiple factors can contribute to errors, such as a gap
between the increased complexity of care in health care settings and outdated communication systems,
poor product design, a shortage of qualified health care personnel, dysfunctional communication
patterns among health care professionals, poor quality of the nursing practice environment, ineffective
nursing staffing and skill mix, among others. Client safety is viewed as going beyond placing the blame
on individual professionals to looking at the multiple system factors and their complex interplay that
ultimately influences whether patient safety is ensured.

Effective interprofessional communication and collaboration also promote client safety and
quality assurance in health care, and thus many professional schools have tried to develop opportunities
for nursing students and other students in the health care professions to learn with, from, and about
each other—all in an effort to improve patient safety.

Client safety concerns also occur in home care situations. Family members, friends, and informal
caregivers under the indirect supervision of medical personnel are taking on complex care, such as
administering intravenous antibiotics, caring for a partner who is paralyzed, helping a family member
recover from a major surgical intervention, or caring for a family member who is dependent on a
respiratory ventilator. The seminal work Safety at Home: A Pan-Canadian Home Care Study (Canadian
Patient Safety Institute, 2013) revealed that individuals receiving home care experienced adverse events
at an annual rate of 10% to 13%, with over half such events deemed preventable; thus people receiving
care at home are as vulnerable to care-associated injury as those receiving care in the hospital. The
safety of caregivers in families may also be at risk as they take on difficult tasks, such as lifting heavy
equipment or moving their family member in and out of bed or a bath. (See Evidence-Informed Practice
box for further discussion related to safety at home)

Evidence-Informed Practice

What Are the Major Patient Safety Issues in Home Care in Canada?

The Canadian Patient Safety Institute funded a study that explored, for the first time in Canada,
issues related to patient safety in home care. As in the case of those receiving care in the hospital
setting, people receiving home care are experiencing high rates of adverse events (13%) with over half
(56%) such events deemed preventable. The main types of adverse events identified are falls,
medication incidents, and infections (mostly occurring in the first 30 days of receiving home care).
Interviews with clients and their caregivers revealed six themes: (1) the unacknowledged challenge of
providing health care in a private home; (2) a fragmented system of home health care delivery; (3)
“creeping” increases in care that unpaid and untrained caregivers must provide in spite of their own
health challenges; (4) “rationing” of oxygen concentrators, especially for people with chronic obstructive
pulmonary disease (COPD), and the subsequent impact on quality of life; (5) clients “doing what it takes”
to be able to stay home—sometimes to the point of hiding their needs; (6) and the decline in the health
of caregivers (often seniors).

Nursing Implications: As more and more health care is shifted into the home setting, nurses
must be aware of the challenges and risks placed on the clients and caregivers in this setting. This study
indicates a fine balance between the benefits and client wishes of staying at home and the risks to
clients and their caregivers. Nurses who work in home care can advocate for better training of lay health
care providers and can influence policymakers on such matters as the need for improved intersectoral
collaboration (e.g., between home care and institutional care); an integrated approach to home health
care (rather than letting caregiver “duty creep” happen); improvements in medication packaging and
equipment for lay users; and improved utilization of risk assessment tools.

Assessing

Assessing clients at risk for unintentional injury involves (a) noting pertinent indicators in the
nursing history and physical examination, (b) using specifically developed risk-assessment tools, (c)
evaluating the client’s home environment, and (d) assessing standards related to patient safety goals in
hospitals.

Nursing History and Physical Examination

 The nursing history and physical examination can reveal considerable data about the client’s
safety practices and risks for injury. Data include age and developmental level; general health status;
mobility status; presence of physiological or perceptual deficits, such as olfactory, visual, tactile, taste, or
other sensory impairments; altered thought processes or impaired cognitive or emotional capabilities;
problematic substance use; indications of abuse or neglect; and a history of unintentional injury. A
safety history also includes the client’s awareness of hazards, knowledge of safety precautions at home
and at work, and any perceived threats to safety (Figure 32.1).

Risk-Assessment Tools

Risk-assessment tools are available to determine which clients are at risk for specific kinds of
injury, such as falls, or for the general assessment necessary to keep clients safe in their homes and in
health care settings. In general, these tools direct the nurse to appraise multiple factors affecting safety.
The tools summarize specific data contained in the client’s nursing history and physical examination.
Client risk factors and environmental hazards for falls are discussed later in this chapter.

Home Hazard Appraisal

Hazards in the home are major causes of falls, fire, poisoning, suffocation, and other incidents,
such as those caused by improper use of household equipment, tools, and cooking utensils.

National Patient Safety Goals

Accreditation Canada plays a major role in improving patient safety through the accreditation of
Canadian health services organizations. The accreditation program evaluates how organizations meet
standards of excellence in ensuring patient safety and providing quality services relative to meeting six
Required Organizational Practices (Accreditation Canada, 2016):

1. Safety culture, as evidenced by such indicators as a documented and coordinated

approach to disclosing patient safety incidents to clients and families
2. Communication (effective information transfer with clients and team members across
the continuum of care), as evidenced by such indicators as the following:
 Clients and families are informed about their role in promoting safety, with staff
taking client or family questions or comments about potential error seriously
 Not using dangerous abbreviations, symbols, and dose designations so as to
avoid medication errors (see Chapter 33)
 Effective mechanisms for transfer of information at care transition points, such
as change of shift, transfer between units or institutions, and discharge home
 Reconciliation of clients’ medications at admission and transfer or discharge
(discussed in detail in Chapter 33)
 A safe-surgery checklist used to confirm safety steps during surgical procedures
(see Chapter 36)
 Clients properly identified using two person-specific indicators before any
service or procedure (Practice Guidelines 33.1 in Chapter 33)
3. Ensuring the safe use of medications, as evidenced by the following indicators:
 Absence of concentrated electrolytes (e.g., potassium chloride ≥2 mmol/L,
sodium chloride >0.9%) from client service areas
 A limited number of heparin concentrations being available on the care unit,
with high-dose formats (e.g., unfractionated heparin 10 000 U/mL) provided
only on a client-specific basis (i.e., not as a stocked medication)
 Adequate and ongoing training for staff on the use of all infusion pumps
 High-alert medications (e.g., insulin, opioids, sedatives, antithrombotics) are
managed effectively (see Chapter 33 for further discussion)
 High-dose, high-potency opioids are removed from patient care units (Chapter
33 provides an in-depth discussion on safety with respect to medications) •
Antimicrobial stewardship that includes appropriate selection, dosing, route,
and duration of antimicrobial therapy.
4. Creating a work life and physical environment that supports the safe delivery of care
and service, as evidenced by the following:
 Training on client safety for all staff
 Staff having a clear understanding of the roles, responsibilities, and
accountabilities of the health team members in relation to the care and safety
of patients or clients Preventive maintenance programs for medical devices,
medical equipment, and medical technology
 Comprehensive strategy to prevent workplace violence
5. Reducing the risk of health care-associated infections and their impact across the
continuum of care and service, as evidenced by the following:
 Ongoing evaluation of compliance with hand-hygiene practices for staff, service
providers, and volunteers
 Adherence to international, federal, and provincial or territorial infection
control guidelines
 Tracking and analysis of health care-associated infections
 Implementation of protocols to ensure the administration of the
pneumococcal vaccine
 Monitoring of processes for reprocessing (cleaning, disinfecting, sterilizing)
equipment
6. Identifying safety risks inherent in the client population, as evidenced by the following:
 Falls-prevention strategy
 Safety risk assessment for clients receiving services in the home
 Assessment of risk for developing pressure injury, with implementation of
interventions to prevent pressure injuries
 Use of an interprofessional and collaborative approach to assess clients who
need skin and wound care and provision of evidence-informed care that
promotes healing and reduces morbidity and mortality
 Assessment and monitoring of clients for risk of suicide
  Identification of clients at risk for venous thromboembolism (pulmonary
embolism and deep vein thrombosis) with provision of appropriate prevention
strategies

Accreditation Canada focuses on system-wide indicators of safety, marking a shift from the
method of finding out who made any particular error (i.e., creating an environment of fear and
scapegoating) to analyzing the system to find out why any particular error occurred (i.e., creating an
environment of learning and improvement).

Diagnosing

Given the broad range of safety issues facing individuals, families, and communities, a large
number of nursing diagnoses of potential risks can be made in relation to safety.

Any of the following, and many more, are possible analyses: risk for poisoning related to lack of
childproofing the home environment; risk for suffocation related to stuffed animal toys and an
improperly fitted mattress in the crib; risk for fall related to polypharmacy, muscle weakness, and unsafe
home environment; risk for unintentional injury related to incorrect car seat choice and improper
installation; risk for scalding related to high hot water temperature and reduced peripheral sensory
apparatus; and risk for drowning related to lack of proper safety proofing of the pool area and
inadequate supervision during bath time. Strength-based diagnoses could include the following:
motivated family seeking to learn injury prevention strategies; falls-prevention strategies implemented
throughout the home; and accurate and effective anticipatory childproofing of the home in relation to
increased mobility of the toddler.

Planning

Nurses must use their knowledge about the predictable and contributing factors related to
unintentional injury as they plan for client care. Nurses can help individuals and families anticipate risks
for injury in relation to changing developmental skills and demands and help them minimize or eliminate
the risks. The major goal for clients with safety risks is to prevent unintentional injury.

Nursing interventions to meet desired outcomes are largely directed toward helping the
individual and family do the following:

 Identify and remove or reduce environmental hazards in the home, workplace,

community, and health care agency
 Demonstrate safety practices appropriate to the home, health care agency,
community, and workplace
 Experience absence of injury or, at least, a decrease in the frequency or severity of
injury
 Demonstrate safe childrearing practices or lifestyle practices

Implementing
Promoting Safety across the Lifespan

Hazards to safety are encountered at all ages and vary according to the age and developmental
level of the individual. Measures to ensure the safety of people of all ages focus on (a) observation or
prediction of potentially harmful situations so that harm can be avoided and (b) health teaching that
promotes wellness by empowering clients and families to protect themselves from injury. Safety
measures covering the lifespan from infancy to older adults are listed in the Teaching: Wellness box.

Newborns and Infants Infants are completely dependent on others for care and are oblivious to
such dangers as falling or ingesting harmful substances. Parents need to learn the amount of
observation necessary to maintain infant safety. They must continually anticipate risks and identify and
remove common hazards in and around the home. Parents must learn first aid, including interventions
for airway obstruction and cardiopulmonary resuscitation (CPR). The leading causes of death related to
injury in children age younger than 1 year of age are suffocation, followed by motor vehicle traffic
collisions (PHAC, 2013a). Education and support of parents can help them become knowledgeable and
better prepared to protect their children.

Toddlers Toddlers are curious and like to feel and taste everything. Their rapidly changing
mobility skills, from crawling to walking to running, mean that they can gain access to physical locations
they were not able to reach as infants. They are fascinated by potential dangers, such as pools and busy
streets, so they need constant supervision and protection. For this age group, motor vehicle traffic
collisions are the leading cause of deaths from unintentional injury, followed by drowning and
suffocation (PHAC, 2013). Parents can prevent many injuries by toddler-proofing the child’s
environment. This practice extends to using proper car restraints, promoting a safe environment to
avoid falls, ensuring water safety, and removing or securing all items that can pose a safety hazard to
the child.

Preschoolers Preschool-age children are active and sometimes clumsy, which makes them
susceptible to injury. Environmental control continues during this stage, keeping hazards, such as
matches, medicines, and other hazardous substances, out of sight and reach. Safety education includes
learning how to cross streets and how to ride bicycles safely. Children must be cautioned to avoid
known hazards, such as swimming without adult supervision. Parents must maintain careful surveillance
as the developmental level of the preschooler does not allow for self-reliance in matters of safety. For
example, telling a preschooler to stay away from the pool when no one is around cannot replace a
latched enclosure in promoting the child’s safety. The preschool-age child’s cognitive and motor skills
develop quickly; hence, safety measures must keep up with the acquisition of new skills.

School-Age Children By the time children begin to attend school, they are learning to think
before they act and must make safety decisions on their own, as they are away from the constant
supervision of parents and caregivers. They want to play with other children and engage in such
activities as bicycling, swimming, and skating. Although sensitive to peer pressure, the schoolage child
generally follows rules. Motor vehicle traffic collisions are the leading cause of unintentional death in
this age group, followed by drowning among boys and falls among girls (PHAC, 2013b).
 Adolescents Obtaining a driver’s licence can be an important event in the life of an adolescent,
but the privilege comes with many risks. Motor vehicle collisions remain the leading cause of death and
disability among Canadian teenagers. Because teens lack driving experience and may use driving as an
outlet for stress and as a way to assert independence or to impress peers, parents need to assess the
teenager’s level of responsibility, problem solving, and ability to resist peer pressure as they determine
driving privileges. The age of the teenager alone does not determine readiness to handle this
responsibility. Adolescents are at risk for sports injuries because their coordination skills are not fully
developed. However, sports activities are important to the adolescent’s self-esteem and overall
development so all efforts must be made to provide protective equipment and foster safe play. Young
workers have been identified as a particularly high-risk group for traumatic occupational injuries in
Canada. Part-time employment status, lack of preparation and education in workplace risks, eagerness
to please, and viewing aches or pain simply as part of the job can all contribute to occupational injuries.
Parents can coach their adolescents to ensure that they get the necessary safety training specific for
their jobs.

The adolescent’s mental health may give rise to safety concerns related to suicide risk.
Economic deprivation, family breakup, depression, being a victim of bullying, and access to firearms are
factors that can influence the suicide rate in this age group. Concerns about potential suicidal risk should
be referred to a mental health professional or a crisis centre.

Clinical Alert

Many families are not aware that car seats have expiry or useful-life dates, generally between 6
and 8 years. Car seats should not be used past these dates, and it is advisable to permanently discard car
seats, rather than donating or giving them to friends or relatives.

Young Adults

Motor vehicle collisions are the leading cause of mortality for this group followed by suicide
(PHAC, 2013); other causes of death from unintentional injury include drowning (especially men), burns,
poisonings, and firearms. Exposure to natural radiation from sunbathing or outdoor activities is a safety
hazard for many young adults. Suicide is another leading cause of death in this age group, and it is
thought that many suicides are mistaken for accidental death (e.g., automobile accidents, drug
overdoses). As with adolescents, the prevention of suicide includes identifying behaviours that indicate
potential problems: depression, decreased interest in previously pleasurable activities, and an increase
in isolation. A young adult identified as being at risk for suicide should be referred to a mental health
professional or a crisis centre.

Middle-Aged Adults Changing physiological factors, as well as preoccupations with personal,

family, and work-related responsibilities, may contribute to the accident rate of middle-aged persons.
Motor vehicle collisions are the most common cause of death from unintentional injury in this age
group. Decreased reaction times and decreased visual acuity can make the middle-aged adult prone to
accidents. Other causes of death related to injury in this age group include falls, burns, poisonings, and
drowning. Occupational accidents continue to be a significant safety hazard during the middle years.
 Older Adults Injury prevention is a major concern with regard to older adults. For some,
climbing stairs, driving a car, and even walking require caution because vision is limited, reflexes are
slowed, and bones are brittle. Driving, particularly at night, requires caution because the
accommodation of the eye to light is impaired and peripheral vision is diminished. Older adults need to
learn to turn their head before changing lanes and should not rely on side vision, for example, when
crossing a street or changing lanes.

Fires are a hazard if memory problems are present; appliances may be left on or cigarettes may
not be extinguished. Because of reduced sensitivity to pain and heat, care must be taken to prevent
burns when bathing or using heating devices. People at risk for wandering because of organic brain
syndromes need to wear identification devices. They can also be registered with the local Alzheimer
Society of Canada’s Safely Home program.

Impairment of temperature regulation in the older adult can increase the risk of hypothermia
and hyperthermia. Reduced renal function increases the risk of toxicity from medications (e.g., the older
adult who takes analgesics or sedatives may become lethargic or confused). The nurse must teach older
clients about the importance of taking only prescribed medications and about reporting use of over-the-
counter (OTC) medications because they can influence the pharmacokinetics and/or pharmacodynamics
of prescribed medications.

A home environment that was previously safe may need modifications for the older adult to
prevent injury. A plan and the telephone numbers of those to call should be available for emergency
situations.

Unfortunately, the incidence of suicide in older adults, especially men, is increasing (Statistics
Canada, 2012). It often goes unnoticed when the causes are starvation, overdosing with medications,
and noncompliance with the medical treatment plan. Factors that have been linked to suicide risk in
older adults are uncontrollable pain, loss of a loved one, major life changes, major depression, and social
isolation. Unlike other age groups, older adults rarely threaten to commit suicide; they just do it .

Safety Problems across the Lifespan

Domestic violence is a safety concern involving individuals of all ages. It includes child abuse,
intimate partner abuse, and abuse of older adults, and it affects the health and safety of families and the
community. Statistics are likely inaccurate because of the underreporting of incidents. Nurses should be
involved in working with all phases of domestic violence: prevention, screening, referrals for treatment,
and follow-up care. Situations of domestic violence usually necessitate interprofessional collaboration
among the health care team, law enforcement agencies, and other community agencies.

Safety in the Health Care Setting

Health care agencies across Canada have rallied to address client safety, and national
organizations, such as the Canadian Patient Safety Institute, Patients for Patient Safety Canada, and the
Institute for Safe Medication Practices Canada, play an active role in advocating for safety in the health
care setting. The basis for the provision of safe nursing care is addressed in a number of chapters in this
book (e.g., Chapter 33 addresses safe medication administration practices, and Chapter 34 focuses on
nursing care to minimize health care–associated infection). Beyond learning specific details of direct
nursing care and knowing the Accreditation Canada safety goals (see page 765), nurses can work to
ensure that they meet national patient safety competencies identified by the Canadian Patient Safety
Institute (2015):

 Contribute to a culture of patient safety. A commitment to applying core patient safety

knowledge, skills, and attitudes to everyday work.
 Work in teams for patient safety. Working within interprofessional teams to optimize
patient safety and quality of care.
 Communicate effectively for patient safety. Promoting patient safety through effective
healthcare communication.
 Manage safety risks. Anticipating, recognizing, and managing situations that place
patients at risk.
 Optimize human and environmental factors. Managing the relationship between the
individual and environmental characteristics to optimize patient safety.
 Recognize, respond to, and disclose adverse events. Recognizing the occurrence of an
adverse event or a “close call” and responding effectively to mitigate harm to the
patient, ensure disclosure, and prevent recurrence.

Preventing Specific Hazards

Implementing measures to prevent specific hazards or unintentional injuries, such as scalds and
burns, fires, falls, poisoning, suffocation, and electrocution, is a critical aspect of nursing care. Nurses
have many opportunities and responsibilities to implement health teaching about a range of known
safety hazards.

Scalds and Burns A scald is a second-degree or thirddegree burn caused by a hot liquid or
vapour, such as steam. A burn results from excessive exposure to thermal (scald, flame, contact),
chemical, electric, or radioactive agents.

Examples of home hazards that can cause scalds include pot handles that stick out over the edge
of a stove, electric appliances (used to heat liquids or oils) with dangling cords, and excessively hot bath
water. Use of stove guards and cord attachment devices along with diligent efforts at turning pot
handles in can help promote safety in the kitchen. Hot water tanks (except electric water heaters)
should be set at no more than 49°C* (or set at Warm or Medium if there is no temperature reading) to
avoid scalds from tap water (Parachute Canada, 2015). Unfortunately, the majority of water tanks in
Canadian homes are set at 60°C, the temperature at which a person can sustain a third-degree burn
within 1 to 5 seconds! Lowering the risk of scalds from tap water must be balanced with the risk of
bacterial growth in water tanks (i.e., lowering gas and oil-fired water heaters below 49°C or electric
water heaters below 60°C), which can lead to the growth of the bacterium Legionella that causes
legionnaires’ disease.
 Fires Fires are a risk in both health care settings and homes. Agency fires usually result from
malfunctioning electrical equipment or combustion of anesthetic gas. Home fires most frequently result
from careless disposal of burning cigarettes or matches, from grease, or from faulty electrical wiring.

Agency Fires In health care agencies, fire is particularly hazardous when people are
incapacitated and unable to leave the building without assistance. It is extremely important for nurses to
be aware of the fire safety regulations and fire-prevention practices of the agency in which they work.
When a fire occurs, the nurse follows four sequential priorities that can easily be remembered by using
the mnemonic RACE:

R Rescue and Remove persons who are in immediate danger.

A Activate the fire alarm, and call for help.

C Contain or Confine the fire and smoke (e.g., close doors).

E Extinguish the fire, if possible; otherwise Evacuate.

Extinguishing the fire requires knowledge of four categories of fire, classified according to the
type of material that is burning:

*The Asthma Society of Canada recommends that clothing and bedding be washed in water at
least 55°C to kill dust mites and their allergens. Instead of using very hot water, several other options
should be considered. A dust mite control additive can be used in a low-temperature wash. Dust mites
will also be killed by drying fabrics at a high setting for 1 hour.

 Class A: Ordinary combustibles (e.g., paper, wood, upholstery, rags, rubbish)

 Class B: Flammable and combustible liquids (e.g., gasoline, natural gas)
 Class C: Electrical material (e.g., electrical wiring, equipment, fuse box)
 Class D: Combustible metals (e.g., potassium)

The right type of extinguisher must be used to fight the fire. Extinguishers have picture symbols
showing the type of fire for which they are to be used. Directions for use are also attached. The nurse
uses the mnemonic PASS when using a fire extinguisher:

P Pull out the extinguisher’s safety pin

A Aim the hose at the base of the fire

S Squeeze or press the handle to discharge the material onto the fire

S Sweep from side-to-side across the base of the fire until the fire is out

Home Fires Nursing interventions for home fires focus on teaching fire safety, including the
following:
  Keep lighters and matches out of reach of children, have regular inspections of electrical
systems, and adopt a no smoking policy (especially in bed or on the couch).
 Keep emergency numbers near the telephone or stored for speed dialling.
 Ensure that smoke alarms and fire extinguishers are operable and appropriately located.
 Test smoke alarms monthly and change batteries annually (or more often if required) (if not
hardwired) and change alarms every 10 years (Fire Prevention Canada, 2015). Choosing
special days, such as birthdays or the days the clocks change for daylight savings time, can
help people remember this important safety measure.
 Have a family fire drill plan aimed at evacuating the home. In the event of a fire, close the
windows and doors, if possible; cover your mouth and nose with a damp cloth when exiting
through a smoke-filled area; and avoid heavy smoke by assuming a bent position with the
head as close to the floor as possible.

Falls A fall is an unexpected event in which the person comes to rest at a lower level (e.g., the
ground or the floor), with or without injury. People of any age can fall, but infants, toddlers, and older
adults are particularly at risk for falls that cause serious injury. Falls are the leading cause of
unintentional injuries among older adults, especially women. The most common complication of a fall in
an older person is a fractured bone (generally the femur or hip), and attention must be given to the risk
of developing a traumatic brain injury (especially with falling forward and hitting the head). Falls can
even lead to permanent disability and death (PHAC, 2014). Falls in older adults are linked to multiple
modifiable and nonmodifiable biological or intrinsic, behavioural, environmental, and socioeconomic
factors (PHAC, 2014).

Biological or intrinsic factors include gait deficit; muscle weakness; impaired balance or mobility;
vision problems, such as reduced acuity, difficulty accommodating to light and darkness; cognitive
impairment; chronic illness, such as arthritis, cerebrovascular accident (stroke), and Parkinson’s disease;
and acute illness events.

Behavioural factors include a history of falls; fear of falling, which can lead to tension and
stiffness, making the person more susceptible; risk-taking behaviour, such as not heeding warnings of
risk; taking culprit medications, such as antihypertensive agents or diuretics, that can lead to orthostatic
hypotension or cardiac syncope, and sedatives and hypnotics (e.g., benzodiazepine); polypharmacy
(taking five or more medications); excessive alcohol intake; and inappropriate footwear (e.g., poor
fitting, slippery footing), clothing (can cause tripping or can get caught on objects or in doorways), and
handbags (can cause imbalance or get caught in doorways).

Environmental factors include uneven or excessively high or narrow stairs; stairs with unmarked
edges; lack of hand railings or poorly fitted hand rails; walking surfaces that are wet or snowy or icy; and
in-home factors, such as lack of grab bars, inadequate lighting (too dark or too bright), clutter, and
presence of scatter rugs.

Socioeconomic factors include low income, poor housing, and reduced sense of connectedness
(which is related to going out unassisted). The role that social and economic factors play in falls is poorly
understood but could relate to such factors as poor nutrition, resulting in weakened muscles, or lack of
funds to install protective equipment, such as grab bars

. Most falls occur in the home and usually involve falling down the stairs and in the bedroom or
bathroom. Fear of falling is common in older adults, especially those who live alone. In such cases, the
nurse should encourage daily or more frequent contact with a friend or family member, installation of a
personal emergency response system, and measures to maintain a physical environment that prevents
falls. Selected risk factors and associated preventive measures for falls are shown in Table 32.1. The
Canadian Patient Safety Institute recommends that health care agencies adopt Universal Fall
Precautions, indicated by the acronym SAFE (Safe environment; Assist with mobility; Fall-risk reduction;
and Engage client and family) (Figure 32.6 portrays the Universal Fall Precautions sign)

Table 32.1 Falls: Risk Factors and Preventive Measures

Risk Factors Preventive Measures

History of falling
Poor vision
Presence of stairs, in particular, stairs that are
nonuniform, steep, winding, or curved in shape
 Conduct a detailed analysis of the reasons
underlying any previous falls to determine
modifiable factors or circumstances that
can become preventive measures.
 Communicate risk while maintaining
patient confidentiality (e.g., one Canadian
agency places a picture of a leaf on the
patient’s bed to indicate the risk of fall
(leaves fall); similarly, another agency puts
green-colored socks on its clients who are
at risk for falls)
 Ensure that the client’s eyeglasses are
effective. Encourage the client to allow
time for visual adjustment if he or she is
wearing bifocals.
 Ensure that lighting is appropriate,
including having a light switch at the top
and bottom of stairs. Night lighting of
stairs and hallways that does not need to
be switched on is also recommended.
 Mark doorways and stair edges, as
needed.
 Encourage the client to keep the
environment tidy.
 Look for securely attached handrails on
each side of the stairway; handrails should
extend, without a break, the full length of
the stairs as well as beyond the bottom
and top of the stairs with a tactile
indicator (i.e., slight bend) to indicate the
stairway is coming to an end.

Cognitive dysfunction (confusion, disorientation,
impaired memory, or judgment)
Gait instability (impaired gait or balance) or lower-
limb weakness or dysfunction
Difficulty getting in and out of a chair or bed
Orthostatic hypotension
 Stairs must meet safe standards: riser no
higher than 180 mm and run no shorter
than 280 mm; clients with severe physical
limitations should consider installing a
stair lift
 Have clients set safe limits to activities.
 Remove unsafe objects.
 Consider the need for constant
surveillance.
 Ask the client to wear shoes or well-fitting
slippers with nonskid soles.
 Use antislip shoe devices (e.g., crampons)
in icy conditions
 Have the client use ambulatory devices, as
necessary (cane, crutches, walker, braces,
wheelchair)
 Ensure the environment is uncluttered and
that rugs are securely fastened.
 Suggest that the client adapt living
arrangements to one floor, if feasible. It
may be necessary to install an additional
phone or bathroom and to place
frequently used items close to the client.
 Encourage planned, structured, repetitive
physical activity, such as balance training;
strength and resistance training; and
three-dimensional exercises, such as
dance or Tai Chi to maintain muscle
strength and joint flexibility and to
possibly reduce the fear of falling
(Kendrick et al., 2014).
 Hip protectors (underwear types are
available) or elbow and knee protectors
may be used as protective measures.
However, the effectiveness of hip
protectors in reducing the incidence of hip
fracture in older adults has not been
clearly established; these protectors may
work best in frail older adults in nursing
care (Gillespie, Gillespie, and Parker, 2010)
 Encourage the client to request assistance.
 Keep the bed in the low position. Install a
side rail on the bed to provide grip.
 Install grab bars in bathrooms and raised
toilet seats.
 Instruct the client to rise slowly from the
lying position, to the sitting position, and

Urinary frequency, nocturia (urge to get up in the
night to urinate), receiving diuretics
Weakness from disease process or therapy
Polypharmacy (clients taking more than five
medications) or those prescribed hypnotics,
sedatives, tranquilizers, or diuretic
finally to the standing position and to
stand in place for several seconds before
walking
 Provide a bedside commode (without
wheels).
 Assist the client with voiding on a
frequent and scheduled basis
 Encourage the client to summon help.
 Monitor activity tolerance.
 Monitor orientation and alertness status.
 Discuss how alcohol contributes to fall-
related injuries, and encourage the client
not to mix alcohol and medications or to
avoid alcohol, if necessary.
 Encourage annual or more frequent
review of all medications prescribed.
 Discuss alternative solutions (other than
benzodiazepines) for such symptoms as
anxiety and insomnia.

Regardless of efforts to prevent falls, they may still occur; in the event of such, clients should try
to land on their buttocks, wait a while before getting up to make sure that there is no injury, and, most
important, not become less active to avoid falls, as this will only serve to weaken the muscles that are, in
fact, needed to prevent falls (PHAC, 2014). (See the Clinical Alert box about fractures related to falls in
older adults.)

Clinical Alert

Falls can cause broken bones, but sometimes, broken bones can cause falls. When a client is
brought to hospital for treatment of a bone fracture, it is important to determine if a fracture caused the
fall or if the fall caused the fracture. The health history of the former scenario generally reveals pain or a
“cracking noise” before the fall. Falls in older adults may result from arrhythmias, problems with the
vestibular apparatus, hypoglycemic episodes, hypotensive episodes, or being pushed (in the case of
abuse).

The nurse can use an assessment tool, called the Get Up and Go Test (GUGT), in the hospital
setting, the subacute care setting, or the home setting. The GUGT consists of the following steps:

1. Observe the client’s posture while he or she sits in a straight-backed chair.

2. Ask the client to stand. Observe whether the client stands by using only the leg muscles
or if the client needs to push himself or herself up with the hands.
3. Once the client is comfortably standing, ask him or her to close the eyes. Does the client
sway?
 4. Ask the client to open his or her eyes, walk 3 metres, turn around, and return to the
chair. Observe gait, balance, speed, and stability. How smoothly does the client turn?
5. When the client gets to the chair, ask him or her to turn and sit down. Observe how
smoothly the client performs this motion.

The GUGT score ranges from 0 to 4. The client who is able to perform all five steps with ease
receives a score of 0; the score is 1 if the client must use his or her hands to get out of the chair; the
client who is able to stand but requires multiple pushes to get up scores a 3; and the client who is unable
to get up without assistance receives a 4. This quick assessment, along with an assessment of the client’s
environment, can help the nurse recommend safety measures to the client and family.

Prevention of falls in health care agencies is an ongoing concern. Other than the illness process
that necessitates hospitalization, being in a hospital poses additional fall risks (e.g., an unfamiliar
environment, reluctance to ask for help for fear of being a burden, and a lack of usual safety reminders).
Health care environments are designed with many safety features to reduce the risk of falls, such as
railings along corridors; call bells at each bedside; safety bars in toilet areas; locks on bed, wheelchair,
and stretcher wheels; side rails on beds; and night lights. In addition, nurses can implement measures to
decrease the incidence of falls (see Practice Guidelines 32.1).

Electronic devices are available to detect when clients are attempting to get out of bed. A bed
or chair safety monitoring device has a position-sensitive switch that triggers an audio alarm when the
client attempts to get out of the bed or chair. Skill 32.1 describes how to use these devices.

Seizures A seizure is a sudden onset of excessive electrical discharges in one or more areas of
the brain. Seizures can develop at any time during a person’s life.

SKILL 32.1 USING A BED OR CHAIR EXIT SAFETY MONITORING DEVICE

1. PURPOSES
 To alert the nurse that the client is attempting to get out of bed
 To help decrease the risk of client falls
2. ASSESSMENT
Assess
 Mobility status
 Judgment about ability to get out of bed safely
 Clients usual pattern of exiting the bed or chair
 Proximity of client’s room to nurses’ station
 Position of side rails
 Functioning status of call light
Clinical Reasoning
What possible meaning will the client and his or her family place on the use of the monitoring
device (e.g., will they see it negatively, such as a form of restraint or invasion of privacy, or
 positively as a safety resource)? Are there any modifiable factors (e.g., presence of infection;
medications altering judgment) that have been overlooked as a possible reason for the client
needing the extra monitoring?
3. PLANNING
Determine the best type of device and appropriate location for the device. Whatever device will
be applied, choose a location on the body where skin is intact.
Equipment
 Alarm and control device
 Sensor device
 Connection to nurse call system
4. IMPLEMENTATION
Performance
a Before performing the procedure, introduce yourself to the client, and verify the client’s
identity by using two identifiers. Explain to the client and family the purpose and
procedure of using a safety monitoring device.
 Explain that the device does not limit mobility in any manner; rather, it alerts
the staff when the client is about to get out of bed.
 Explain that the nurse must be called when the client needs to get out of bed.
b Perform hand hygiene, and follow other appropriate infection prevention and control
procedures.
c Provide for client privacy.
d Test the battery device and alarm sound. Rationale: Testing ensures that the device is
functioning properly before use.
e Apply the sensor pad or leg band.
 Place the leg band according to the manufacturer’s recommendation (see ❶).
Place the client’s leg in the straight, horizontal position. Rationale: The alarm
device is position sensitive; that is, when it approaches a near-vertical position
(as in walking, crawling, or kneeling as the client attempts to get out of bed),
the audio alarm will be triggered
 For the bed or chair device, the sensor is usually placed under the buttocks area
(see ❷).
 For a bed or chair device, set the time delay for determining the client’s
movement patterns from 1 to 12 seconds.
 Connect the sensor pad to the control unit and the nurse call system.
f Instruct the client to call the nurse when the client wants or needs to get up, and assist,
as required.
 When assisting the client up, deactivate the alarm.
 Assist the client back to bed, and reattach the alarm device.
g Ensure client safety with additional safety precautions.
 Place the call light within client reach, and ensure other relevant safety
measures (e.g., one side rail elevated to assist with turning), and lower the bed
 to its lowest position. Rationale: The alarm device is not a substitute for other
precautionary measures.
 Place ambulation monitoring stickers on the client’s door, chart, and other
relevant locations.
h Document the type of alarm used, where it was placed, and its effectiveness in the client
record by using forms checklists supplemented by narrative notes when appropriate.
Record all additional safety precautions and interventions discussed and employed.
5. EVALUATION
 If the alarm is too sensitive to client movements that are not an attempt to move from
the bed or chair, reassess and modify alarm controls accordingly.
 Conduct appropriate follow-up relating to effectiveness of the safety precautions.
 Report any difficulties in using the device or any falls to the appropriate members of
the health care team.

Clients may be prone to seizures because of permanent or temporary medical conditions, such
as drug reactions or epilepsy; seizures can occur with no known cause.

Seizures are classified into two categories: partial and generalized. Partial seizures (also called
focal seizures) involve electrical discharges from one area of the brain. In contrast, generalized seizures
affect the whole brain. Each of these seizure categories includes different types of seizure depending on
the characteristics of the seizure activity (e.g., loss of consciousness or no impairment to consciousness).
Thus, it is important for the nurse to thoroughly describe the observations before, during, and after a
seizure episode. Clients are at risk for injury if they experience seizures that involve the entire body,
such as grand mal (tonic–clonic) seizures or any seizure that includes loss of consciousness. Seizure
precautions are safety measures taken by the nurse to protect lients from injury should they have a
seizure. Skill 32.2 describes how to implement seizure precautions. (See also the Continuity Care box.)

POISONING Inadequate supervision and improper storage of medications (including vitamin and
iron supplements) and household products (e.g., cleaning products, alcohol, pesticides) are the major
reasons for poisoning among children (Parachute Canada, 2015). Implementing poison prevention for
children is focused on childproofing the environment, including disposing of unused medications by
returning them to a pharmacy and properly storing risky products.

Adolescent and adult poisonings are usually caused by excess intake of drugs used for recreation
or in suicide attempts. Implementing poison prevention in these age groups focuses on providing
information and counselling. Poisoning in the older adult usually results from unintended ingestion of a
toxic substance (e.g., because of failing eyesight) or an overdose of prescription or OTC medications.
People with altered mental status, such as dementia, are at risk for poisoning as they may lack judgment
or memory about risky substances. Poison prevention focuses on safeguarding the environment,
monitoring the underlying problems, and regularly reviewing prescription and OTC medications. A
telephone number for the nearest poison control centre should be readily available so that accurate, up-
to-date information about potential hazards and recommended treatment can be obtained, as needed.
 Nurses intervene in community settings by educating the public about what to do in the event of
poisoning. Identify the specific poison by searching for an opened container, empty bottle, or other
evidence. Contact the poison control centre, indicate the exact quantity of poison the person ingested,
and state the person’s age and apparent symptoms. Keep the person as quiet as possible and have him
or her lying on the side or sitting with the head placed between the legs to prevent aspiration of
vomitus. The Teaching: Wellness box provides additional guidelines for helping clients to prevent
poisoning.

Carbon Monoxide Poisoning Carbon monoxide (CO) is a colourless, odourless, toxic gas that is a
byproduct of incomplete combustion. Exposure to CO can cause such symptoms as headaches, dizziness,
weakness, nausea, vomiting, and loss of muscle control. Prolonged exposure can lead to
unconsciousness, brain damage, and death. Learning how to prevent CO exposure is important because
of CO emission from all gasolinepowered vehicles or generators; lawn mowers; kerosene lanterns,
heaters, and stoves; propane stoves; charcoal barbecues; and burning wood. Health Canada
recommends that all homes have CO detectors installed; they are mandatory in some Canadian cities.

SKILL 32.2 IMPLEMENTING SEIZURE PRECAUTIONS

1. PURPOSE
To protect the client from injury
2. ASSESSMENT
Assess the history of seizures during the admission assessment. If the client has experienced a
seizure previously, ask for detailed information, including characteristics of an aura or warning
symptoms that indicate the seizure is beginning, duration and frequency of the seizures,
consequences of the seizures (e.g., incontinence or difficulty breathing), and actions that should
be taken to prevent or reduce seizure activity.
Clinical Reasoning
How do the client and his or her family interpret the need for seizure precautions? Are they
frightened by what the cause of the seizures might be? Are they familiar with seizure activity
and what to do if one occurs, or are they dealing with uncertainty about how to know if a
seizure is happening and what to do in that event? While the precautions are aimed at
promoting safety, is it possible that the client will become isolated or fearful as a result?
Planning
Review emergency procedures: A respiratory arrest or other injury can result from a seizure.
Equipment
 Blankets or other linens to pad side rails
 Oral suction equipment
 Oxygen equipment
3. IMPLEMENTATION
Performance
a Before performing the procedure, introduce yourself to the client, and verify the client’s
identity by using two identifiers. Explain to the client what you are going to do, why it is
necessary, and how he or she can participate.
 bPerform hand hygiene, and follow other appropriate infection prevention and control
procedures. If the client is actively seizing, apply clean gloves in preparation for
performing respiratory care measures.
c Provide for client privacy.
d Pad the bed of any client who might have a seizure. Secure blankets or other linens
around the head, foot, and side rails of the bed (see ❶).
e Put oral suction equipment in place and test to ensure that it is functional. Rationale:
Suctioning may be needed to prevent aspiration of oral secretions.
f If a seizure occurs:
 Remain with the client and call for assistance. Do not restrain the client.
 If the client is not in bed, assist him or her to the floor, and protect the client’s
head in your lap or on a pillow. Loosen any clothing around the client’s neck
and chest. Move items in the environment to ensure the client does not
experience an injury.
 Do not insert anything into the client’s mouth.
 Time the seizure duration.
 Observe the progression of the seizure, noting the sequence and type of limb
involvement. Observe skin colour. When it is possible during the seizure, check
pulse and respirations.
 Apply oxygen, according to agency policy.
 Use equipment to suction the oral airway if the client vomits or has excessive
oral secretions.
 Administer anticonvulsant medications, as prescribed.
 When the seizure has subsided, assist the client to a comfortable position.
Reorient the client. Explain what happened, and reassure the client. Provide
hygiene, as necessary. Allow the client to verbalize his or her feelings about the
seizure.
 If the seizure continues (status epilepticus) monitor the respiratory status and
prepare to start CPR in the event of respiratory arrest.
 If applied, remove and discard gloves, and then perform hand hygiene. 7.
Document the event in the client record.
4. EVALUATION
 Perform a detailed follow-up examination of the client. Administer medications, if
indicated and prescribed.
 Report any significant deviations from normal to the appropriate members of the
health care team.

Continuity Care

Implementing Seizure Precautions in the Home Environment

  If clients have frequent or recurrent seizures or take anticonvulsant medications, they should
wear a medical identification tag (bracelet or necklace) and carry a card listing any medications
they take.
 When making home visits, inspect clients’ anticonvulsant medications, and confirm that clients
are taking them correctly. Blood level measurements may be required periodically.
 Assist clients in determining which persons in the community should or must be informed of
their seizure disorder (e.g., employers, motor vehicle department if the client drives, friends).
 Discuss safety precautions for inside and out of the home. If seizures are not well controlled,
activities that may require restriction or direct supervision by others include tub bathing,
swimming, cooking, using electric equipment or machinery, and driving.
 Discuss the factors that may precipitate a seizure with clients and their families.
 Children who have frequent seizures may need to wear helmets for protection of the head in
case of a fall during the seizure.

Teaching Wellness

Preventing Poisoning

Clients can be given the following instructions to help prevent poisonings:

 Lock potentially toxic products, including prescription and OTC drugs and cleaning agents, in a
cupboard, or attach childproof latches or devices to cabinet doors to keep them securely closed.
Do not let children watch you open the latches. Kids learn fast!
 Keep medications and potential poisons in their original containers so that warning labels and
child-resistant packaging remain intact. Do not reuse empty containers to store different
substances. The labels of poisons usually specify first aid and precautionary measures.
 Do not rely on cooking to destroy the 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.
 Do not refer to medicine as “candy” or pretend enjoyment when taking medications in front of
children; allow them to understand the necessity for taking the medicine without glamorizing it.
• Read and follow label directions on all products before using them.
 Remove poisonous plants from the home, and avoid planting poisonous plants in the yard
 Be aware of the local poison control centre’s emergency phone number, and display it near or
on all telephones in the home so that it is available to babysitters, family, and friends.

Choking or Suffocation Choking occurs when a person’s trachea is obstructed by either a foreign
body (e.g., a chunk of food) or a liquid (e.g., vomitus), and it leads to suffocation. The universal sign of
distress for a choking victim is the grasping of the anterior neck and being unable to speak or cough. The
emergency response to choking is the Heimlich manoeuvre, or abdominal thrust, which can dislodge the
foreign object and re-establish the airway (Figure 32.7).
 Suffocation, also referred to as asphyxiation, is lack of oxygen intake that can ultimately lead to
unconsciousness and death. Suffocation occurs in situations of crush injuries to the chest, drowning, CO
poisoning, or smothering (as when a child covers his or her face with a plastic bag).

Other causes of suffocation are drowning, gas or smoke inhalation, strangulation by the shoulder
harness of a seatbelt, and being trapped in a confined space (e.g., a discarded refrigerator). If a person
does not receive immediate relief from suffocation, the interrupted breathing leads to respiratory and
cardiac arrest and death. Any obstruction to the air passages must be immediately removed and life
support measures instituted when an arrest occurs.

Excessive Noise Excessive noise is a health hazard that can cause hearing loss, depending on the
overall level of noise, the frequency range of the noise, and the duration of exposure and individual
susceptibility. Sound levels above 120 decibels (dB) are painful and may cause hearing damage, even if a
person is exposed for only a short period. Exposure to 85 dB to 95 dB for several hours a day can lead to
progressive or permanent hearing loss. Noise levels below 85 dB do not usually affect hearing.

Noise in hospital can be one of several factors contributing to sensory overload. Physiological
effects of noise include increased heart and respiratory rates, increased muscular activity, nausea, and
hearing loss (if the noise is sufficiently loud).

Noise can be minimized by using acoustic tile on ceilings, walls, and floors; installing drapes and
carpeting to absorb sound; playing background music to mask noise and create a calming effect (on
some people); keeping your voice down while giving care or talking in the background; and making
appropriate alarm settings to reduce false alarms.

Electrical Hazards All electric equipment must be properly grounded. The electric plug of grounded
equipment has three prongs. The two short prongs transmit the power to the equipment. The third,
longer prong is the grounding device, which carries short circuits or stray electric current to the ground.
Grounding prongs offer a path of least resistance to stray electric currents.

Faulty equipment, such as equipment with a frayed cord, presents a danger of electric shock or
may start a fire. For example, an electric spark near certain anesthetic gases or a high concentration of
oxygen can cause a fire or explosion. Actions to reduce electrical hazards are described in the Teaching:
Wellness box.

Teaching Wellness

Reducing Electrical Hazards

Take the following steps to reduce electrical hazards:

 Check cords for fraying or other signs of damage before using an appliance. Do not use it if the
cord is damaged.
 Avoid overloading outlets and fuse boxes with too many appliances; use grounded outlets and
plugs.
  Always pull a plug from the wall outlet by firmly grasping the plug and pulling it straight out.
Pulling a plug by its cord can damage the cord-and-plug unit.
 Ensure that ground fault circuit interrupters have been installed wherever electrical appliances
or equipment can inadvertently come in contact with water, such as near sinks, bathtubs, or
showers, or outdoors.
 Keep electric cords and appliances out of the reach of children, and place protective covers over
wall outlets to protect young children.
 Carefully read instructions before operating electric equipment.
 Always disconnect appliances before cleaning or repairing them.
 Unplug any appliance that has given a tingling sensation or shock when touched, and have an
electrician check the appliance.
 Keep electric cords coiled or taped to the ground away from areas of traffic to prevent people
from damaging the cords or tripping over them.

When major electrical injury does occur, such as macroshock (when the current finds a pathway
through the body), the victim may sustain both superficial and deep burns, muscle contractions, and
cardiac and respiratory arrest, necessitating CPR and life support. Small currents can cause microshock
(when the current flows through a direct pathway to the heart), such as during intracardiac
catheterization. Using machines in good repair, wearing shoes with rubber soles, standing on a
nonconductive floor, and using nonconductive gloves can prevent shock. Rescuers must not touch the
victim until the electricity is shut off or the victim has been removed from contact with the electric
current; otherwise, the rescuer can also receive electrical injury.

Firearms Canada has strict regulations about firearm ownership. Any gun owner is required to
follow a range of safety precautions to ensure that no harm or injury results from improper gun use or
storage. Access to firearms is a serious concern in homes with children and in situations of suicidal
ideation or domestic violence. Members of any household in which guns are present must take full
responsibility for following basic firearm safety rules: Store all guns in sturdy locked cabinets, and make
sure the keys are inaccessible to children; store bullets in a different location from the gun; and do not
use firearms while under the influence of alcohol or other drugs of any kind, including OTC medications
that can change sensorium.

Radiation Radiation injury can result from overexposure to radioactive materials used in diagnostic
and therapeutic procedures. Clients being examined by 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. Exposure to radiation can be
minimized by (a) limiting the time near the source, (b) providing as much distance as possible from the
source, and (c) using shielding devices, such as lead aprons, when near the source. Nurses need to
become familiar with agency protocols related to radiation therapy.

Procedure-Related and Equipment-Related Risks

 Risk assessment in the health care setting must include risks related to procedures and equipment.
Whether giving a medication or assisting a person out of bed, nurses need to follow safeguards to
prevent errors or unintentional injury. Nurses must be aware of and adhere to provincial or territorial
regulations of occupational health and safety. In 2015, Canada implemented the Workplace Hazardous
Materials Information System, a national chemical classification and hazard communication standard for
workplace chemicals. The WHMIS incorporates the Globally Harmonized System of Classification and
Labelling of Chemicals (or GHS) for workplace chemicals. Figure 32.8 is an example of a pictogram used
by the GHS.

When an error or unintentional injury does occur, most agencies require that the incident be
reported. Indeed, in some agencies where client safety is a priority, personnel are encouraged to report
near-misses so that an analysis can be conducted and preventive measures put in place to ensure client
safety. For additional information about incident reports, see Chapter 6.

Restraining Clients

Restraints are physical, chemical, or environmental measures used to control the physical or
behavioural activity of a person or a portion of his or her body. Physical restraints comprise any manual
method or physical or mechanical device, material, or equipment attached to the client’s body (e.g., vest
or wrist restraint); they cannot be removed easily, and they restrict the client’s movement.
Environmental restraints control a person’s mobility, such as when two full bedside rails or four split
bedside rails are raised or the client is placed on a secured unit. Chemical restraints are medications,
such as neuroleptics, anxiolytics, sedatives, and psychotropic agents, used to control disruptive
behaviour. Generally, the only justifiable reasons for applying restraints are to avoid or prevent
purposeful or accidental harm to a client when all other methods have been tried or to do what is
required to provide medically necessary treatment that could not be provided through any other means.
To reiterate, restraints should be used only after all other possible means of ensuring safety have been
unsuccessful and documented. If restraints are deemed necessary, then a policy of least restraint—the
use of the minimum amount of restraint needed to ensure safety (e.g., by securing one hand rather than
both)—should be applied. Most agencies have strict policies and procedures related to the use of
restraints.

Restraints can contribute to muscle atrophy, skin deterioration, urinary incontinence, constipation,
and respiratory infection because the client is more likely to remain recumbent or confined to bed when
restrained. Coroners’ reports have linked restraints to deaths, such as death by suffocation from
becoming trapped between bedrails when trying to climb out of bed, strangulation when the ties of a
restraint vest encircle the neck, or aspiration from vomitus when protective movements are limited by
restraints. In addition to the physical safety concerns, many consider restraints to be demeaning and to
limit a client’s autonomy. They can be harmful psychologically, such as by making clients feel ashamed
or guilty. For clients with a history of sexual abuse or other forms of violence, being placed in restraints
has been linked to flashbacks and potential exacerbation of posttraumatic stress disorder (PTSD)
symptoms. The focus in health care is to explore ways to prevent, reduce, and eliminate the use of
restraints while protecting a client’s safety, rights, and dignity.
 Legal Implications of Restraints Because restraints restrict the individual’s freedom, their use has
legal implications. Nurses need to know agency policies and provincial or territorial laws about
restraining clients. A clear understanding of what constitutes a restraint is important. For example, if a
client has the side rails up to help with side-to-side movement in the bed, then this situation is not one
of restraint; if, however, the side rails are up to confine the client, then the use of side rails is considered
an environmental restraint. Most agencies and provincial or territorial legislation require informed
consent of the client or the legal representative before implementing restraints in nonemergency
situations. A collective prescription or policy will generally identify the steps to be followed before using
restraints. Some institutions allow for individual decision making in emergency situations, but the trend
is toward documented interdisciplinary and client or family dialogue before the use of restraints.
Continued use of restraints must also be addressed, often within specific time frames (e.g., involuntary
restraint may require reassessment every 2 to 4 hours, and voluntary restraint is generally reviewed
every 8 or 24 hours). Most agencies require visual or auditory supervision of any client in restraint so
that any safety issues can be quickly addressed. (See the Clinical Alert box regarding restrained clients.)

Clients have the right to be free from restraints that are not medically necessary. As a result, there
must be justification that the use of restraints will protect the client and that less restrictive measures
were attempted and found ineffective. Restraints cannot be used for staff convenience or client
punishment. To reiterate, generally, the only justifiable reasons for applying restraints are to avoid or
prevent purposeful or accidental harm to a client when all other methods have been tried and have
failed and to do what is required to provide medically necessary treatment that could not be provided
through any other means. Given that the above conditions are met and physical restraints are needed, it
is important for the nurse to be able to correctly apply the restraints without endangering client safety.

Selecting a Physical Restraint Before selecting a physical restraint, nurses need to understand its
purpose clearly and measure it against the following five criteria:

1. It restricts the client’s movement as little as possible. If a client needs to have one arm
restrained, do not restrain the entire body.
2. It does not interfere with the client’s treatment or health problem. If a client has poor blood
circulation to the hands, apply a restraint that will not aggravate that circulatory problem.
3. It is readily changeable. Restraints need to be changed frequently, especially if they become
soiled. Keeping other guidelines in mind, choose a restraint that can be changed with minimal
disturbance to the client.
4. It is safe for the particular client. Choose a physical restraint with which the client cannot self-
inflict injury. For example, a physically restrained person could be injured trying to climb out of
bed if one wrist is tied to the bed frame. A jacket restraint would restrain the person more
safely.
5. It is the least obvious to others. Clients and visitors can be embarrassed by a physical restraint,
even though they understand why it is being used. The more discreet the restraint, the more
comfortable people feel.

Clinical Alert
Restrained clients may become more restless and anxious as a result of loss of self-control. The nurse
must keep in mind that such behaviours may be the result of pain or hypoxia from improper restraint
application. A client who was agitated and suddenly becomes quiet must be assessed to ensure that the
change in behaviour is the result of calmness rather than a hypoxic or other physiological event.

Types of Physical Restraints Several types of physical restraints are available. Among the most common
for adults are jacket or vest restraints, belt restraints, mitt or hand restraints, and limb restraints.
Although bed rails can be used to aid in turning or repositioning and reduce the risk of clients falling out
of bed during transport, they are also seen as restraints in that they can limit purposeful movement.
Geri-chairs and wheelchairs with lap trays are also classified as forms of restraints. Physical restraints for
infants and children include mummy restraints, elbow restraints, and crib nets. When considering or
using restraints, the nurse will find Practice Guidelines 32.2 helpful.

Several types of vest restraints are used, but all are essentially sleeveless jackets or vests with
straps (tails) that can be tied to the bed frame under the mattress. These body restraints are used to
ensure the safety of confused or sedated clients in beds or wheelchairs. “Front” and “back” labels on
vest restraints ensure that they are applied correctly and safely.

Belt or safety strap body restraints (Figure 32.9) are used to ensure the safety of clients who are
being moved on stretchers or in wheelchairs. Some wheelchairs have a soft, padded safety bar that
attaches to side brackets that are installed under the armrests. To prevent the person from slumping
forward, the nurse then attaches a shoulder Y strap to the bar and over the client’s shoulders to the rear
handles. Other safety belt models have a three-loop design. One loop surrounds the person’s waist and
the other two attach to the rear handles. If such restraints are unavailable, the nurse can place a folded
towel or small sheet around the client’s waist and fasten it at the back of the wheelchair. Belt restraints
can also be used for certain clients confined to bed or to chairs.

A mitt or hand restraint (Figure 32.10) is used to prevent confused clients from using their
hands or fingers to scratch and injure themselves. For example, a confused client may need to be
prevented from pulling at intravenous tubing or at a head bandage following neurosurgery. Hand or mitt
restraints allow the client to be ambulatory and to move the arm freely rather than be confined to a bed
or a chair. Mittens need to be removed on a regular basis to permit the client to wash and exercise the
hands. The nurse also needs to take off the mitten to check the circulation to the hand.

Limb restraints (Figure 32.11) can be used to immobilize a limb, primarily for therapeutic reasons (e.g.,
to maintain an intravenous infusion). See Skill 32.3 for applying restraints. See also the Lifespan
Considerations box on the use of restraints that follows.

Evaluating

To prevent client injury, the nurse’s role is largely that of an educator, and desired outcomes
reflect the client’s acquisition of knowledge of hazards, behaviours that incorporate safety practices, and
skills to perform in the event of certain emergencies. The nurse needs to individualize these for clients.
Examples of desired outcomes include the client being able to do the following:
  Describe methods to prevent specific hazards (e.g., falls, suffocation, scalds, fires,
drowning, electric shock)
 Report use of home safety measures (e.g., fire safety measures, smoke detector and CO
detector maintenance, fall-prevention strategies, burn-prevention measures, poison-
prevention measures, firearm safety precautions, water safety precautions, motor
vehicle safety)
 Alter home physical environment to reduce the risk of unintentional injury
 Describe emergency procedures such as for poisoning or fire
 Describe age-specific risks, work safety risks, or community safety risks
 Demonstrate correct use of child safety seats

SKILL 32.3 APPLYING PHYSICAL RESTRAINTS

1. PURPOSES
 To promote safety and prevent injury only when all other less restrictive measures have
been exhausted
 To allow a medical or surgical treatment to proceed without client interference (e.g., to
prevent movements that would disrupt therapy to a limb connected to tubes or an
appliance)
2. ASSESSMENT
Assess
 The behaviour indicating the possible need for a restraint
 Underlying causes for the assessed behaviour
 What other protective measures can be implemented before applying a restraint
 The status of skin to which a restraint is to be applied
 The circulatory status distal to restraints and of extremities •
 The effectiveness of other available safety precautions
Clinical Reasoning
Was something that might explain why this client seems to need restraints (e.g., hypoxemia,
psychological distress) missed during the assessment phase? If that reason could be identified
and addressed, would it mean that restraints are not needed? If the client is agitated or angry,
was an opportunity given to share his or her feelings and frustrations? How will the client and
the family interpret the use of the physical restraint, and how can the nurse buffer the
potentially negative feelings? Is it possible that the family and the client see the restraints as
helpful and are relieved that restraints will be used, for example, when it is feared that the
client might self-extubate unless the hand is gently restrained?
3. PLANNING
Review institutional policy for restraints, and seek consultation, as appropriate, before
independently deciding to apply a restraint. Many Canadian institutions require interdisciplinary
discussions and informed client or legal guardian consent before instituting restraints.
 Equipment
 Appropriate type and size of restraint
4. IMPLEMENTATION
Performance
a Once consent has been obtained and before performing the procedure, introduce
yourself to the client, and verify the client’s identity by using two identifiers. Explain to
the client and the family what you are going to do, why it is necessary, and how they can
participate. Allow time for the client to express his or her feelings about being
restrained. Provide needed emotional reassurance that the physical restraints will be
used only when absolutely necessary and that the nurse will be in close contact with the
client in case assistance is required.
b Perform hand hygiene, and follow other appropriate infection prevention and control
procedures.
c Provide for client privacy, if indicated.
d Apply the selected restraint.
Belt Restraint (Safety Belt)
 Determine that the safety belt is in good order. If a Velcro safety belt is to be used,
make sure that both pieces of Velcro are intact.
 If the belt has a long portion and a shorter portion, place the long portion of the belt
behind (under) the client confined to bed and secure it to the movable part of the bed
frame. Rationale: The long, attached portion will then move up when the head of the
bed is elevated and will not tighten around the client.
 Place the shorter portion of the belt around the client’s waist, over the gown. There
should be a finger’s width between the belt and the client.
 Or attach the belt around the client’s waist, and fasten it at the back of the chair.
 Or if the belt is attached to a stretcher, secure the belt firmly over the client’s hips or
abdomen. Rationale: Belt restraints must be applied to all clients on stretchers, even
when the side rails are up.
Jacket Restraint
 Place the vest on the client, with opening at the front or the back, depending on the
vest type.
 Pull the tie on the end of the vest flap across the chest, and place it through the slit in
the opposite side of the chest.
 Repeat for the other tie.
 Use a half-bow (quick-release) knot to secure each tie around the movable bed frame
or behind the chair to a chair leg (see ❶ and ❷). Rationale: A half-bow (quickrelease)
knot does not tighten or slip when the attached end is pulled but unties easily when the
loose end is pulled.
 Or fasten the ties together behind the chair by using a slip or quick-release knot.
 Ensure that the client is positioned appropriately to enable maximum chest expansion
for breathing.
 Mitt Restraint
 Apply the commercial thumbless mitt (see Figure 32.10) to the hand to be restrained.
Make sure the fingers can be slightly flexed and are not caught under the hand.
 Follow the manufacturer’s directions for securing the mitt.
 If a mitt is to be worn for several days, remove it at regular intervals per agency
protocol. Wash and exercise the client’s hand, then reapply the mitt. Check agency
practices about recommended intervals for removal.
 Assess the client’s circulation to the hands shortly after the mitt is applied and at
regular intervals. Rationale: Client complaints of numbness, discomfort, or inability to
move the fingers could indicate impaired circulation to the hand.
Wrist or Ankle Restraint
 Pad the bony prominences on the wrist or ankle, if needed, to prevent skin breakdown.
 Apply the padded portion of the restraint around the ankle or wrist.
 Pull the tie of the restraint through the slit in the wrist portion or through the buckle
and ensure that the restraint is not too tight (see ❸).
 By using a half-bow knot (quick-release knot), attach the other end of the restraint to
the movable portion of the bed frame. Rationale: If the ties are attached to the movable
portion, the wrist or ankle will not be pulled when the bed position is changed.
e Adjust the plan of care, as required, for example, to include releasing the restraint,
providing skin care, helping with range-of-motion exercises, and attending to the client’s
physical needs by providing fluids, nutrition, and toileting care.
f Record on the client’s chart the behaviour(s) indicating the need for the restraint, all
other interventions implemented in an attempt to avoid the use of restraints and their
outcomes, and the time the physician was notified of the need for restraint. Also, record
the following:
 The type of restraint applied, the time it was applied, and the goal for its
application
 The client’s response to the restraint, as well as the rationale for its continued
use
 The times that the restraints were removed and skin care given
 Any other assessments and interventions
 Explanations given to the client and significant others
6. Evaluation
 Perform a detailed follow-up of the need for the restraints and the client’s
physical and emotional responses. Relate these findings to previous data, if
available. Evaluate circulatory status of restrained limbs at least on an hourly
basis.
 Evaluate skin status beneath restraints at least on an hourly basis.
 Remove the restraints as soon as they are no longer needed, and document
the removal.
  When restraints are released, ensure that the client is not experiencing any
emotional or physical consequences. Reaffirm that the physical restraints were
a last resort to protect the client and that they were not a form of punishment.
 Report significant deviations from normal to the appropriate members of the
health care team.

Lifespan Considerations

1) Restraints

Infants

Elbow restraints (Figure 32.12) are used to prevent infants or small children from flexing their
elbows to touch or reach their face or head, especially after surgery. Ready-made elbow restraints are
available commercially.

A mummy restraint (Figure 32.13) is a folding of a blanket or sheet around the infant to prevent
movement during a procedure, such as eye irrigation or collection of a blood specimen.

 Obtain a blanket or sheet large enough so that the distance between opposite corners
is about twice the length of the infant’s body. Lay the blanket or sheet on a flat, dry
surface.
 Fold down one corner, and place the baby on it in the supine position.
 Fold the right side of the blanket over the infant’s body, leaving the left arm free (see
Figure 32.13A). The right arm is in a natural position at the side.
 Fold the excess blanket at the bottom up under the infant (see Figure 32.13B, 2).
 With the left arm in a natural position at the baby’s side, fold the left side of the blanket
over the infant, including the arm, and tuck the blanket under the body (see Figure
32.13B, 3).
 Remain with the infant who is in a mummy restraint until the specific procedure is
completed.
Children
A crib net is simply a device placed over the top of a crib to prevent active young children from climbing
out of the crib. At the same time, it allows them freedom to move about in the crib. The crib net or
dome is not attached to the movable parts of the crib so that the caregiver can have access to the child
without removing the dome or net.
 Place the net over the sides and ends of the crib.
 Secure the ties to the springs or frame of the crib. The crib sides can then be freely lowered
without removing the net.
 Test with your hand that the net will stretch if the child stands against it in the crib