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Chapter 9: Safety and Security

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Chapter 9: Safety and Security

6 problems · 0 figures

Case Study 9.1.1 §9.1 source ↗

Refer back to Chapter 8 Admission, Transfer, and Discharge for Unfolding Case Study Parts 1–2 to review the patient data. A 65-year-old patient was admitted to the cardiology unit for observation after a suspected myocardial infarction. The patient went to the cardiac catheterization lab, where two coronary artery stents were successfully placed. The patient has just returned to her room after the procedure. During morning rounds, the team noted the patient appears restless and agitated. She repeatedly attempts to get out of bed without assistance, despite reminders to call the nurse before getting up.

Past Medical History Medical history: Hypertension, type 2 diabetes, coronary artery disease
Family history: Mother deceased, father alive with severe dementia; two healthy sons in their early 40s
Social history: Previous divorce, married to current husband, George, for twenty years
Allergies: Latex
Current medications:

• Aspirin 81 mg PO once daily

• Metformin 500 mg PO twice daily

• Lisinopril 10 mg PO once daily

• Atorvastatin 30 mg PO once daily
Flow Chart 1200: Assessment
Blood pressure: 135/82 mm Hg
Heart rate: 97 beats/min
Respiratory rate: 20 breaths/min
Temperature: 98.6°F (37°C)
Oxygen saturation: 95 percent on room air
Pain: 5/10 (headache)
Nursing Notes 1200: Assessment
Patient reports headache pain rated 5/10 on numerical scale. Oxycodone previously administered at 1030 for postprocedure pain.
Recognize cues: What cues are most concerning to the nurse at this time?

Answer

The most concerning cue is the patient’s inability to remain safely in bed. It is also concerning that the patient is restless and agitated, as this may be indicative of an underlying problem.

Case Study 9.1.2 §9.1 source ↗

Refer back to Chapter 8 Admission, Transfer, and Discharge for Unfolding Case Study Parts 1–2 to review the patient data. A 65-year-old patient was admitted to the cardiology unit for observation after a suspected myocardial infarction. The patient went to the cardiac catheterization lab, where two coronary artery stents were successfully placed. The patient has just returned to her room after the procedure. During morning rounds, the team noted the patient appears restless and agitated. She repeatedly attempts to get out of bed without assistance, despite reminders to call the nurse before getting up.

Past Medical History Medical history: Hypertension, type 2 diabetes, coronary artery disease
Family history: Mother deceased, father alive with severe dementia; two healthy sons in their early 40s
Social history: Previous divorce, married to current husband, George, for twenty years
Allergies: Latex
Current medications:

• Aspirin 81 mg PO once daily

• Metformin 500 mg PO twice daily

• Lisinopril 10 mg PO once daily

• Atorvastatin 30 mg PO once daily
Flow Chart 1200: Assessment
Blood pressure: 135/82 mm Hg
Heart rate: 97 beats/min
Respiratory rate: 20 breaths/min
Temperature: 98.6°F (37°C)
Oxygen saturation: 95 percent on room air
Pain: 5/10 (headache)
Nursing Notes 1200: Assessment
Patient reports headache pain rated 5/10 on numerical scale. Oxycodone previously administered at 1030 for postprocedure pain.
Analyze cues: Based on the recognized cues, what safety concerns should the nurse have?

Answer

Based on the cues assessed, the nurse should be concerned about the patient’s increased risk for falls. Additionally, the nurse may have concerns related to the patient’s mental status since they are exhibiting signs of restlessness and agitation following the procedure.

Case Study 9.1.3 §9.1 source ↗

Refer back to Chapter 8 Admission, Transfer, and Discharge for Unfolding Case Study Parts 1–2 to review the patient data. A 65-year-old patient was admitted to the cardiology unit for observation after a suspected myocardial infarction. The patient went to the cardiac catheterization lab, where two coronary artery stents were successfully placed. The patient has just returned to her room after the procedure. During morning rounds, the team noted the patient appears restless and agitated. She repeatedly attempts to get out of bed without assistance, despite reminders to call the nurse before getting up.

Past Medical History Medical history: Hypertension, type 2 diabetes, coronary artery disease
Family history: Mother deceased, father alive with severe dementia; two healthy sons in their early 40s
Social history: Previous divorce, married to current husband, George, for twenty years
Allergies: Latex
Current medications:

• Aspirin 81 mg PO once daily

• Metformin 500 mg PO twice daily

• Lisinopril 10 mg PO once daily

• Atorvastatin 30 mg PO once daily
Flow Chart 1200: Assessment
Blood pressure: 135/82 mm Hg
Heart rate: 97 beats/min
Respiratory rate: 20 breaths/min
Temperature: 98.6°F (37°C)
Oxygen saturation: 95 percent on room air
Pain: 5/10 (headache)
Nursing Notes 1200: Assessment
Patient reports headache pain rated 5/10 on numerical scale. Oxycodone previously administered at 1030 for postprocedure pain.
Prioritize hypotheses: What factors do you think may be contributing to the patient’s inability to remain safely in bed?

Answer

The patient was given oxycodone, which could alter their mental status and their ability to remain safe when out of bed. Additionally, the patient just returned to the unit from a procedure where sedation and pain medications were likely administered. Other factors that may potentially be affecting the patient’s ability to remain safely in bed include age, sensory impairments, and/or vision problems. It is important for the nurse to assess for and address these underlying issues to decrease the patient’s risk for falls.

Case Study 9.1.4 §9.1 source ↗

Refer back to Unfolding Case Study: Unfolding Case Study #2: Part 3 for a review of the patient data.

Nursing Notes 1400: Assessment
During hourly rounding, patient was found lying on the floor. Patient states, “I needed to go to the bathroom, but you were taking too long to come help me!” Upon further assessment, the bed alarm was turned off, and there was no evidence of the patient’s call light being pushed for assistance. Patient was helped back to bed by three nursing staff and fall reported to charge nurse.
Generate solutions: What interventions could the nurse implement to prevent the patient from falling again?

Answer

The nurse should implement fall risk precautions including moving the patient’s room closer to the nurse’s station, applying fall risk socks and arm bands, keeping the bed locked and in the lowest position, and turning on the bed alarm. The nurse should assess why the bed alarm was off and if the patient is able to turn it off themselves. If they can do so, other interventions such as a 1:1 sitter may need to be initiated.

Case Study 9.1.5 §9.1 source ↗

Refer back to Unfolding Case Study: Unfolding Case Study #2: Part 3 for a review of the patient data.

Nursing Notes 1400: Assessment
During hourly rounding, patient was found lying on the floor. Patient states, “I needed to go to the bathroom, but you were taking too long to come help me!” Upon further assessment, the bed alarm was turned off, and there was no evidence of the patient’s call light being pushed for assistance. Patient was helped back to bed by three nursing staff and fall reported to charge nurse.
Take action: What are the priority actions by the nurse at this time?

Answer

Before anything else, the nurse must ensure that the patient is safe and uninjured from the fall. After getting the patient back to bed, the nurse should conduct a thorough physical assessment and document any apparent bruising or marks left from the fall. The nurse should also notify the provider about the fall, as they may want to order imaging to look for internal injury, especially of the head. After confirming that the patient is not injured from the fall, an incident report must be filed by the nurse.

Case Study 9.1.6 §9.1 source ↗

Refer back to Unfolding Case Study: Unfolding Case Study #2: Part 3 for a review of the patient data.

Nursing Notes 1400: Assessment
During hourly rounding, patient was found lying on the floor. Patient states, “I needed to go to the bathroom, but you were taking too long to come help me!” Upon further assessment, the bed alarm was turned off, and there was no evidence of the patient’s call light being pushed for assistance. Patient was helped back to bed by three nursing staff and fall reported to charge nurse.
Evaluate outcomes: After implementing fall risk precautions for the patient, what findings would indicate that the interventions were successful?

Answer

The patient should remain safely in bed and free from harm after the implementation of fall precautions. The patient and patient’s family members should also express understanding of the care plan and need for fall risk precautions. If the patient continues to get up from the bed without assistance, the care plan will need to be revised and reevaluated to find more effective solutions.

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Problems and answers are adapted from Fundamentals of Nursing by Christy Bowen, Lindsay Draper and Heather Moore, OpenStax, and are used under the CC BY-NC-SA 4.0 licence. Access for free at https://openstax.org/books/fundamentals-nursing/pages/1-introduction. Illustrations: Copyright Rice University, OpenStax, under CC BY-NC-SA 4.0 license. This adaptation is released under the same licence, is non-commercial, and is neither affiliated with nor endorsed by OpenStax or Rice University.