CHAPTER 4 Supporting A Hygienic Environment

BEDMAKING
Bed making is one of the important nursing techniques to prepare various types of bed for patients or clients to ensure comfort
and useful position for a particular condition. The bed is especially important for patients who are sick. The nurse plays
inevitable role to ensure comfort and cleanliness for ill patient. It should be adaptable to various positions as per patient’s need
because they spend varying amount of the day in bed.
Purpose of Bed Making in Hospital:
Bed-making is a nursing art. The purpose of the bed-making should be patients or clients-centered. The main purposes of bed-
making are to prevent complications by ensuring comfort and security to patient.
To provide rest and sleep.
To provide physical and psychological comfort and security to the patient. To give the unit neat appearance.
To establish an effective nurse patients relationship. To provide active and passive exercise to the patient. To promote fresh and
cleanliness.
To develop skill in the posture/body alignment of the nurse in bed-making. To observe, identify and prevent patient’s
complications.
To accommodate the patient’s needs.
To reduce patient’s exertion by bed-making.
To eliminate irritants to skin from patient’s body. To dispose soiled and dirty linen properly.
Another purpose of bed-making is to save time, effort and material properly.

Basic Principle of Bed Making in Hospital:

Skillful bed making contributes patients comfort. Some basic principles of bed-making are pointed below
It is important to learn that how to make a bed in such a way where least amount of energy and time is required.
During bed-making, use good body movement and make each step purposeful. Keep everything ready on bed side before
starting bed-making.
Change bed linen frequently to assure cleanliness.
To ensure the patient need by providing a safe and comfortable bed. It should have a finished appearance.
To make bed tight and free from wrinkles, place all linen straight line on the bed. Prevent complications of prolonged bed
ridden patient such as pressure sore.
Soiled linen or linen whether clean or dirty should not be thrown on the floor, but it is should be kept in a dirty linen box.

After cleaning bed, dump soap water and disinfectant properly.

Try to prevent cross infection of microorganism during bed-making. Ensure all bed-making in a nursing unit alike for
uniformity of appearance.

Remember During Bed Making in Hospital:

During bed-making we should remember some knowledge those are useful for us and also to patient.
During bed-making, bed position keep elevated and ensures nursing staff’s good body alignments
During the procedure, the nurse should study her movements so as to avoid waste of time and energy.
After completing, bed should be lower position.
During occupied bed making, confirm patient safety and comfort.
Wash hands before and after bed making and use gloves during bed-making. Maintain privacy while making bed.
Keep soiled linen away from uniform which may have germs. Do not shake dirty linen to prevent germs spread around room.
Do not mix soiled and clean linen during bed-making.
For bed ridden patient, mattress must be turned air and ensure free of lumps and fold.

A: Occupied Bed
An occupied bed is making the bed where the patient physically available in the bed or the bed is being retained for patient.
Soiled linen is infectious to patient. If patient is unable to move or leave the bed, you will need to change the bed sheets while
the patient is occupied in bed. Occupied bed making is tough for the one person. This is best bed accomplished by two nurses.
Before starting procedure, make sure all supplies are ready beforehand to streamline the process as much as possible.
Purpose of Occupied Bed Making:
The main purposes of occupied bed making have listed in the following:
To provide a neat and clean bed.
To refresh the patient who is confined to the bed.
To change the linen with the least possible disturbance to the patient.
To draw or fix the sheets under the patients very firmly so that it would not wrinkle.
To remove crumbs from the bed.
To make patient feel comfortable.

Equipment of Occupied Bed Making:

The below equipment’s are very important for occupied bed making: Bed or cot,
Mattress with cover, Bed sheet -2,
Pillowcase -1 or 2,
1 Protective sheet and cotton draw sheet,
Mackintosh-1, Paper bag, Chair-1, Bucket-1.

Procedure of Occupied Bed Making:

All the procedures of occupied bed making have presented in the below:
Two nurses must work together when the patent is seriously ill or difficult to manage.
Wash hand before making occupied bed or occupied bed making.
Gather all equipment’s at patient bed side and explain procedure to patient.
Loosen the tucked linens at the foot part that covers all around the bed.
Remove pillow unless contraindication.
Place clean and dry top sheet over dirty top sheet and then remove the dirty linen one by one.
Leave one cover over the patient and maintain privacy by bed side screening.
Turn the patient on half of the bed on the other side of the bed and keep side rails up.
Place a pillow between patient and side rails.
Work on the unoccupied side of the bed and roll the draw sheet, mackintosh and bottom sheet if soiled.
Rolls the soiled linens toward patient back and tucks the roll slightly under the patient.
Covers dirty and moist areas of the soiled linen with a waterproof pad.
Place clean bottom sheet and tuck head part miter corner.
Place draw sheet over the mackintosh on near side of the mattress, with the center vertical fold at the center of the bed.
Place the patient on the clean side of the bed.
Work on the other side and remove dirty linens.
Make the other side of the bed and spread clean linens.
Tuck the head part of the bottom sheet, miter at the side.
Place patient to the center of the patient.
Place the pillow and make the patient comfortable.
Spread the top sheet and fold head part up to the patient chest.
Arrange blanket if necessary.

Remember During Occupied Bed Making in Hospital:

You must have to remember the below points during occupied bed making in hospital:
Maintain privacy as situations requires.
Carefully turn the patient to prevent over exertion and feeling insecurity.
Carefully observe the patient skin to identify any sign of bedsore.
If patient wear glasses, ask for removing to prevent broken and injury.
Ensure enough space for the patient to roll without smacking nose on a side rail.
Ensure patient’s arm on the bed is not in an awkward position when patient is rolled.
Ensure bed in flat position and rise to appropriate working height.
Remove patient’s personal items from bed and disconnects call devices.
Carefully checks that no tubes (such as IVS pole, Foley catheter, oxygen tube, gastric tube, NG tube, drain) are entangled in the
bed linens.
Apply diaper when patient in side position.
Do not place clean linen on another patient’s bed or furniture.
Keep side rails up when patient turn.
Keep bed sheet smooth and wrinkles free to prevent friction.
Ask patient help if patient can participate.
Place all dirty linens in laundry bag or hamper without contaminating uniform.
Never put soiled linen on the floor or on the other surfaces.
Return bed in low and safe position and keep side rails up.
After occupied bed making, attaches call light within patient’s reach.
Re-position bedside table and over bed table within patient reach.

B: Unoccupied Bed
An unoccupied bed is a bed that is empty at the time it is made and it is the easiest bed to make. The unoccupied bed can be
made either as a closed bed or as an open bed. When no client has been assigned to the bed, it is made as a closed bed. An open
bed is a bed to which a client is already assigned.

Objectives of Making an Unoccupied Bed

To meet the patient’s need by providing a safe comfortable bed.
For neatness and tidiness.
Principles of Bedmaking: (Techniques vary but principles are the same).
Have everything ready on hand before starting.
Remember that the bed is made for use, for durability and comfort and that it should have a finished appearance.
Place all linen on perfectly straight line on the bed, otherwise, it would be impossible to make bed tight and free from wrinkles.
All comes should look neat, smooth and firm.
Throughout the procedure, the nurse should study her movements so as to avoid waste of time and energy
When finished inspect the bed and see if it measures to the highest standard of health and comfort of the patient economy of
time, effort and materials and smooth finished appearance

Note: Do not use torn linen and in private rooms avoid stained linen.

Principles:
Safety:
Wash hands before proceeding. All beddings must be clean.
Protect mattress, pillows and rubber sheets from getting in contact with patient’s body. Avoid contact of beddings with floor
and other patient’s Unit.
Remove each piece of linen separately so that valuables will not be accidentally discarded.

Comfort:

Make under-bedding smooth, tight and securely tucked in.

Place upper bedding high enough to cover patients shoulder comfortably. Secure to bedding at foot so that it will stay in well
and be loose over the feet. Resources: (time, energy and materials)
Bring all equipment to bed at one time. Remove all used equipment at one time.
Avoid unnecessary trips around the bed by placing each piece on bed before going to far aide of bed.
Sure accurate movements will make it unnecessary to pat and straighten linen.

Workmanship:
Smooth tight bed with well-made corners. Smooth flat pillows with cases evenly fitted. Keep unit orderly during procedure.
Check unit for standard equipment and see that patient’s personal effects are in good order.
Place hand bell or signal cord within easy reach of patient.

C: Environment
Control of the environment has been the foundation of good nursing care in most settings throughout much of nursing's
professional history. More than a century ago, Florence Nightingale, the founder of modern nursing, and Lillian Wald, a public
health nurse advocate, voiced concerns about the environments in which people lived and worked. In 1860 Nightingale said:
In watching disease, both in private homes and public hospitals, the thing which strikes the experienced observer most forcibly
is this, the symptoms or suffering generally considered to be inevitable and incident to the disease are very often not symptoms
of the disease at all, but of something quite different—of want of fresh air, or of light, or of warmth, or of quiet, or of
cleanliness, or of punctuality and care in the administration of diet, of each or all of these.”
Clean air, clean water, moderate temperature and activity, healthy foods and rest formed the basis of nursing care for many
years. Today's nurses, working in all countries of the world under all conditions, continue to recognize the role of the natural
environment in human health and the interrelationship between the health of a country, a community or individual, and the
everyday environment.
Environmental Health
Environmental health comprises those aspects of human health, including quality of life, that are determined by physical,
chemical, biological, social, and psychosocial processes in the environment. It also refers to the theory and practice of assessing,
correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of
present and future generations.
According to the World Health Organization (WHO), "Health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity." We can, building on that definition, describe environmental health as freedom

from illness or injury resulting from exposure to toxic agents and environmental conditions potentially detrimental to human
health. Environmental hazards can be chemical, physical, biological, or psychosocial. For nurses, who work in all kinds of
settings, the health care environment can be the home, hospital, clinic, school, or workplace. Any environment can be
considered as coming under a nurse's purview. In this article, however, we will limit ourselves to the hospital, to medical waste,
and to pollution-prevention activities involving nurses.
Control of Temperature and Humidity in Hospitals
Temperature and relative humidity affect the airborne survival of viruses, bacteria and fungi. Thus, environmental control in
hospitals is important because of infectious disease transmission from the aerosol or airborne infection.
Environmental exposure is a common hazard for all such organisms (whether viruses, bacteria or fungi) during this journey
between hosts. Factors such as temperature, humidity (both relative and absolute), sunlight (ultraviolet light) exposure and even
atmospheric pollutants can all act to inactivate free-floating, airborne infectious organisms.
Maintaining hospital premises at a certain temperature and a certain relative humidity (%rh), likely to reduce the airborne
survival and therefore transmission of influenza virus. Temperature and RH settings in different parts of a hospital differ
slightly between summer and winter. In summer, the recommended room temperatures range from
23°C-27°C in the ER (emergency room), including in-patient and out-patient areas, as well as X-ray and treatment rooms and
offices. The corresponding recommended RH is fairly constant throughout the hospital, between 50- 60%rh. In winter, the
recommended temperatures are generally slightly lower, ranging from 20°C in some in-patient and out- patient areas, as well as
offices, up to 24°C -26°C in in-patient and out-patient areas.
Temperature is one of the most important factors affecting virus survival, as it can affect the state of viral proteins and the virus
genome. Virus survival decreases progressively at 20.5°C –24°C then < 30°C temperatures. This relationship with temperature
held throughout humidity range of 23%rh- 81%rh.

D: Definition of Terms
Bedmaking Occupied Bed Unoccupied Bed Closed Bed Open Bed Environment Soiled Bed Operative Bed Amputation Bed
Fractured Bed Blanket Bed

E: Types of Bed
Other types of hospital beds CLOSED BED
It is an empty bed in which the top covers are so arranged that all linen beneath the spread is fully protected from dust
and dirt.

Purposes of Closed Bed:

To provide the patient with a comfortable and safe bed to take rest and sleep.
To give the unit or ward a neat appearance.
To give medical and nursing treatment to the patient.
To prevent bed sores.
To promote cleanliness.
To provide active and passive movements to the patient.
To create an effective nurse-patient relationship
OPERATIVE BED
Preparation of a surgical bed permits easy patient transfer from surgery and promotes cleanliness and comfort.
Purposes of Operation Bed:

To receive the patient in a warm, and comfortable bed.

To give him necessary position, which is suitable for the operation.
To protect the patient from being chilled.
To be prepared to meet any emergency.
To protect the mattress and bedding from bleeding, vomiting, drainage or discharges.

AMPUTATION BED
Preparation of a surgical bed permits easy patient transfer from surgery and promotes cleanliness and comfort.

Purposes:

To Keep the stump in good position.

To be able to watch the stump for haemorrhage and apply tourniquet instantly if necessary.
To allow the nurse to do repeated procedures such as bladder irrigation, without exposing the patient.
To allow the nurse to make frequent observations. I.e. after amputation of the leg without disturbing the patient.

FRACTURE BED
Fracture Bed is prepared for patient with fracture of the trunk and extremities. A hard-firm board is used to give support.
Purposes:

To give firm, even support to the fracture limbs and back.

To maintain position.

To immobilize the fractured so that the pain is less.

To make the patient comfortable
BLANKET BED
Blanket bed is prepared for a patient with renal diseases or rheumatism.
Purposes:

To promote elimination through the skin.

To Provide absorption of patient's perspiration.
To carry the weight of the bed clothes off the painful joints.
To provide extra warmth to the body.

OSTOMY CARE
Introduction

Certain diseases and/or conditions involving the bowel or bladder require surgical intervention to create an opening into the
abdominal wall for fecal or urinary elimination. The creation of a bowel or urinary diversion may be temporary or permanent.
A portion of intestinal mucosa or segment of ureter is brought out to the abdominal wall, and a new opening is formed to allow
feces or urine to drain. This opening is called an ostomy.

The piece of intestine that is brought out onto the client's abdomen is called a stoma. The drainage from the stoma is called
effluent. A stoma can cause serious body image changes, particularly if it is permanent. You must help the client to understand
that a normal lifestyle is possible with an ostomy.

TYPES OF BOWEL DIVERSIONS

An enterostomy is any surgical

procedure that produces an artificial stoma in a portion of intestine through the abdominal wall. Surgical openings may be
created in the ileum (ileostomy) or colon (colostomy), with the ends of the intestine brought through the abdominal wall.

The location of the ostomy determines the consistency of stool passed or effluent passed. An ileostomy bypasses the entire large
intestine, so stools are liquid, frequently contain digestive enzymes, and must be pouched at all times. A colostomy of the
transverse colon generally results in a thicker, semi-formed stool.

There are various types of colostomy construction:

Loop colostomy: A loop colostomy is usually performed in a medical emergency when closure of the colostomy is
anticipated. The loop ostomy has two openings through the one stoma. The proximal end drains stool and the distal portion
drains mucus.

End colostomy: The end colostomy consists of one stoma formed from the proximal end of the bowel with the distal portion
of the GI tract either removed or sewn closed. For many clients, end colostomies are a result of surgical treatment of colorectal
cancer.

Double-barrel colostomy: In a double-barrel colostomy, the bowel is surgically severed and the two ends are brought out
onto the abdomen. The double- barrel colostomy consists of two distinct stomas. The proximal functioning stoma and the distal
nonfunctioning stoma. The distal stoma may excrete mucus.

STOMA CARE

A pouch is placed over the stoma to collect all effluent and protect the skin from irritating drainage. A pouch with its skin
barrier should fit comfortably, cover the skin surface around the stoma, and create a good seal. The skin barrier of a pouching
system should be changed every 3 to 5 days.

Many types of pouches and skin barriers are available. A clear pouching system allows visualization of the stoma without
having to remove the pouch. Some pouches have skin barriers directly pre-attached and are called one-piece pouching systems.
The manufacturer already precuts some of these one-piece pouches to size, whereas others must be custom cut to size for the
client's stoma measurement. One-piece pouches are open-ended pouches that can be opened periodically to empty effluent
without having to remove the pouch from around the stoma.

Other systems are two separate pieces. The pouch is applied to the skin barrier by attaching it to the flange (a plastic ring) on the
barrier. Often the skin barrier needs to be custom cut to the client's specific stoma size. For two-piece systems, the skin barrier
with flange must be used with the corresponding size pouch that fits that flange from the same manufacturer to prevent leakage.

SKILL: Changing a Bowel Diversion Ostomy Appliance

PURPOSES

To assess and care for the peristomal skin

To collect stool for assessment of the amount and type of output

To minimize odors for the client’s comfort and self-esteem

ASSESSMENT

Determine the following:

The type of ostomy and its placement on the abdomen. Surgeons often draw diagrams when there are two stomas. If there is
more than one stoma, it is important to confirm which is the functioning stoma.
The type and size of appliance currently used and the special barrier substance applied to the skin, according to the nursing care
plan.

Assess:

Stoma color: The stoma should appear red, similar in color to the mucosal lining of the inner cheek and slightly moist. Very
pale or darker-colored stomas with a dusky bluish or purplish hue indicate impaired blood circulation to the area. Notify the
surgeon immediately.

Stoma size and shape: Most stomas protrude slightly from the abdomen. New stomas normally appear swollen, but swelling
generally decreases over 2 or 3 weeks or for as long as 6 weeks. Failure of swelling to recede may indicate a problem, for
example, blockage.
Stomal bleeding: Slight bleeding initially when the stoma is touched is normal, but other bleeding should be reported.
Status of peristomal skin: Any redness and irritation of the peristomal skin—the 5 to 13 cm (2 to 5 in.) of skin surrounding the
stoma—should be noted. Transient redness after removal of adhesive is normal.
Amount and type of feces: Assess the amount, color, odor, and consistency. Inspect for abnormalities, such as pus or blood.
Complaints: Complaints of burning sensation under the skin barrier may indicate skin breakdown. The presence of abdominal
discomfort and/or distention also needs to be determined.
Learning needs of the client and family members regarding the ostomy and self-care.

The client’s emotional status, especially strategies used to cope with the body image changes and the ostomy.

Stoma Complications

Observe your client for any signs of possible stoma complications:

Bleeding

Necrosis (evidenced by purple or black discoloration in stoma with impaired circulation)

Prolapse

Hernia
Laceration

Irritation

Retraction

Stenosis

PLANNING
Review features of the appliance to ensure that all parts are present and functioning correctly.

DELEGATION

Care of a new ostomy is not delegated to UAP. However, aspects of ostomy function are observed during usual care and may be
recorded by a WOCN in addition to the unit nurse. Abnormal findings must be validated and interpreted by the nurse. In some
agencies, UAP may remove and replace well-established ostomy appliances.

PLANNING—URINARY OSTOMY EQUIPMENT

The equipment necessary to pouch a

urinary diversion includes the following:

Clean disposable gloves

Underpad, washcloth, towel, and warm water

Scissors with pointed end

Measuring guide

Tissue or toilet paper

Gauze pad or tampon

New pouch, skin barrier, and adhesive (if required)

Urinary drainage bag

Planning—Bowel Ostomy Equipment

The equipment necessary to pouch a bowel diversion includes the following:

Pouch: clear, drainable colostomy/ileostomy in correct size for two-piece system or custom cut-to-fit, one-piece type with
attached skin barrier

Pouch closure device, such as a clamp

Ostomy measuring guide

Adhesive remover (optional)

Clean disposable gloves

Ostomy deodorant

Gauze pads or washcloth

Towel or disposable waterproof barrier

Basin with warm tap water

Scissors

Skin barrier such as sealant wipes or wafer

Stoma paste or Stomahesive (optional)

Tape or ostomy belt

Planning—Expected Outcomes

You should explain the procedure as it is being performed. This lessens the client's anxiety and promotes the client's
participation.

Expected outcomes after completion of the procedure include:

The client is without discomfort.

The stoma is moist and reddish pink.

The skin is intact and free of irritation.

The stoma is functioning with a moderate amount of liquid or soft stool and flatus (bowel diversion) or moderate amount of
urine (urinary diversion) in the pouch.

The client observes the stoma and participates in ostomy care.

The client asks questions about the procedure and may attempt to assist with changing the pouch.

IMPLEMENTATION

Preparation

Determine the need for an appliance change.

Assess the used appliance for leakage of stool.

Rationale: Stool can irritate the peristomal skin.

Ask the client about any discomfort at or around the stoma.

Rationale: A burning sensation may indicate breakdown beneath the faceplate of the pouch.
Assess the fullness of the pouch. Rationale: The weight of an overly full bag may loosen the skin barrier and separate it from
the skin, causing the stool to leak and irritate the peristomal skin.
If there is pouch leakage or discomfort at or around the stoma, change the appliance.

Select an appropriate time to change the appliance.

Avoid times close to meal or visiting hours. Rationale: Ostomy odor and stool may reduce appetite or embarrass the client.
Avoid times immediately after meals or the administration of any medications that may stimulate bowel evacuation.
Rationale: It is best to change the pouch when drainage is least likely to occur.

The best time to change a pouching system is first thing in the morning or 2 to 4 hours after meals, when the bowel is least
active (Scemons, 2013, p. 37).

Performance

Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
Explain to the client what you are going to do, why it is necessary, and how he or she can participate.
Discuss how the results will be used in planning further care or treatments.

Changing an ostomy appliance should not cause discomfort, but it may be distasteful to the client.
Communicate acceptance and support to the client.

It is important to change the appliance competently and quickly. Include support people as appropriate.
Perform hand hygiene and observe other appropriate infection prevention procedures.
Apply clean gloves.
Provide for client privacy preferably in the bathroom, where clients can learn to deal with the ostomy as they would at home.

Assist the client to a comfortable sitting or lying position in bed or preferably a sitting or standing position in the bathroom.
Rationale: Lying or standing positions may facilitate smoother pouch application, that is, avoid wrinkles.
Unfasten the belt if the client is wearing one.

Empty the pouch and remove the ostomy skin barrier.

Empty the contents of a drainable pouch through the bottom opening into a bedpan or toilet.
Rationale: Emptying before removing the pouch prevents spillage of stool onto the client’s skin.
If the pouch uses a clamp, do not throw it away because it can be reused.

Assess the consistency, color, and amount of stool.

Peel the skin barrier off slowly, beginning at the top and working downward, while holding the client’s skin taut.
Rationale: Holding the skin taut minimizes client discomfort and prevents abrasion of the skin.
Discard the disposable pouch in a moisture-proof bag.

Clean and dry the peristomal skin and stoma.

Use toilet tissue to remove excess stool.

Use warm water, mild soap (optional), and a washcloth to clean the skin and stoma.

❶ Check agency practice on the use of soap.

Rationale: Soap is sometimes not advised because it can be irritating to the skin. If soap is allowed, do not use deodorant or
moisturizing soaps.
Rationale: They may interfere with the adhesives in the skin barrier.

Dry the area thoroughly by patting with a towel.

Rationale: Excess rubbing can abrade the skin.

Assess the stoma and peristomal skin.
Inspect the stoma for color, size, shape, and bleeding.

Inspect the peristomal skin for any redness, ulceration, or irritation. Transient redness after the removal of adhesive is normal.
10. Place a piece of tissue or gauze over the stoma, and change it as needed. Rationale: This absorbs any seepage from the
stoma while the ostomy appliance is being changed.
Prepare and apply the skin barrier (peristomal seal).

Use the guide

❷ to measure the size of the stoma.

On the backing of the skin barrier, trace a circle the same size as the stomal opening.

Cut out the traced stoma pattern to make an opening in the skin barrier.
❸ Make the opening no more than 1/8 inch larger than the stoma (Piras & Hurley, 2011).

Rationale: This allows space for the stoma to expand slightly when functioning and minimizes the risk of stool contacting
peristomal skin.
Remove the backing to expose the sticky adhesive side. The backing can be saved and used as a pattern when making an
opening for future skin barriers.

For a One-Piece Pouching System

Center the one-piece skin barrier and pouch over the stoma, and gently press it onto the client’s skin for 30 seconds.

❹,
❺ Rationale: The heat and pressure help activate the adhesives in the skin barrier.

For a Two-Piece Pouching System

Center the skin barrier over the stoma and gently press it onto the client’s skin for 30 seconds.
Remove the tissue over the stoma before applying the pouch.

Snap the pouch onto the flange or skin barrier wafer.

For drainable pouches, close the pouch according to the manufacturer’s directions.

Remove and discard gloves. Perform hand hygiene.

Document the procedure in the client record using forms or checklists supplemented by narrative notes when appropriate.
Record pertinent assessments and interventions. Report any increase in stoma size, change in color indicative of circulatory
impairment, and presence of skin irritation or erosion. Record on the client’s chart discoloration of the stoma, the appearance of
the peristomal skin, the amount and type of drainage, the client’s reaction to the procedure, the client’s experience with the
ostomy, and skills learned by the client.
MOBILITY AND EXERCISE

Overview

Mobility refers to the ability to engage in activity and unrestricted movement that includes walking, running, sitting, standing,
lifting, pushing, pulling and performing activities of daily living (ADL). Mobility is often considered an indicator of health
status because it influences the correct functioning of many body systems, especially the respiratory, gastrointestinal, and
urinary systems. Mobility enhances muscle tone , increases energy level, ang is associated with psychological benefits such as
independence and freedom.

Normal Movement
It is defined as the most efficient and economical movement or performance of a given task and is specific to individual. It is a
way to describe the optimal way to perform a certain movement.

One of the major contributors to normal movement is called postural control.

Postural control is the use of postural muscles of the body to maintain and achieve balance when performing self-initiated tasks
( example:reaching for a glass) or through external disturbances ( example: someone unexpectedly bumping into you).

It uses many sensory systems in our body (example: vision vestibular) to help provide stability during various static and
dynamic activities such as sitting, standing, walking or kneeling.

Alignment and Posture

One of the most important things about body mechanics and posture is
alignment.
Alignment refers to how the head, shoulders, spine, hips, knees and ankles relate and line up with each other. Proper alignment
of the body puts less stress on the spine and helps you have a good posture.
Good posture requires our spine and pelvic girdle to be in alignment or neutral.
When our spine is in correct alignment we place virtually no stress on our mucles,
joints, and ligaments. As Joseph Pilates stated “The age of your body is in direct relation to the age of your spine”.

Poor posture is where our bones are not aligned properly and our joints, muscles and ligaments take more stress and strain than
nature intended. Poor posturefrequntly results in aches and pains, particularly in our back, hips knees and shoulders.

Factors affecting body alignment and activity

Growth and Development
Physical Health
Mental Health
Nutrition
Personal Values and Attitudes
External Factors
Prescribed limitations
Problems with neck and posture are frequently seen together. People who work at computer screens or spend a lot of time sitting
will tend to acquire a forward head posture, compressing the back of the neck and the shoulders will begin to round forwards.
This is called upper crossed syndrome and causes tightness in the front of the chest and back of the neck, and weakness in
the upper back and front of the neck. So pain in our upper back frequently stems from this tendency to slump in the spine and
round the shoulders.

Joint Movements
A joint is a point where two or more bones meet. There are three main types of joints;
Fibrous (immovable), Cartilaginous (partially moveable) and the Synovial (freely movable joint).

Fibrous Joints
It is also called synarthrodial . It is held together by just a ligament. Examples are where the teeth are held to their bony sockets
and at both the radioulnar and tibiofibular joint.

Cartilaginous Joints
These joints (synchondroses and symphyses) occur where the connection between the articulating bones is made up of cartilage.
Example between vertebrae in the spine.

Synchondroses are temporary joints which are only present in children, up until the end of puberty . For example the epiphyseal
plates in long bones.
Symphysis joints are permanent cartilaginous joints, for example, the pubic symphysis.

Synovial joints
Also known as diarthrosis. Synovial joints are by far the most common classification of a joint within a human body. They are
highly movable and all have a synovial capsule (collagenous
structure) surrounding the entire joint , a synovial membrane (the inner layer of the capsule)
which secretes the synovial fluid ( a lubricating liquid) and cartilage known as hyaline cartilage which pads the ends of the
articulating bones.

Types of Synovial Joint

Hinge Joint
Movement - Flexion/ Extension
Examples: Elbow/ Knee
Pivot Joint
Movement- Rotation of one bone around another
Examples: Top of the neck ( atlas and axis bones)

Ball and Socket

Movement- Flexion/ Extension/ Adduction/ Abduction/ Internal Rotation/ External Rotation
Examples: Shoulder/ Hip

Saddle
Movement- Flexion/ Extension/ Adduction/ Abduction/Circumduction
Examples: CMC joint at the base of the thumb
Condyloid
Movement- Flexion/ Extension/ Adduction/ Abduction/Circumduction
Examples: Wrist/ MCP in the hand and MTP joints in the foot

Gliding
Gliding movements
Intercarpal joints in the hands

Balance
Balance is the ability to sit, stand or walk safely without postural deviation, falling or reaching external items for support.
Balance like gait is coordinated response of the neuromuscular and musculoskeletal systems as well as vision and sensory
perception. Vestibular and cortico-cerebellar levels in the brain are also involved in maintaining stability. Balance assessment is
used to evaluate the patient’s ability to maintain appropriate posture during functional activities. It is usually evaluated statically
and dynamically. Gait or walking is a coordinated action of the neuromuscular and musculoskeletal systems. The coordination
of muscle contraction, joint movement and sensory perception allows the human body to move in the environment. Individuals
with neuromuscular and/or musculoskeletal involvement may have abnormal or inappropriate muscle activation, joint motion,
or sensory perception.
The result may be decreased mobility and function, and altered gait. Gait assessment is important to identify areas of
impairment. Once a reason for gait impairment is determined, a treatment plan can be developed. The goals of therapy are to
minimize functional loss, restore mobility and promote safety

Cortico-cerebellar
Pertaining to the cerebellum and the cerebral cortex of the brain.
Dynamic
Movement such as walking that is due to muscle contracting.
Electromyography
An evaluation tool that detects electrical activity of muscles.
Force platform
A large plate, usually mounted in the floor, that records forces when an individual
stands or walks on it.
Forefoot
The front portion of the foot from the ankle.
Functional reach test

A test that evaluates stability when reaching out beyond an individual’s base of support.
In this test the patient stands and tries to reach out with one hand as far as possible
without losing balance. The reach is recorded in inches.

Get-up-and-go test
Evaluates balance during a functional activity. The test is scored based on the patient’s ability to get up from a chair, walk
forward about 10 feet (3m) , return to the chair and sit
down. The test may be timed to monitor progress.

Motion analysis
Use of instrumented system to record whole body and joint movement for later analysis.

Neuromuscular
Pertaining to the nervous and muscle systems.

Normative
A group that is free from dysfunction compared to a group that has dysfunction.

Proprioception
The ability to sense movement and position of the body.

Rear foot
The back portion of the foot that includes the ankle and heel.

Sensory Perception
The ability to perceive touch, pressure, pain and joint position in the limbs and trunk.

Static
Without movement, standing still, with or without, muscle contraction.
Tinnetti balance test
A battery of tests to assess balance and identify individuals at risk for falling.

Vestibular
Pertaining to the apparatus in the inner ear that senses orientation and movement of the body in space.

Coordinate body movement

Motor coordination is the combination of body movements created with the kinematic (such as spatial direction) and kinetic
(force) parameters that result in intended actions. Motor coordination is achieved when subsequent parts of the same movement,
or the movements of several limbs or body parts are combined in a manner that is well timed, smooth, and efficient with respect
to the intended goal.

This involves the integration of proprioceptive information detailing the position of movement of the musculoskeletal system
with the neural processes in the brain and spinal cord which control, plan, and relay motor commands. The cerebellum plays a
critical role in this neural control of movement and damage to this part of the brain or its connecting structures and pathways
results in impairment of coordination, knwn as ataxia.
Types of Exercise Definition:
Exercise is physical activity for conditioning the body, improving health,
and maintaining fitness. There are seven basic movements the human body can perform and all other exercises are merely
variations of these seven.
Range of Motion Exercises Overview:
Range of Motion (ROM) exercises are done to preserve flexibility and mobility of the joints on which they are performed.
These exercises reduce stiffness and will prevent or at least slow down the freezing of your joints as the disease progresses and
you move less often. Range of Motion is the term is the term that is used to describe the amount of movement you have at each
joint. Every joint in the body has “normal” range of motion. Joints maintain their normal range of motion by being moved. It is
therefore very important to move all your joints everyday. Stiff joints can cause pain and can make it hard for you to do your
normal activities.

Purposes:
Promote and maintain joint mobility
Prevent contractures and shortening of muscles and tendons
Increase circulation to extremities
Facilitate comfort for the patient

Kinds of ROM Exercises:

Active range of motion exercises
Exercises the client is able to perform independently.
Passive range of motion exercises
-Exercises performed for the client by someone else.
Active assisted range of motion exercises
Performed by a client with some assistance. Client can move a limb
partially through its ROM, but needs help completing the ROM.

Benefits of Exercise

Regular exercise and physical activity may:

Help you control your weight

Along with diet, exercise plays an important role in controlling your weight
and preventing obesity. To maintain your weight, the calories you eat and
drink must equal to energy you burn. To lose weight, you must use more
calories than you eat and drink.

Reduce your risk of heart disease

Exercise streghtens your heart and improves your circulation.
The increase
blood flow raises the oxygen levels in your body. This helps lower your risk
of heart disease s such as high cholesterol, coronary artery disease ,and
heart attack . It can also lower your blood pressure and triglyceride levels.

Help your body manage blood sugar and insulin levels

Exercise can lower your blood sugar level and help your insulin work better.
This can cut down your risk for metabolic syndrome and type 2 diabetes.
And if you have one of those diseases, exercise can help you to manage it.

Help you quit smoking

Exercise may make it easier to quit smoking by reducing your cravings and
withdrawal symptoms . It can also limit the weight you might gain when you
stop smoking.

Improve your mental health and mood

During exercise, your body releases chemicals that can improve your mood
and make you feel more relaxed. This can help you deal with stress
and reduce your risk of depression.

Help keep you, and judgment skills sharp as you age r thinking, learning
Exercise stimulates your body to release proteins and other chemicals that
improve the structure and function of your brain.
Strengthen your bones and muscles
Regular exercise can help kids and teens build strong bones. Later in life,
it can also slow the loss of bone density that comes with age. Doing muscle-
strengthening activities can help you increase or maintain your muscle mass
and strength .

Reduce your risk of some cancers

including colon, breast, uterine, and lung cancer.

Reduce your risk of falls

For older adults, research shows that doing balance and muscle-
strengthening activities in addition to moderate intensity aerobic activity
can help reduce your risk of falling.

Improve your sleep

Exercise can help you to fall asleep faster and stay asleep longer

Improve your sexual health

Regular exercise may lower the risk of erectile dysfunction (ED) in men.
For those who have ED , exercise may help improve their sexual function.
In women, exercise may increase sexual arousal.

Increase your chances of living longer

-Studies show that physical activity can reduce your risk of dying early from the leading causes of death, like heart disease and
some cancers.
Principles of Body Mechanics Definition:
Body Mechanics the term used to describe the efficient, coordinated,
and safe use of
the body to move objects and carry out the Activities of Daily Living (ADL’s)

Purposes:
To maintain good balance
To reduce the energy required
To avoid excessive fatigue
To avoid muscle strains or tears
To avoid skeletal injuries
To avoid injury to the patient
To avoid injury to assisting staff members

Principles:
The wider the base of support , the greater the stability.
The lower the center of gravity, the greater the stability
The equilibrium of an object is maintained as long as the line of gravity
passes through its base of support.
Facing the direction of movement prevents abnormal twisting of the spine.

Dividing balance activity between arms and legs reduces the risk of back injury.
It is easier to pull, push, or roll an object than it is to lift it.
Movements should be smooth and coordinated rather than jerky.
When friction is reduced between the object to be moved and the surface on which it is moved, less force is required to move it.
Less energy or force is required to keep an object moving than it is to start and stop it.
Use the arm and leg mucles as much s possible, the back muscles as little as possible.
Keep the work as close as possible to your body. It puts less of strain on your back , legs, and arms.
Keep the work at a comfortable height to avoid excessive bending at the waist.
Keep your body in good physical condition to reduce the chance of injury.
Rest between periods of work promotes work endurance.

Effects of Immobility

Neurologic
Sensory deprivation
Cardiovascular
-Increased cardiac workload
-Orthostatic hypotension
-Formation of thrombus
Respiratory
Increased respiratory effort
Hypostatic pneumonia
Altered gas exchange
Musculoskeletal
Decreased bone density ( Increased risk of fracture)
Contractures
Muscle atrophy
-Increased pain
Gastro intestinal
Decrease appetite
-Stress ulcers
-Constipation
-Fecal impaction
Urinary
-Urinary stasis
-Urinary Tract Infection
Calculi
Integumentary
Skin shearing
Pressure ulcers
Psychological
-Anxiety
Depression
Helplessness
-Hopelessness

Lifting Techniques
General considerations prior to action:
Know the weight of your patient and consider the mode of transportation ( gurney,
stretcher , wheelchair)
Know your own limitations and be realistic. If you cannot safely move the patient on
your own, get help.
Have a plan of action. Whether your working alone or with a partner,
know how you plan on moving the patient , what steps you’ll be taking, and what you
will do if Plan A doesn’t work.

Proper Technique for general movement

Consider your alignment. By keeping your head and neck aligned with your spine you
minimize the risk of your sprains and strains.
Bend and lift with the knees , not at the waist. Bending at the waist puts unnecessary
stress on your lower spine.
Avoid twisting your body, especially while bending, for the same reason as above.
Hold the patient close to your body while lifting and transferring them. The closer you
hold them the easier it is to maintain your natural center of gravity and remain steady
on your feet. By extending your arms, you engage weaker muscles and increase the risk
of slips, falls, and possibly dropping your patient.
Maintain a stance that is shoulder –width apart whenever possible, thus helping to
maintain your balance and distribute your patient’s weight evenly.
Moving and Turning Patients
Repositioning a patient in Bed
The longer a patient is confined to a bed the more like it is that you will have to reposition them, both for their comfort and to
avoid pressure ulcers or bed sores. This requires that there is a draw sheet already positioned under the patient , which is most
cases there will be.It is recommended that this is performed as atwo-person technique.
Lock the bed rails to prevent accidental falls.
Raise the bed waist height for a better spinal alignment for both you and your partner.
To roll a patient from their back to a side position, have one person grab the edge of the draw sheet while the person on the
opposite side of the bed gently holds the patient’s side. While one person pulls the sheet , causing the patient to begin a roll, the
second person assists the roll until the patient is lying comfortablyon their side.
Additionally, the patient can grab the side rail and pull themselves as the nurse or aide pulls the draw sheet behind them.
To move a patient up in the bed, such as from prone position to a seated position with their head centered higher, start with the
same two-person system. Getting to a close as possible to the patient and while maintaining proper stance, both people shouls
slide their hands under the patient’s upper back and knees and lift until the patient is shifted up the head.

Transferring Patients

Bed to Wheelchair

Preparation:
Think through the steps before you act, and get help if you need it. If you are not able to support the patient by yourself, you
could injure yourself and the patient.
Make sure any loose rugs are out of the way to prevent slipping. You may want to put non-skid socks or shoes on the patient’s
feet if the patient needs to step onto a slippery surface.

The following steps should be followed:

Explain the steps to the patient.

Park the wheelchair next to the bed, close to you.
Put the brakes on and move the footrests out of the way.

Getting a Patient Ready to Transfer:

Before transferring into the wheelchair, the patient must be sitting. patient feels dizzy

-Allow the patient to sit for a few moments, incase the when first sitting up.

Steps To get the patient into a seated position, roll the patient onto and one use the

the same side as the wheelchair.

Put one of your arms under the patient’s shouldersbehind the knees .

Swing the patien’s feet off the edge of the bed and momentum to help the patient into a sitting

position. the bed so

Make the patient to the edge of the bed and lower the patient’s feet are touching the ground

Pivot Turn
If you have a gait belt, place it on the patient to help you get a grip during the transfer . During the turn, the patient can either
hold onto you or reach for the wheelchair.
Stand as close as you can to the patient , reach around the chest, and lock your hands behind the patient or grab the gait belt.

Steps:
Place the patient’s outside leg ( the one farthest from the wheelchair) between your knees for support . Bend your knees and
keep your back straight.
Count to three and slowly stand up. Use your legs to lift.
At the same time, the patients hould place their hands by their sides and help push off the bed.
The patient should help support their weighton their good leg during the transfer.
Pivot towards the wheelchair , moving your feet so your back is aligned with your hips.
Once the patient’s legs are touching the seat of the wheelchair , bend your knees to lower the patient into the seat. At the same
time, ask the patient to reach for the wheelchair armrest.

Reminder: If the patient starts to fall during the transfer, lower the person to the nearest flat surface, bed, chair, or floor.

Chair to Bed
Steps:
Position the wheelchair directly next to the bed. A slight angle 30-45 degrees is helpful but not absolutely necessary.
Lock the wheelchair breaks and move the footrests out of the way of the feet. The armrest on the side you will be transferring to
can also be moved out of the way if desired.
Always talk to the person being transferred so that assistance is being given at the appropriate time, allowing for coordination of
efforts.

SAFETY, SECURITY AND PRIVACY

Applying Restraints
The most common reasons for restraints in healthcare agencies are to prevent falls, to prevent injury to self and/ or others and to
protect medically necessary tubes and catheters such as an intravenous line and a tracheostomy tube, for example.

All healthcare environments adopt the philosophy and goal of a restraint free environment; however, it is not often possible to
prevent the use of restraints and seclusion. These are rare occasions when the use of restraints is not preventable because the
restraints have become the last resort to protect the client and others from severe injuries.

A “restraint” is defined as any physical or chemical means or device that restricts client’s freedom to and ability to move about
and cannot be easily
remove or eliminated by the client.
A “physical restraint” is defined as “any manual method or physical or mechanical device , material, or equipment attached to
or adjacent to resident’s body that the individual cannot remove easuly which restricts freedom of movement or normal access
to one’s body”, according to the Centers for Medicare and Medicaid Services. (e.g. Vest restraint to prevent a patient fall)

A “ chemical restraint” is defined as “any drug used for discipline or convenience and not required to treat medical symptoms”
according
to the Centers for Medicare and Medicaid Services.
(e.g. Sedating medication to control disruptive behavior)

Other terms:

A “safety device”, also referred to as a protective device, is defined as a device that is customarily used for a particular
treatment. Safety devices are not considered a restraint, even though they limit freedom of movement, because they are a device
that is customarily and traditionally used for a particular treatment.
(e.g. An intravenous arm board that is used to stabilize an intravenous line).

“Preventive measures” is defined as those things that are done to prevent the use of restraints.

The “least restrictive restraint” is defined as the restraint that permits the most freedom of movement to meet the needs of the
client.

( e.g Mittens are the least restrictive device or restraint that can be
use to prevent dislodging of catheters and medically necessary lines such as the intravenous line or a central venous device.

Assessing the Appropriateness of the Type of Restraint Used

Nurses assess and determine the need for a client to be restrained or secluded and they are also assess the appropriateness of the
type of restraint/ safety device that is used in context with the client’s current condition and behaviors; they assess and reassess
the client in a regular and ongoing basis to insure that the client is safe and that their needs have been met when the use of
restraints or seclusion cannot be avoided.
These assessments also explore the client’s condition within the context of the appropriateness of the restraint in terms of its
being the least restrictive alternative and being used for the shortest possible period of time.

Following the Requirements for the Use of Restraints and Safety Devices According to the Joint Commission on
the Accreditation of Health care Organizations and the Centers for Medicare and Medicaid Services, there are many regulations
and requirements that address restraints and restraint

use including:
The initiation and evaluation of preventive measures that can prevent the use of restraints
The use of the least restrictive restraint when a restraint is necessary
Monitoring the client during the time that a restraint has been applied
The provision of care to clients who are restrained

Alternative Preventive Measures

Some of the preventive, alternative measures that can be decrease the need for restraints to prevent a fall include:

Accurate client assessment for the risk of falls

The immediate initiation of special falls risk interventions when a client is
assessed as “at risk” for falls
More frequent monitoring
Providing frequent reminders to the client to call for help before arising from the bed or chair
Using bed and chair alarms
Using a companion, sitter, etc.
Reorienting the person

Some of the preventive, alternative measures that can be decrease the need for restraints in order to prevent violent behaviors
that place self and /or others at risk for imminent harm include:
Behavior management techniques
Behavior modificationtechniques
Keepint the client away from triggers
Stress management and relaxation techniques
Positive and Negative reinforcements

Restraint Orders
A complete doctor’s order is needed to initiate the use of restraints except under extreme emergency situations when a
registered nurse can initiate the emergency use of restraints using an established protocol until the doctor’s order is obtained
and/ or the dangerous behaviors no longer exist. Restraints without a valid and
complete order are considered false imprisonment. The minimal components of orders for restraint include the reason for and
rationale for the use of the restraint, the type of restraint to be used, how long the restraint can be used , the client behaviors that
necessitated the use of the restraints and any special instructions beyond and above those required by the facility’s policies and
procedures.

The Least Restrictive Restraint

The least restrictive restraint to correct the problem like falls and the dislodgment of tubes, lines and catheters is used when
restraints are necessary.

Restraints, from the least restrictive to the most restrictive, are:

Mitten restraints that are used to prevent the dislodgment of tubes, lines
and catheters
Wrist restraints that are used to prevent the dislodgment of tubes, lines and catheters
A vest restraint that is used to prevent falls as well as disturbed violent behavior
Arm and leg restraints that are used to prevent violent behavior
Leather restraints that are also to prevent violent behavior

Reminder: Restraints should NEVER be used for staff convenience or client punishment.

Monitoring the Client during Restraint

When you monitor the patient or resident who Is restrained, you must observe and monitor the patient’s physical condition, the
patient’s emotional state , and the patient’s resposes to the restraint or seclusion

Is the patient safe?

Are the restraints still in place and safely applied? Are the patient’s vital signs normal?
Are the skin color, intactness of the skin, and circulation good? Is the restraint too tight?
Is the patient comfortable and without any physical needs that you can attend to like toileting, food and / or fluids?
Is the person confused?
Is the patient or resident angry, upset or agitated? Is the person afraid or fearful?

After the restraint is applied, initial monitoring is done whenever necessary but at least every 15 minutes for the first hour by a
licensed independent practitioner (LP)
or the qualified registered nurse (RN). When the patient or resident is stable and without significant changes, the monitoring and
correlate documentation is then done at least every 4 hours for adults , every 2 hours for chidren from 9 to 17 years of age, and
at least every hour for those less than 9 years of age.

The scope of monitoring must include an evaluation or reassessment of the patient’s:

Physical status, including vital signs, any injuries, nutrition, hydration, circulation,
range of motion, hygiene, elimination and physical comfort.

Psychological and emotional status, including psychological comfort and the maintaining of dignity, safety and patient rights.
Restraint need, discontinuation readiness and how the patient or resident acts
and reacts when the restraint is temporarily removed for ongoing care. Does the
patient’s or resident’s condition justify the need for continuation of the current
restraint device , a less or more restrictive restrain or the discontinuation of restraints?
The correct and safe application, removal and reapplication of the restraint.

The provision of Care to Restrained Clients

The following aspects of care must be provided as needed to a restrained patient
or resident and documented at least every two (2) hours when the person is retrained for non-behavioral reasons, and at least
every four (4) hours when the person is restrained for behavioral reasons and more often for children,every two (2) hours for
those 9 to 17 years of age, and at least every hour for those less than 9 years of age unless the person needs more frequent care.

The components of this care are based on the client’s needs and it typically includes:
Range of motion exercices to the restrained body part unless the person is sleeping
Turning and repositioning the individual
Skin care if the skin assessment indicates a need to do so
Checking the circulatory status of the affected body part
Providing for all other physical needs such as toileting, hydration, nutrition, etc.
Providing for the patient’s psychological needs, such as their need for dignity and
respect and freedom from anxiety.

Some facilities use restraint flow sheets to document and record the use of restraints, the monitoring of the client, the care
provided and the responses of
the patient who is restained or in seclusion. When this flow sheets are not used,
the nurse must document all monitoring and care elements in the progress notes.

Monitoring and Evaluating Client Response to Restraints and Safety Devices When the registered nurse monitors
and evaluates the client’s responses to the restraints or safety device, the nurse will assess and evaluate the client and their:

Mental Status.
Is the person afraid or fearful?
Is the person confused?
Is the person or resident angry, upset or agitated?
Physical Status.
Is the person safely restrained and safe from strangulation from a vest restraint, for example?
Are the client’s respiratory and circulatory systems normal?
Is the person clean, comfortable , and dry?
Is the skin showing any signs of irritation or breakdown?
Response to the Restraints.
Has the person improved to the point where they may no longer need of the restraint?

Operating the Fire Extinguisher

Fires and Fire Prevention:

Fire prevention in health care facilities includes the education and training of staff, smoke detectors, sprinkler systems, fire
doors and policies and procedures relating to fire and fires threats including no smoking policies, oxygen and medical gases use,
maintenance and storage policies and procedures, and electrical safety policies and procedures.

The procedure for dealing with and managing patients during a fire is easily remembered with the acronym RACE. You MUST
RACE when a fire starts. RACE includes these elements in correct sequential order of priority.

R: Step number one is rescue everyone in danger; get all clients and visitors out of danger by following the fire plan set up
and established by the facility you work in.
A: Step number two is pull the alarm.
C: Step number three is to contain the fire in the smallest possible area by closing all windows and doors. This prevents the
fire from spreading to other areas of the healthcare facility.
E: Step number four is extinguishing the fire when it is small enough to do so safely.

Step one, which is rescuing everyone in danger , may mean that nurses and
other members of the nursing team must follow instructions for a vertical for a vertical or horizontal evacuation of patients.
When patients are moved from one level or floor of the health care facility to another floor, it is referred to as vertical
evacuation; and when you move patients from one area of the floor to another area on the same floor , it is referred to as a
horizontal evacuation. Elevators are never used to evacuate because elevators are for the exclusive use of fire fighters and the
equipment that is necessary to extinguish the fire. All medical facilities and households must have fire extinguishers

Different types of Fire Extinguishers and their uses:

Type A fire extinguisher
- Used to put out fires on common solid things like paper, mattresses and cloth including clothing. This type of fire extinguisher
is somewhat limited.
Type B fire extinguisher
- Used to fight oil, gasoline and grease fires, including kitchen grease fires. It is also limited in terms of its use. For example ,
Type B fire extinguisher cannot be used to combat an electrical fire.
Typde C fire extinguisher
- Used to extinguish electrical fires.
Type AB fire extinguishers
-Combine the uses of a Type A and type B fire extinguishers. They can be used in solids , like paper, wood, cloth as well as oil,
gasoline and grease.
Type ABC fire extinguishers
- It is a combination of A,B,and C uses.They are used for all types of fires. They are the ideal choice for home and in most areas
of a health care facility.

It is required for all fire extinguishers to be checked regularly to insure that they are fully charged and ready to use in an
emergency.

Using a fire extinguisher is quite simple if you remember and use the acronym PASS :
Pull the pin on the fire extinguisher.
Aim at the bottom of the fire.
Squeeze the trigger on the fire extinguisher to release the spray and then
Sweep the spray from side to side over the base of the fire until it is extinguished.

When a person has clothing that has caught on fire, the person should STOP, DROP AND ROLL. Tell the person, to
STOP,DROP, and not to run, and as you also cover the person with a blanket to smother the fire.

GET LOW AND GO if a room fills with smoke . Some and heat rise so get to the floor and crawl out.

The Nurse’s Role in Responding to External Disasters:

Performing the Heimlich Maneuver

- Heimlich Maneuver, also known as Abdominal Thrust is a procedure used to help a
choking person who is conscious and unstable to talk. The Heimlich maneuver pushes air out of the person,s lungs and make
him cough. The force of the cough may then move the object out of his airway.
Providing side rails Patient Safety
-Patients who have problems with memory, sleeping, inconteninence, pain uncontrolled body movement, or who get out of bed
and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling.
Assessment by the patient’s health care team will help to determine how to best keep the patient safe. Historically, physical
straints (such as vest, ankle or wrist restraints) where used to try keep patient safein health care facilities. In recent years, the
health care community has recognized that physical restraining patients can be dangerous. Although not indicated for this use,
bed rails are sometimes used as restarints. Regulatory agencies, health care organizations, product manufacturers and advocacy
groups encourage hospitals, nursing homes providers to assess patient’s and to provide safe care without restraints.

The Benefits and Risks of Bed Rails

Potential Benefits of bed rails include:
Aiding in turning and repositioning within the bed.
Providing a hand-hold for getting into or out of bed.
Providing a feeling of comfort and security.
Reducing the risk of patients falling out of bed when being transported.
Providing easy access to bed controls and personal care items.

-Potential risk of bed rails may include:

Strangling, suffocating, bodily injury or death when patients part of their body caught between rails or between the rails and
mattress.
More serious injuries frm falls when patients climb over rails.
Skin bruising, cuts , and scrapes.
Inducing agitated behavior when bed rails are used as a retraint.
Feeling isolated or unnecessarily restricted.
Preventing patients, who are able to get out of bed , from performing routine activities such as going to the bathroom or
retrieving something from a closet.
Meeting Patients Needs for Safety:
Use beds that can be raised and lowered closed to the fllorto accommodate bothpatient and health worker needs.
Keep the bed in the lowest position with wheels locked.
When the patient is at risk of faaling ot of bed, place mats next to the bed, as long as this does not create a greater risk of
accident.
Use transfer or mobility aids.
Monitor patients frequently.
Anticipate the reason patients get out of bed such as hunger, thirst, going to the, bathroom, restlessness, and pain; meet these
needs by offering food and fluids, scheduling ample toileting and providing calming intervention and pain relief.
When bed rails are used, perform an on-going assessment of the patient’s physical and mental status; closely monitor high risk
patients. Consider the following:
Lower one or more sections of the bed rail, such as the foot rail.
Us e a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the matress and
rail.
Reduce the gaps between the matress and side rails.

Which Ways of Reducing Risks are Best?

A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety. Many patients go
through a period of adjustment to become comfortable with new options. Patients and their families should talk to their health
care planning team to find out which options are best for them.
Strangling, suffocating, bodily injury or death when patients part of their body caught between rails or between the rails and
mattress.
More serious injuries frm falls when patients climb over rails.
Skin bruising, cuts , and scrapes.
Inducing agitated behavior when bed rails are used as a retraint.
Feeling isolated or unnecessarily restricted.
Preventing patients, who are able to get out of bed , from performing routine activities such as going to the bathroom or
retrieving something from a closet.

Meeting Patients Needs for Safety:

Use beds that can be raised and lowered closed to the fllorto accommodate bothpatient and health worker needs.
Keep the bed in the lowest position with wheels locked.
When the patient is at risk of faaling ot of bed, place mats next to the bed, as long as this does not create a greater risk of
accident.
Use transfer or mobility aids.
Monitor patients frequently.
Anticipate the reason patients get out of bed such as hunger, thirst, going to the, bathroom, restlessness, and pain; meet these
needs by offering food and fluids, scheduling ample toileting and providing calming intervention and pain relief.
When bed rails are used, perform an on-going assessment of the patient’s physical and mental status; closely monitor high risk
patients. Consider the following:
Lower one or more sections of the bed rail, such as the foot rail.
Us e a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the matress and
rail.
Reduce the gaps between the matress and side rails.

Which Ways of Reducing Risks are Best?

A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety. Many patients go
through a period of adjustment to become comfortable with new options. Patients and their families should talk to their health
care planning team to find out which options are best for them.

Patient or Family Concerns About Bed Rail Use- If patients or family ask about using bed rails, health care providers should:

Encourage patients or family to talk to their health care planning team to determine whether or not bed rails are indicated.
Reassure patients and their families that in many cases the patient can sleep safely without bed rails.
Reassess the need for using bed rails on a frequent, regular basis.

Providing bed pan (male and female)

Toileting Aids to Assist Immobile Patients- There are a various types of bedpans, urinals and mobile toileting aids that
can be used when a patient or user has limited mobility, caused either by a medical condition or during a period of surgical
recovery.

Example: Bedpans are designed to be as comfortable as possible to the user, also helping carers to support individuals and help
them retain dignity and independence.

Introduction

Bedpan use in today’s society is not that different fron use I the 18th century. Bedpans are a way of addressing elimination
concerns when the traditional toilet is not an option due to high risk of injury or debilitating illness in sick, bed- confined
indivividuals.

There are two types of bedpans: regular or fracture.

Regular- is larger than its fracture counterpart

Fracture – has one flat end for ease of use with specific patient populations

Indications:

Medical necessity may warrant the use of a bedpan, for example as with immobile patients with the following concerns:

Fractures: hip, lower extremity

Debilitating illness or profound fatigue

Surgical considerations
High fall risk and increased injury potential

Obstetrical and gynecological

Equipment:

Bedpans come in regular size or a smaller, fracture pan. Bedpans are chosen based on diagnosis, patient comfort or
preference and if any contraindications exist for using the regular size such as a fracture. Gather all supplies
before you start the procedure.
Supplies:
Bedpan: Fracture or regulas with bariatic considerations
Personal protective equipment such as gloves
Hand hygiene products, soap, a basin of water
Incontinence pads, diapers
Linens such as wash cloths, sheets, privacy blankets
Disposable wipes
Privacy Curtain
Powder if advised per policy and no contraindicationfor use exist
Toilet paper
Trashcan
Soiled linen hamper and location of the dirty soiled utility room
Graduated cylinder to measure output if a requirement
Stool containers if cultures or other fecal tests are necessary

Steps:
Lower the head of the bed to place the patient on the bedpan and when removing the pan, especially if in a patient that can not
assist in raising their hips.
Address patient by their given name and introduce yourself, provide your name and title. Ensure identification of your patient
with two unique identifiers.
Explain what is about to happen and determine if the patient has any requests to facilitate task related to past experiences.
Perform hand hygiene.
Ensure patient privacy by pulling curtains. If in a semi-private room, consider asking any visiting family to leave the room.
Bedpa use is often a souce of embarrassment and discomfort for the patient, maintain patient dignity at all times.
Put gloves on and follow any isolation precautions in place that requires gowns or other personal protective equipment (PPE).
Raise the bed to a comfortable height which ensures proper ergonomic principles are followed to prevent a back injury.
An incontinence pad should be placed under the patient to act as aprotective barrier from soiling the linens.
The pad gets placed on the bottom sheet, under perineal area including buttocks and upper thighs.
Place the bedpan under the patient by assisting the patient to roll on their side with their buttocks toward the healthcare provider
Powder or tissue paper may be used to prevent the patient’s skin from adhering to the pan. Do not use powder if any
contraindications for use.
(e.g. wounds, allergies , sensitivities)

The bedpan will be placed under the patient according to the contour or shape of the device. The wide area of the bedpan points
towards the patient’s head and narrow area towards feet.
Make sure the buttocks are firm against the bedpan, pushed in a down ward motion into the stretcher or mattress pad.
Hold the bedpan with one hand and the hip with the other and roll the patient onto the bedpan.
Avoid patient injury by never forcibly facing the pan under the buttocks. If a bariatric bedpan is needed, multiple staff members
should assist to prevent injury to staff and patients.

Factors affecting safety What is Safety?

S- Sense the error
A- Act to prevent it
F- Follow Safety Guidelines
E- Enquire into accidents/ deaths
T- Take appropriate remedial measure
Y- Your responsibility

Categories of factors emerged that could affect patient involvement in safety:

Patient- Related ( e.g patients’ demographic characteristics)
Illness- Related (e.g illness severity)
Health-Care Professional -Related
( e.g health care professional’s knowledge and beliefs )
Health Care setting –Related ( e.g primary or secondary care)
Task-Related (e.g whether the required patient safety behavior challenges clinician’s clinical abilities)

Keywords:
patient involvement
patient participation
patient safety
treatment decision-making

Promoting safety across the lifespan

Safety is a fundamental concern of all nurses. From bedside to the community, nurses see to it that accidents and injuries are
prevented. From a simple act of reminding patients to call them whenever they need assistance , to preparing emergency
equipment, nurses demonstrate the act of being protectors of patients under their care.

Despite nurses’ attentiveness, accidents cannot be totally avoided. Part of nurses’responsibilities is to assist those who have
been injured due to vehicle accidets, drowning, fires, and poisoning. There is a great

need for nurses to have a high awareness of the elements of a safe environment. Moreover, accidents are usually caused by
human conduct. Thus accidents can be prevented.

Newborns and Infants

The first year of life is prone to accidents.It is not surprising that accidents are the leading cause of death in infants. Being
dependent on others for care and them being oblivious to hints of danger make them vulnerable to injuries.
Common accidents during infancy include burns, choking and suffocation, falls and poisoning. Here’s how nurses and parents
alike can promote a safe environment for newborns and infants:
Use a federally approved car seat at all times. It should be in the back seat, facing backward.
Never leave the infant unaatended on a raised surface.
Check the temperature of the baby’s bath water and formula prior to using.
Hold the infants upright during feeding . Do not prop the bottle. Cut food into small pieces, and do not feed the infants peanuts
or popcorn.
Provide large soft toys with no small detachable or sharp-edged parts.
Cover electric outlets. Coil cords out of reach.
Place plants, household cleaners, and wastebaskets out of reach. Lock away potential poisons ( e.gmedicines, paints, and
gasoline)
Toddlers

Preventing specific hazards- Before getting into some of the common dangers of nursing, remember: many professions
have safety issues and threats. But reducing risk and accident prevention can help, as can using best practices and following
proper protocols for activities like:

Lifting and moving patients

Handling sharp objects
Dealing with chemicals
Wearing protective clothing and equipment
Following safety procedures and precautions in the hospital.
The more you protect yourself and the more precautions you take , the better equipped you will be to stay safe , healthy and
happy.

How do Nursing Hazards Affect Patient Care?

The phrase “ Culture of Safety” is a term you might have heard. A culture of safety is one that elevates the importance of
keeping patients safe from errors and injury.
Yet, workplace safety for nurses does not always receive the attention it should. The reality is, failing to keep nurses safe from
workplace hazards, illness or injury can have direct consequences on patient care.

Bottom line: When nurses are healthy, well rested, and safe on the job, they have more job satisfaction ( and life
satisfaction)overall – which in turn, has an impact on patient outcomes and quality of care.

J. Transferring Patients Bed to Wheelchair

Follow these steps to move a patient from a bed to wheelchair. The techniques below assumes the patient can stand on at least
one leg.
If the patient cannot use at least one leg , you will need to use a lift to transfer the patient.
Preparation:
Think through the steps before you act, and get help if you need it. If you are not able to support the patient by yourself, you
could injure yourself and the patient.
Make sure any loose rugs are out of the way to prevent slipping. You may want to put non-skid socks or shoes on the patient’s
feet if the patient needs to step onto a slippery surface.
The following steps should be followed:
Explain the steps to the patient.
Park the wheelchair next to the bed, close to you.
Put the brakes on and move the footrests out of the way.
Getting a Patient Ready to Transfer:
Before transferring into the wheelchair, the patient must be sitting.Allow the patient to sit for a few moments, in case the patient
feels dizzy when first sitting up.
The following steps should be followed when getting ready to transfer a patient:
To get the patient into a seated position, roll the patient onto the same side as the
wheel chair.
Put one of your arms under the patient’s shoulders and one behind the knees.
Swing the patient’s feet off the edge of the bed and use the momentum to help the patient into a sitting position.
Make the patient to the edge of the bed and lower the bed so the patient’s feet are touching the ground.
Pivot Turn
If you have a gait belt, place it on the patient to help you get a grip during the transfer.
During
the turn, the patient can either hold onto you or reach for the wheelchair.

Stand as close as you can to the patient, reach around the chest, and lock your hands behind
the patient or grab the gait belt.

Steps:
Place the patient’s outside leg (the one farthest from the wheelchair) between your knees for support. Bend your knees and keep
your back straight.
Count to three and slowly stand up. Use your legs to lift.

At the same time, the patients hould place their hands by their sides and help push off the bed.
The patient should help support their weighton their good leg during the transfer.
Pivot towards the wheelchair , moving your feet so your back is aligned with your hips.
Once the patient’s legs are touching the seat of the wheelchair , bend your knees to lower the patient into the seat. At the same
time, ask the patient to reach for the wheelchair armrest.
Reminder: If the patient starts to fall during the transfer, lower the person to the nearest flat surface, bed, chair, or floor.
Wheelchair to Bed
As with any transfer, the environment must to be set up appropriately beforehand for successful completion. Transfers between
level surfaces tend to be easier to perform. To perform a true pivot transfer, the two surfaces should be adjacent to each other so
that no steps need to be taken. The floor should be dry and clear of obstacles to preventslips and tips.
Steps:
Position the wheelchair directly next to the surface (bed, toilet, tub bench ,car, sofa, etc.). A slight angle 30-45 degrees is helpful
but not absolutely necessary.
Lock the wheelchair breaks and move the footrests out of the way of the feet. The armrest on the side you will be transferring to
can also be moved out of the way if desired.
Always talk to the person being transferred so that assistance is being given at the appropriate time, allowing for coordination
of efforts.
Gait/ transfer belt should be placed securely.
Move person’s bottom to the front of surface they are sitting on so that the feet are
in firm contact with the floor.
If needed, assistance can be given to block the person’s knees to provide additional support for weight bearing.
To complete the transfer, the person should lean forward over their feet , use their hands to push from the surface they are
sitting on , swing their bottom around to the adjuscent surface nand slowly sit back down.

Bed to Stretcher
If a patient can’t move independently between a bed and stretcher, gather at least three nurses to perform the transfer. ( Four or
five nurses may be needed to safely transfer a patient who’s extremely delibitated or overweight; obese patients require a
hydraulic lifter). Obtain a transfer board or transfer sheet to reduce the risk of injury to the patient or a nurse.

Steps:
Lower the head of the bed so the patient is flat (unless contraindicated or not tolerated) and cover the with a sheet or blanket for
privacy and warmth. Explain the procedure and assess level of consciousness, ability to understand and follow directions, and
ability to assist with the transfer. Close door or draw the curtains for privacy and perform hand hygiene. (Use personal
protective

equipment if indicated). Raise the level of the bed so it’s slightly higher than the stretcher. Make sure the brakes are locked on
both the bed and stretcher.
Remove the pillow from the bed and place it on the stretcher. Ask the patient to roll away from the stretcher. ( help the patient
turn, if necessary). Then place the sliding board over the gap between the bed and stretcher.
Help the patient return to a supine position on the sliding board and ask to cross the patient’s arm on chest.
Eacg nurse should assume a broad base of support with one foot in front of the other and knees and hips flexed, keeping the
body aligned and the back straight. On the count of three, the two nurses on the stretcher side of the bed should gently pull the
sliding board towards themselves.
Roll the patient to side and remove the sliding board.
Center the patient on the stretcher with body in alignment. Make sure the patient is comfortable and raise the rails on the
stretcher.