AED	Automated external defibrillator
C	Centigrade
CMS	Centers for Medicare & Medicaid Services
CPR	Cardiopulmonary resuscitation
EMS	Emergency Medical Services
F	Fahrenheit
FBAO	Foreign-body airway obstruction
ID	Identification
MSDS	Material safety data sheet
OBRA	Omnibus Budget Reconciliation Act of 1987
OSHA	Occupational Safety and Health Administration
PASS	Pull the safety pin, aim low, squeeze the lever, sweep back and forth

Safety is a basic need. Residents are at great risk for accidents and falls. (See Chapter 13 for falls.) Some accidents and injuries cause death.

The health team must provide for safety. This includes you. Ordinary and sometimes extraordinary measures are needed to prevent accidents and keep residents safe. The goal is to decrease the person’s risk of accidents and injuries without limiting mobility and independence.

The Omnibus Budget Reconciliation Act of 1987 (OBRA) requires that nursing centers follow safety policies and procedures. So do accrediting agency standards. The intent is to keep residents, visitors, and staff safe. Measures to protect residents must not interfere with their rights (Chapter 2).

Common sense and simple safety measures can prevent most accidents. You must protect residents, visitors, yourself, and co-workers. The safety measures in this chapter apply to nursing and everyday life. The care plan lists other safety measures for the person.

A safe setting

In a safe setting, a person has little risk of illness or injury. The person’s setting is free of hazards to the extent possible. A hazard is any thing in the person’s setting that may cause injury or illness.

The person feels safe and secure physically and mentally. The risk of infection, falls, burns, poisoning, and other injuries is low. Temperature and noise levels are comfortable. Smells are pleasant. There is enough room and light to move about safely. The person and the person’s property are safe from fire and intruders. The person is not afraid. He or she has few worries and concerns.

The person must receive the right care and treatment. The person is protected from falls, burns, poisoning, suffocation, and infection. To protect the person from harm, follow the person’s care plan. Also practice the safety measures in this chapter.

See Teamwork and Time Management: A Safe Setting.

TEAMWORK AND TIME MANAGEMENT

A Safe Setting

The entire health team must provide a safe setting. You may see something unsafe. Correct the matter right away if it is something you can do. For example:

• You see a water spill. Wipe up the spill right away. Do so even if you did not cause the spill.

• You see a person sliding out of a wheelchair. Position the person correctly in the chair. Do so even if a co-worker is responsible for the person’s care.

• A person is having problems holding a cup of coffee. Offer to help the person.

• Food is left unattended in a microwave oven. Turn off the device. Then tell your co-worker the reason for your action.

• A grab bar is loose in the bathroom. Tell the nurse. Follow center policy for reporting the problem.

You cannot correct some safety issues. Follow center policy for reporting such problems. They include:

• Electrical outlets or switches coming out of the wall

• Electrical outlets that do not work

• Water leaks from windows, doors, ceilings, pipes, faucets, tubs, showers, toilets, hot water heaters, fountains, and other water sources

• Toilets that do not work properly

• Water from faucets that does not warm up or that is very hot

• Broken windows

• Windows and doors that do not work properly

• Knobs and handles that are broken or do not work properly

• Hand rails and grab bars that are loose or need repair

• Odd smells and odors

• Odd sounds

• Signs of rodents, flies, or other pests

• Broken or damaged furniture

• Lights and lamps that do not work or have burnt-out bulbs

• Flooring (carpeting, tiles) in need of repair

Accident risk factors

Some people cannot protect themselves. They present dangers to themselves and others. They rely on others for safety. Know the factors that increase a person’s risk of accidents and injuries. Follow the person’s care plan to provide for safety.

• Age. Changes from aging increase the risk for falls and other injuries. Older persons have decreased strength and move slowly. Some are unsteady. Often balance is affected. These changes prevent quick and sudden movements to avoid dangers and prevent falls. Older persons also are less sensitive to heat and cold. They have poor vision, hearing problems, and a dulled sense of smell. Confusion, poor judgment, memory problems, and disorientation may occur (Chapter 44).

• Awareness of surroundings. People need to know their surroundings to protect themselves from injury. Coma is a state of being unaware of one’s surroundings and being unable to react or respond to people, places, or things. A coma can occur from illness or injury. The person in a coma relies on others for protection. Confused and disoriented persons may not understand what is happening to and around them.
See Residents With Dementia: Accident Risk Factors (Awareness of Surroundings).

• Agitated and aggressive behaviors. Pain can cause these behaviors. So can confusion, decreased awareness of surroundings, and fear of what may happen.

• Vision loss. Persons with poor vision have problems seeing things. They can fall or trip over toys, rugs, equipment, furniture, and cords. Some have problems reading labels on cleaners and other containers. Poisoning can result. It also can result from taking the wrong drug or the wrong dose.

• Hearing loss. Persons with hearing loss have problems hearing explanations and instructions. They may not hear warning signals or fire alarms. Some cannot hear approaching meal carts, drug carts, stretchers, or people in wheelchairs. They do not know to move to safety.

• Impaired smell and touch. Illness and aging affect smell and touch. The person may not detect smoke or gas odors. When touch is reduced, burns are a risk. The person has problems sensing heat and cold. Some people have a decreased pain sense. They may be unaware of injury. For example, Mrs. Parks does not feel a blister from her shoes. She has poor circulation to her legs and feet. The blister can become a serious wound.

• Impaired mobility. Some diseases and injuries affect mobility. A person may know there is danger but cannot move to safety. Some persons cannot walk or propel wheelchairs. Some persons are paralyzed. Paralysis means loss of muscle function, loss of sensation, or loss of both muscle function and sensation. Paraplegia is paralysis in the legs and lower trunk. Quadriplegia (tetraplegia) is paralysis in the arms, legs, and trunk. Hemiplegia is paralysis on one side of the body.

• Drugs. Drugs have side effects. They include loss of balance, drowsiness, and lack of coordination. Reduced awareness, confusion, and disorientation can occur. The person may be fearful and uncooperative. Report behavior changes to the nurse. Also report the person’s complaints.

RESIDENTS WITH DEMENTIA

Accident Risk Factors (Awareness of Surroundings)

Some persons suffer from dementia. Dementia is the loss of cognitive and social function caused by changes in the brain (Chapter 44). Memory and the ability to think and reason are lost. Dementia is caused by diseases and injuries.

Persons with dementia are confused and disoriented. Their awareness of surroundings is reduced. They may not understand what is happening to and around them. Judgment is poor. They no longer know what is safe and what are dangers. They may access closets, cupboards, or other unsafe and unlocked areas. They may eat or drink cleaning products, drugs, or poisons. Accidents and injuries are great risks. The health team must meet all safety needs.

Identifying the person

You will care for many people. Each has different treatments, therapies, and activity limits. You must give the right care to the right person. Life and health are threatened if the wrong care is given.

The person may receive an identification (ID) bracelet when admitted to the center (Fig. 12-1). The bracelet has the person’s name, room and bed number, birth date, age, doctor, and center name. Other identifying information may include the person’s ID number given by the center. Some centers include the person’s religion.

You use the bracelet to identify the person before giving care. The assignment sheet states what care to give. To identify the person:

• Compare identifying information on the assignment sheet with that on the ID bracelet (Fig. 12-2). Carefully check the information. Some people have the same first and last names. For example, John Smith is a very common name.

• Use at least two identifiers. An identifier cannot be the person’s room or bed number. Some centers require that the person state his or her name and birth date. Others require using the person’s ID number. Always follow center policy.

• Call the person by name when checking the ID bracelet. This is a courtesy given as you touch the person and before giving care. Just calling the person by name is not enough to identify him or her. Confused, disoriented, drowsy, hard-of-hearing, or distracted persons may answer to any name.

Alert and oriented residents may choose not to wear ID bracelets. This is noted on the person’s care plan. Follow center policy and the care plan to identify the person.

Some nursing centers have photo ID systems (Fig. 12-3). The person’s photo is taken on admission. Then it is placed in the person’s medical record. If your center uses such a system, learn to use it safely.

Fig. 12-3 The person’s photo is at the head-board. Her name is under the photo. The nursing assistant is using the photo to identify the person.

See Promoting Safety and Comfort: Identifying the Person.

PROMOTING SAFETY AND COMFORT

Identifying the Person

Safety

Always identify the person before you begin a task or procedure. Do not identify the person and then leave the room to collect supplies and equipment. You could go to the wrong room and give care to the wrong person. And the person for whom the care was intended would not receive it. This too could cause harm.

Sometimes ID bracelets become damaged from water, spilled food and fluids, and everyday wear and tear. Make sure you can read the information on the ID bracelet. If you cannot, tell the nurse. The nurse can have a new bracelet made for the person.

Comfort

Make sure the person’s ID bracelet is not too tight. You should be able to slide 1 or 2 fingers under the bracelet. If it is too tight, tell the nurse.

Preventing burns

Burns are a leading cause of death among children and older persons. Smoking, spilled hot liquids, electrical items, and very hot water (hand sinks, tubs, showers) are some causes in nursing centers. Risk factors for burns in older persons are decreased skin thickness, decreased sensitivity to heat, reduced reaction time, decreased mobility, communication problems, confusion, and dementia.

Burn severity depends on water temperature and length of exposure (Table 12-1). The person’s condition also is a factor.

• Superficial (first degree) burn—involves the epidermis (top layer of skin). Sunburn is an example. The skin is red and painful to touch. There may be mild swelling.

• Partial-thickness (second degree) burn—involves the epidermis and dermis. The skin appears deep red. The person has pain and blisters. The skin may appear glossy from leaking fluid.

• Full-thickness (third degree) burn—the epidermis and dermis, fat, muscle, and bone may be injured or destroyed. These burns are not painful. Nerve endings are destroyed. The skin appears charred or has white, brown, or black patches.

Table 12-1

Water Temperature and Length of Exposure for a Third Degree Burn

Fahrenheit (F)	Centigrade (C)	Time Required for a Third Degree Burn to Occur
155° F	68° C	1 second
148° F	64° C	2 seconds
140° F	60° C	5 seconds
133° F	56° C	15 seconds
127° F	52° C	1 minute
124° F	51° C	3 minutes
120° F	48° C	5 minutes
100° F	37° C	Usually a safe temperature for bathing

Modified from Centers for Medicare & Medicaid Services: State operations manual, Baltimore, Md, April 10, 2009, U.S. Department of Health and Human Services.

The safety measures in Box 12-1 can prevent burns.

Box 12-1

Safety Measures to Prevent Burns

Eating and drinking

• Assist with eating and drinking as needed. Spilled hot food or fluids can cause burns.

• Be careful when carrying hot foods and fluids near older persons.

Water

• Turn on cold water first, then hot water. Turn off hot water first, then cold water.

• Measure bath or shower water temperature (Chapter 20). Check it before a person gets into the tub or shower.

• Check for “hot spots” in bath water. Move your hand back and forth.

Appliances

• See “Preventing Equipment Accidents” (p. 141).

• Do not allow the use of space heaters.

• Do not let the person sleep with a heating pad.

• Do not let the person use an electric blanket.

• Turn off curling irons, electric rollers, and hair dryers when not in use.

Smoking

• Be sure residents smoke only in smoking areas.

• Do not leave smoking materials at the bedside. They are only left at the bedside if the person is trusted to smoke alone in smoking areas. Follow the care plan.

• Supervise the smoking of persons who cannot protect themselves.

• Do not allow smoking in bed.

• Do not allow smoking where oxygen is used or stored (Chapter 28).

• Be alert to ashes that may fall onto an older person.

Other

• Follow safety guidelines when applying heat and cold (Chapter 35).

Preventing poisoning

Poisoning also is a health hazard and a major cause of death. Older persons are at risk. Drugs and household products are common poisons. Poisoning in adults may be from carelessness, confusion, or poor vision when reading labels. As a result, a person may take too much of a drug. Sometimes poisoning is a suicide attempt.

The measures in Box 12-2 can prevent poisoning.

Box 12-2

Safety Measures to Prevent Poisoning

• Keep harmful products in locked areas.

• Keep child-resistant caps on all harmful products.

• Store personal care items according to center policy. Soap, mouthwash, lotion, deodorant, and shampoo are examples. These items could cause harm when swallowed.

• Use and store harmful products according to the manufacturer’s instructions (p. 143).

• Do not leave harmful products unattended when in use.

• Make sure all harmful products are labeled (p. 144).

• Do not mix cleaning products.

• Read all labels carefully. Have good lighting.

• Keep harmful products in their original containers. Do not store them in food containers.

• Do not store harmful products near food.

• Discard harmful products that are outdated.

• Keep emergency numbers by the telephone: poison control center (1-800-222-1222), police, ambulance, hospital, and doctor.

Preventing suffocation

Suffocation is when breathing stops from the lack of oxygen. Death occurs if the person does not start breathing. Common causes include choking, drowning, inhaling gas or smoke, strangulation, and electrical shock (p. 141).

Carbon monoxide poisoning is another cause. Carbon monoxide is a colorless, odorless, and tasteless gas. It is produced by burning fuel. For example, motor vehicles, furnaces, gas water heaters, gas stoves, and gas dryers use fuel. These devices must be in good working order and used correctly. Otherwise, dangerous levels of carbon monoxide may result. Instead of breathing in oxygen, the person breathes in air filled with carbon monoxide. Headache, nausea, and dizziness are common. So are confusion, breathing problems, sleepiness, and cherry-pink skin. Death can occur.

Measures to prevent suffocation are listed in Box 12-3. Clear the airway if the person is choking.

Box 12-3

Safety Measures to Prevent Suffocation

• Cut food into small, bite-sized pieces for persons who cannot do so themselves.

• Make sure dentures fit properly and are in place.

• Make sure the person can chew and swallow the food served.

• Report loose teeth or dentures.

• Check the care plan for swallowing problems before providing food (including snacks) or fluids. The person may ask for something that he or she cannot swallow.

• Tell the nurse at once if the person has swallowing problems.

• Do not give oral food or fluids to persons with feeding tubes (Chapter 25).

• Follow aspiration precautions (Chapter 24).

• Do not leave a person unattended in a bathtub or shower.

• Move all persons from the area if you smell smoke.

• Position the person in bed properly (Chapter 16).

• Use bed rails correctly (Chapter 13).

• Use restraints correctly (Chapter 14).

• Prevent entrapment in the bed system (Chapter 18).

• See “Preventing Equipment Accidents” (p. 141).

Choking

Foreign bodies can obstruct the airway. This is called choking or foreign-body airway obstruction (FBAO). Air cannot pass through the air passages to the lungs. The body does not get enough oxygen. It can lead to cardiac arrest. Cardiac arrest is when the heart stops suddenly and without warning (Chapter 47).

Choking often occurs during eating. A large, poorly chewed piece of meat is the most common cause. Weakness, dentures that fit poorly, dysphagia (difficulty swallowing), and chronic illness are also causes.So are laughing and talking while eating and excessive alcohol intake.

Unconscious persons can choke. Common causes are aspiration of vomitus and the tongue falling back into the airway. These also occur during cardiac arrest.

Foreign bodies can cause mild or severe airway obstruction. With mild airway obstruction, some air moves in and out of the lungs. The person is conscious and usually can speak. Often forceful coughing can remove the object. Breathing may sound like wheezing between coughs. For mild airway obstruction:

• Stay with the person.

• Encourage the person to keep coughing to expel the object.

• Do not interrupt the person’s efforts to clear the airway. If breathing and coughing, abdominal thrusts are not needed.

• If the obstruction persists, call for help.

Difficulty breathing occurs with severe airway obstruction. Air does not move in and out of the lungs. The person may not be able to breathe, speak, or cough. If able to cough, the cough is of poor quality. When the person tries to inhale, there is no noise or a high-pitched noise. The person may appear pale and cyanotic (bluish color).

The conscious person clutches at the throat (Fig. 12-4). Clutching at the throat is often called the “universal sign of choking.” The conscious person is very frightened. If the obstruction is not removed, the person will die. Severe airway obstruction is an emergency.

Fig. 12-4 A choking person clutches at the throat.

Relieving choking

Abdominal thrusts are used to relieve severe airway obstruction. Abdominal thrusts are quick, upward thrusts to the abdomen. They force air out of the lungs and create an artificial cough. They are done to try to expel the foreign body from the airway.

RELIEVING CHOKING—ADULT OR CHILD (OVER 1 YEAR OF AGE)

Procedure

1 Ask the person if he or she is choking. Help the person if he or she nods “yes” and cannot talk.

2 Have someone call for help:

a In a public area, have someone activate the Emergency Medical Services (EMS) system by calling 911. Send someone to get an automated external defibrillator (AED). See Chapter 47.

b In a center, call the emergency response system. This team quickly responds to give care in life-threatening situations. Send someone to get the AED.

3 If the person is sitting or standing, give abdominal thrusts:

a Stand or kneel behind the person.

b Wrap your arms around the person’s waist.

c Make a fist with one hand.

d Place the thumb side of the fist against the abdomen. The fist is slightly above the navel in the middle of the abdomen and well below the end of the sternum (breastbone). See Figure 12-6, A, p. 140.

e Grasp the fist with your other hand (Fig. 12-6, B, p. 140).

f Press your fist into the person’s abdomen with a quick, upward thrust.

g Repeat thrusts until the object is expelled or the person becomes unresponsive.

4 If the person is lying down but responsive, give abdominal thrusts (Fig. 12-7).

a Straddle the person’s thighs.

b Place the heel of one hand against the abdomen. It is in the middle slightly above the navel and well below the end of the sternum (breastbone).

c Place your second hand on top of your first hand.

d Press both hands into the abdomen with a quick, upward thrust.

e Repeat thrusts until the object is expelled or the person becomes unresponsive.

5 If the person is obese or pregnant, give chest thrusts:

a Stand behind the person.

b Place your arms under the person’s underarms. Wrap your arms around the person’s chest.

c Make a fist. Place the thumb side of the fist on the middle of the sternum (breastbone).

d Grasp the fist with your other hand.

e Give thrusts to the chest until the object is expelled or the person becomes unresponsive.

6 If the object is dislodged, encourage the person to go to the hospital. Injuries can occur from abdominal or chest thrusts.

7 If the person becomes unresponsive, lower the person to the floor or ground. Position the person supine (lying flat on the back). Make sure EMS or the emergency response system was called (step 2). If alone, provide 5 cycles (2 minutes) of CPR first. Then call EMS or the emergency response system.

8 Start CPR. See Chapter 47.

a Do not check for a pulse. Begin with compressions. Give 30 compressions. Chest compressions help dislodge an obstruction.

b Use the head tilt-chin lift method to open the airway (Fig. 12-8). Open the person’s mouth. The mouth should be wide open. Look for an object. Remove the object if you see it and can remove it easily. Use your fingers.

c Give 2 breaths.

d Continue cycles of 30 compressions and 2 breaths. Look for an object every time you open the airway for rescue breaths.

9 If you relieve choking in an unresponsive person:

a Check for a response, breathing, and a pulse.

(1) If no response, normal breathing, or pulse—continue CPR. Attach an AED (Chapter 47).

(2) If no response and no normal breathing but there is a pulse—give rescue breaths. For an adult, give 1 breath every 5 to 6 seconds (10 to 12 breaths per minute). For a child, give 1 breath every 3 to 5 seconds (12 to 20 breaths per minute). Check for a pulse every 2 minutes. If no pulse, begin CPR.

(3) If the person has normal breathing and a pulse—place the person in the recovery position if there is no response (Chapter 47). Continue to check the person until help arrives. Encourage the person to go to the hospital if the person responds.

Abdominal thrusts are not used for very obese persons or pregnant women. Chest thrusts are used (p. 140).

You may observe a person choking. And you may perform emergency measures to relieve choking. Report and record what happened, what you did, and the person’s response (Fig. 12-5).

Relief of choking occurs when the foreign body is removed. Or it occurs when you feel air move and see the chest rise and fall when giving rescue breaths. The person may still be unresponsive.