S



S



6630


Seclusion


Definition: Solitary containment in a fully protective environment with close surveillance by nursing staff for purposes of safety or behavior management


Activities:



• Obtain a physician’s order, if required by institutional policy, to use a physically restrictive intervention


• Designate one nursing staff member to communicate with the patient and to direct other staff


• Identify for patient and significant others those behaviors that necessitated the intervention


• Explain procedure, purpose, and time period of the intervention to patient and significant others in understandable and nonpunitive terms


• Explain to patient and significant others the behaviors necessary for termination of the intervention


• Contract with patient (as patient is able) to maintain control of behavior


• Instruct on self-control methods, as appropriate


• Assist in dressing in clothing that is safe and in removing jewelry and eyeglasses


• Remove all items from seclusion area that patient might use to harm self or others


• Assist with needs related to nutrition, elimination, hydration, and personal hygiene


• Provide food and fluids in nonbreakable containers


• Provide appropriate level of supervision and surveillance to monitor patient and to allow for therapeutic actions, as needed


• Inform patient of video surveillance, as appropriate


• Explain reasons for the video monitoring


• Give careful consideration to who is responsible for watching the video monitor for changes in patient status


• Reassure patient of safety within the seclusion area during monitoring


• Distinguish direct visual inspection from checks performed through video monitoring and document appropriately


• Acknowledge your presence to patient periodically


• Administer PRN medications for anxiety or agitation


• Provide for patient’s psychological comfort, as needed


• Monitor seclusion area for temperature, cleanliness, and safety


• Reduce sensory stimuli around the seclusion area


• Arrange for routine cleaning of seclusion area


• Evaluate, at regular intervals, patient’s need for continued restrictive intervention


• Involve patient, when appropriate, in making decisions to move to a more or less restrictive intervention


• Determine patient’s need for continued seclusion


• Document rationale for restrictive intervention, patient’s response to intervention, patient’s physical condition, nursing care provided throughout intervention, and rationale for terminating the intervention


• Process with the patient and staff, on termination of the restrictive intervention, the circumstances that led to the use of the intervention, as well as any patient concerns about the intervention itself


• Provide the next appropriate level of restrictive intervention (e.g., physical restraint or area restriction), as needed


1st edition 1992; revised 2013



5380


Security Enhancement


Definition: Intensifying a patient’s sense of physical and psychological safety


Activities:



• Provide a nonthreatening environment


• Demonstrate calmness


• Spend time with patient


• Offer to remain with patient in a new environment during initial interactions with others


• Stay with the patient and provide assurance of safety and security during periods of anxiety


• Present change gradually


• Discuss upcoming changes (e.g., an interward transfer) before event


• Avoid causing intense emotional situations


• Give pacifier to infant, as appropriate


• Hold a young child or infant, as appropriate


• Facilitate a parent’s staying overnight with the hospitalized child


• Facilitate maintenance of patient’s usual bedtime rituals


• Encourage family to provide personal items for patient’s use or enjoyment


• Listen to patient’s/family’s fears


• Encourage exploration of the dark, as appropriate


• Leave light on at night, as needed


• Discuss specific situations or individuals that threaten the patient or family


• Explain all tests and procedures to patient/family


• Answer questions about health status in an honest manner


• Help the patient/family identify what factors increase sense of security


• Assist patient to identify usual coping responses


• Assist patient to use coping responses that have been successful in the past


1st edition 1992



2260


Sedation Management


Definition: Administration of sedatives, monitoring of the patient’s response, and provision of necessary physiological support during a diagnostic or therapeutic procedure


Activities:



• Review patient’s health history and results of diagnostic tests to determine if patient meets agency criteria for conscious sedation by a registered nurse


• Ask patient or family about any previous experiences with conscious sedation


• Check for drug allergies


• Determine last food and fluid intake


• Review other medications patient is taking and verify absence of contraindications for sedation


• Instruct the patient and/or family about effects of sedation


• Obtain informed written consent


• Evaluate the patient’s level of consciousness and protective reflexes before administering sedation


• Obtain baseline vital signs, oxygen saturation, EKG, height, and weight


• Ensure emergency resuscitation equipment is readily available, specifically a source to deliver 100% oxygen, emergency medications, and a defibrillator


• Initiate an IV line


• Administer medication as per physician’s order or protocol, titrating carefully, according to patient’s response


• Monitor the patient’s level of consciousness and vital signs, oxygen saturation, and EKG, as per agency protocol


• Monitor the patient for adverse effects of medication, including agitation, respiratory depression, hypotension, undue somnolence, hypoxemia, arrhythmias, apnea, or exacerbation of a preexisting condition


• Ensure availability of and administer antagonists, as appropriate, per physician’s order or protocol


• Determine if the patient meets discharge or transfer criteria (i.e., Aldrete scale), as per agency protocol


• Document actions and patient response, as per agency policy


• Discharge or transfer patient, as per agency protocol


• Provide written discharge instructions, as per agency protocol


2nd edition 1996; revised 2000, 2004




2680


Seizure Management


Definition: Care of a patient during a seizure and the postictal state


Activities:



1st edition 1992; revised 2013



2690


Seizure Precautions


Definition: Prevention or minimization of potential injuries sustained by a patient with a known seizure disorder


Activities:



• Provide low-height bed, as appropriate


• Escort patient during off-ward activities, as appropriate


• Monitor drug regimen


• Monitor compliance in taking antiepileptic medications


• Have patient or significant other keep record of medications taken and occurrence of seizure activity


• Instruct patient not to drive


• Instruct patient about medications and side effects


• Instruct family or significant other about seizure first aid


• Monitor antiepileptic drug levels, as appropriate


• Instruct patient to carry medication alert card


• Remove potentially harmful objects from the environment


• Keep suction at bedside


• Keep Ambu bag at bedside


• Keep oral or nasopharyngeal airway at bedside


• Use padded side rails


• Keep side rails up


• Instruct patient on potential precipitating factors


• Instruct patient to call if aura occurs


1st edition 1992; revised 2013




5390


Self-Awareness Enhancement


Definition: Assisting a patient to explore and understand his/her thoughts, feelings, motivations, and behaviors


Activities:



• Encourage patient to recognize and discuss thoughts and feelings


• Assist patient to realize that everyone is unique


• Assist patient to identify the values that contribute to self-concept


• Assist patient to identify usual feelings about self


• Share observation or thoughts about patient’s behavior or response


• Facilitate patient’s identification of usual response patterns to various situations


• Assist patient to identify life priorities


• Assist patient to identify the impact of illness on self-concept


• Verbalize patient’s denial of reality, as appropriate


• Confront patient’s ambivalent (angry or depressed) feelings


• Make observation about patient’s current emotional state


• Assist patient to accept dependency on others, as appropriate


• Assist patient to change view of self as victim by defining own rights, as appropriate


• Assist patient to be aware of negative self-statements


• Assist patient to identify guilty feelings


• Help patient identify situations that precipitate anxiety


• Explore with patient the need to control


• Assist patient to identify positive attributes of self


• Assist patient/family to identify reasons for improvement


• Assist patient to identify abilities, learning styles


• Assist patient to reexamine negative perceptions of self


• Assist patient to identify source of motivation


• Assist patient to identify behaviors that are self-destructive


• Facilitate self-expression with peer group


• Assist patient to recognize contradictory statements


1st edition 1992; revised 2004



1800


Self-Care Assistance


Definition: Assisting another to perform activities of daily living


Activities:



• Consider the culture of the patient when promoting self-care activities


• Consider age of patient when promoting self-care activities


• Monitor patient’s ability for independent self-care


• Monitor patient’s need for adaptive devices for personal hygiene, dressing, grooming, toileting, and eating


• Provide a therapeutic environment by ensuring a warm, relaxing, private, and personalized experience


• Provide desired personal articles (e.g., deodorant, toothbrush, and bath soap)


• Provide assistance until patient is fully able to assume self-care


• Assist patient in accepting dependency needs


• Use consistent repetition of health routines as a means of establishing them


• Encourage patient to perform normal activities of daily living to level of ability


• Encourage independence, but intervene when patient is unable to perform


• Teach parents/family to encourage independence, to intervene only when the patient is unable to perform


• Establish a routine for self-care activities


1st edition 1992; revised 2008




1801


Self-Care Assistance: Bathing/Hygiene


Definition: Assisting patient to perform personal hygiene


Activities:



• Consider the culture of the patient when promoting self-care activities


• Consider age of patient when promoting self-care activities


• Determine amount and type of assistance needed


• Place towels, soap, deodorant, shaving equipment, and other needed accessories at bedside or in bathroom


• Provide desired personal articles (e.g., deodorant, toothbrush, bath soap, shampoo, lotion, and aromatherapy products)


• Provide a therapeutic environment by ensuring a warm, relaxing, private, and personalized experience


• Facilitate patient brushing teeth, as appropriate


• Facilitate patient bathing self, as appropriate


• Monitor cleaning of nails, according to patient’s self-care ability


• Monitor patient’s skin integrity


• Maintain hygiene rituals


• Facilitate maintenance of patient’s usual bedtime routines, presleep cues/props, and familiar objects (e.g., for children, a favorite blanket/toy, rocking, pacifier, or story; for adults, a book to read or a pillow from home), as appropriate


• Encourage parent/family participation in usual bedtime rituals, as appropriate


• Provide assistance until patient is fully able to assume self-care


1st edition 1992; revised 2008



1802


Self-Care Assistance: Dressing/Grooming


Definition: Assisting patient with clothes and appearance


Activities:



• Consider the culture of the patient when promoting self-care activities


• Consider age of patient when promoting self-care activities


• Inform patient of available clothing for selection


• Provide patient’s clothes in accessible area (e.g., at bedside)


• Provide personal clothing, as appropriate


• Be available for assistance in dressing, as necessary


• Facilitate patient combing hair, as appropriate


• Facilitate patient shaving self, as appropriate


• Maintain privacy while the patient is dressing


• Help with laces, buttons, and zippers, as needed


• Use extension equipment for pulling on clothing, if appropriate


• Offer to launder clothing, as necessary


• Place removed clothing in laundry


• Offer to hang up clothing or place in dresser


• Offer to rinse special garments, such as nylons


• Provide fingernail polish, if requested


• Provide makeup, if requested


• Reinforce efforts to dress self


• Facilitate assistance of a barber or beautician, as necessary


1st edition 1992; revised 2008




1803


Self-Care Assistance: Feeding


Definition: Assisting a person to eat


Activities:



• Monitor patient’s ability to swallow


• Identify prescribed diet


• Set food tray and table attractively


• Create a pleasant environment during mealtime (e.g., put bedpans, urinals, and suctioning equipment out of sight)


• Ensure proper patient positioning to facilitate chewing and swallowing


• Provide physical assistance, as needed


• Provide for adequate pain relief before meals, as appropriate


• Provide for oral hygiene before meals


• Fix food on tray, as necessary, such as cutting meat or peeling an egg


• Open packaged foods


• Avoid placing food on a person’s blind side


• Describe location of food on tray for person with vision impairment


• Place patient in comfortable eating position


• Protect with a bib, as appropriate


• Provide a drinking straw, as needed or desired


• Provide foods at most appetizing temperature


• Provide preferred foods and drinks, as appropriate


• Monitor patient’s weight, as appropriate


• Monitor patient’s hydration status, as appropriate


• Encourage patient to eat in dining room, if available


• Provide social interaction as appropriate


• Provide adaptive devices to facilitate patient’s feeding self (e.g., long handles, handle with large circumference, or small strap on utensils), as needed


• Use a cup with a large handle, if necessary


• Use unbreakable and weighted dishes and glasses, as necessary


• Provide frequent cueing and close supervision, as appropriate


1st edition 1992; revised 2008



1805


Self-Care Assistance: IADL


Definition: Assisting and instructing a person to perform instrumental activities of daily living (IADL) needed to function in the home or community


Activities:



• Determine individual’s need for assistance with IADL (e.g., shopping, cooking, housekeeping, laundry, use of transportation, managing money, managing medications, use of communication, and use of time)


• Determine needs for safety-related changes in the home (e.g., wider door frames to allow for wheelchair access to bathroom, removal of scatter rugs)


• Determine needs for home enhancements to offset disabilities (e.g., large numbers on telephones, increased volume of telephone ringer, laundry and other facilities located on main floor, side rails in hallways, grab bars in bathrooms)


• Provide for methods of contacting support and assistance people (e.g., lifeline; list of telephone numbers for police, fire, poison control, and assistance people)


• Instruct individual on alternative methods of transportation (e.g., buses and bus schedules, taxis, city or county transportation for disabled people)


• Provide cognitive enhancing techniques (e.g., up-to-date calendars, clearly legible and understandable lists such as medication times, easy-to-see clocks)


• Obtain transportation enhancements to offset disabilities (e.g., hand controls on cars, wide rear-view mirror), as appropriate


• Obtain tools to assist in daily activities (e.g., ability to reach items in cupboards, in closets, on countertops, on stovetops, and in refrigerator, and ability to operate household equipment such as stoves and microwaves)


• Determine financial resources and personal preferences regarding modifications to home or car


• Instruct individual to wear clothing with short or tight-fitting sleeves when cooking


• Verify adequacy of lighting throughout house, especially in working areas (e.g., kitchen, bathroom), and at night (e.g., appropriately placed nightlights)


• Instruct individual not to smoke in bed or while reclining, or after taking mind-altering medication


• Verify presence of safety equipment in home (e.g., smoke detectors, carbon monoxide detectors, fire extinguishers, hot water heater set to 120° F)


• Determine whether individual’s monthly income is sufficient to cover ongoing expenses


• Obtain visual safety devices or techniques (e.g., painting edges of steps bright yellow, rearrange furniture for safety when walking, reduce clutter throughout walkways of house, install nonskid surfaces in showers and bathtubs)


• Assist individual in establishing methods and routines for cooking, cleaning, and shopping


• Instruct individual and caregiver on what to do in the event the individual suffers from a fall or other injury (e.g., what to do, how to gain access to emergency services, how to prevent further injury)


• Determine if physical or cognitive ability is stable or declining and respond to changes in either, accordingly


• Consult with occupational and/or physical therapist to deal with physical disability


• Instruct assisting person in completing appropriate setting-up tasks so that individual can complete task (e.g., chop up vegetables so individual can cook with them, place clothing to wear for the day in an easy-to-reach place, unpack groceries on countertop for eventual storage)


• Provide appropriate container for used sharps, as appropriate


• Instruct individual on appropriate and safe storage for medications


• Instruct individual on appropriate use of monitoring equipment (e.g., glucose-monitoring device, lancets)


• Instruct individual on appropriate methods of dressing wounds and appropriate disposal of soiled dressings


• Verify that individual is able to open medication containers


• Refer to family and community services, as needed


4th edition 2004





1806


Self-Care Assistance: Transfer


Definition: Assisting a patient with limitation of independent movement to learn to change body location


Activities:



• Review chart for activity orders


• Determine current ability of patient to transfer self (e.g., mobility level, limitations of movement, endurance, ability to stand and bear weight, medical or orthopedic instability, level of consciousness, ability to cooperate, ability to comprehend instructions)


• Select transfer technique that is appropriate for patient


• Instruct patient in all appropriate techniques, with the goal of reaching the highest level of independence


• Instruct individual on techniques for transfer from one area to another (e.g., bed to chair, wheelchair to vehicle)


• Instruct individual in use of ambulatory aids (e.g., crutches, wheelchairs, walkers, trapeze bars, cane)


• Identify methods to prevent injury during transfer


• Provide assistive devices (e.g., bars attached to walls, ropes attached to headboard or footboard for help in moving to center or edge of bed) to help individual transfer independently, as appropriate


• Make sure equipment works before using it


• Demonstrate technique, as appropriate


• Determine amount and type of assistance needed


• Assist patient in receiving all necessary care (e.g., personal hygiene, gathering belongings) before performing the transfer, as appropriate


• Provide privacy, avoid drafts, and preserve the patient’s modesty


• Use proper body mechanics during movements


• Keep patient’s body in proper alignment during movements


• Raise and move patient with a hydraulic lift, as necessary


• Move patient using a transfer board, as necessary


• Use a belt to assist a patient who can stand with assistance, as appropriate


• Assist patient to ambulate using your body as a human crutch, as appropriate


• Maintain traction devices during move, as appropriate


• Evaluate patient at end of transfer for proper body alignment, nonocclusion of tubes, wrinkled linens, unnecessarily exposed skin, adequate patient level of comfort, raised side rails, and call bell within reach


• Provide encouragement to patient as he/she learns to transfer independently


• Document progress, as appropriate

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