Safety

Procedures Checklist
BED OR CHAIR EXIT SAFETY MONITORING DEVICE

Procedure 30-1: Using a Bed or Chair Exit Safety Monitoring Device

Performed
Preparation Yes No Mastered Comments
1. Assess:
• Mobility status
• Judgment about ability to get out
of bed safely
• Proximity of client’s room to
nurses’ station
• Position of side rails
• Functioning status of call light
2. Determine:
• Appropriate location for the
device
• If the device will be applied to a
thigh, ensure that the location has
intact skin.
3. Assemble equipment and supplies:
• Alarm and control device
• Sensor
• Connection to nurse call system
(optional)
Procedure
1. Explain to the client what you are
going to do, why it is necessary, and
how she can cooperate.
2. Wash hands and observe
appropriate infection control
procedures.
3. Provide for client privacy.
4. Explain to client and support
persons the purpose and procedure
of using safety monitoring device.
Explain that the device does not limit
mobility in any manner; rather, it
alerts the staff when the client is
about to get out of bed.
Explain that the nurse must be called
when the client needs to get out of
bed.
5. Test the battery device and alarm
sound.
 6. Apply the sensor pad or leg band.
Place the leg band according to the
manufacturer’s recommendation.
Place the client’s leg in a straight
horizontal position.
For the bed or chair device, the sensor
is usually placed under the buttocks
area.
For a bed or chair device, set the time
delay for determining the client’s
movement patterns from 1 to 12
seconds.
Connect the sensor pad to the control
unit and the nurse call system.
7. Instruct the client to call the nurse
when the client wants or needs to get
up, and assist as required.
When assisting the client up,
deactivate the alarm.
Assist the client back to bed, and
reattach the alarm device.
8. Ensure client safety with additional
safety precautions.
Place call light within client reach, lift
all side rails, and lower the bed to its
lowest position.
Place ambulation monitoring stickers
on the client’s door, chart, and
Kardex.
9. Document the type of alarm used,
where it was placed, and the
effectiveness of alarm in the client
record.
10. Record all additional safety
precautions and interventions
discussed and employed.
Procedure 30-2: Implementing Seizure Precautions
Performed
Preparation Yes No Mastered Comments
1. Assess:
• History of seizures
• Last seizure event
2. Assemble equipment and supplies:
• Blankets or other linens to pad
side rails
• Oral suction equipment
• Oral airway or padded tongue
depressor
• Oxygen equipment
Procedure
1. Explain to the client what you are
going to do, why it is necessary, and
how he can cooperate.
2. Wash hands and observe
appropriate infection control
procedures.
If the client is actively seizing, apply
clean gloves in preparation for
performing respiratory care measures.
3. Provide for client privacy.
4. Pad the bed. Secure blankets or
other linens around the head, foot,
and side rails of the bed.
5. Place oral suction equipment in
place, and test to confirm that it is
functional.
6. If agency policy prescribes, tape the
tongue depressor that has been
wrapped with gauze padding or an
oral airway within reach of the
head of the bed.
7. If a seizure occurs:
Remain with the client and call for
assistance, if needed.
If the client is not in bed, assist client
to the floor and protect the head in
your lap or on a pillow.
According to policy, insert the airway
or tongue depressor between the
client’s upper and lower teeth.
Apply oxygen by mask.
Turn the client to a lateral position, if
possible.
Time the seizure duration.
 Move items in the environment to
ensure the client does not experience
an injury.
Observe the progression of the
seizure, noting the sequence and type
of limb involvement. Observe skin
color. When the seizure allows, check
pulse and respirations.
Administer ordered anticonvulsant
medications.
Use equipment to suction the oral
airway if the client vomits or has
excessive oral secretions.
When the seizure has finished, assist
client to a comfortable position.
Provide hygiene as necessary. Allow
the client to verbalize feelings about
the seizure.
8. When the seizure has subsided,
document pertinent information in
the client record.
APPLYING RESTRAINTS

Procedure 30-3: Applying Restraints

Performed
Preparation Yes No Mastered Comments
1. Assess:
• The behavior indicating the
possible need for a restraint
• Underlying cause for assessed
behavior
• What other protective measures
may be implemented before
applying a restraint
• Status of skin to which restraint
is to be applied
• Circulatory status distal to
restraints and of extremities
• Effectiveness of other available
safety precautions
2. Review institutional policy for
restraints.
3. Assemble equipment and supplies:
• Appropriate type and size of
restraint
Procedure
1. Explain to the client and family
what you are going to do, why it is
necessary, and how they can
cooperate.
2. Wash hands and observe
appropriate infection control
procedures.
3. Provide for client privacy, if
indicated.
4. Apply the selected restraint.
Belt Restraint (Safety Belt)
Determine that the safety belt is in
good order. If a Velcro safety belt is
to be used, make sure that both pieces
of Velcro are intact.
If the belt has a long portion and a
shorter portion, place the long portion
of the belt behind (under) the
bedridden client and secure it to the
movable part of the bed frame. Place
the shorter portion of the belt around
the client’s waist, over the gown.
There should be a finger’s width
between the belt and the client.
Or:
 Attach the belt around the client’s
waist, and fasten it at the back of the
chair.
Or:
If the belt is attached to a stretcher,
secure the belt firmly over the client’s
hips or abdomen.
Jacket Restraint
Place vest on client, with opening at
the front or the back, depending on
the type.
Pull the tie on the end of the vest flap
across the chest, and place it through
the slit in the opposite side of the
chest.
Repeat for the other tie.
Use a half-bow knot to secure each
tie around the movable bed frame, or
behind the chair to a chair leg.
Fasten the ties together behind the
chair using a square (reef) knot.
Ensure that the client is positioned
appropriately to enable maximum
chest expansion for breathing.
Mitt Restraint
Apply the commercial thumbless mitt
to the hand to be restrained. Make
sure the fingers can be slightly flexed
and are not caught under the hand.
Follow the manufacturer’s directions
for securing the mitt.
If a mitt is to be worn for several
days, remove it at least every 2–4
hours. Wash and exercise the client’s
hand, then reapply the mitt. Check
agency practices about recommended
intervals for removal.
Assess the client’s circulation to the
hands shortly after the mitt is applied
and at regular intervals.
Wrist or Ankle Restraint
Pad bony prominences on the wrist or
ankle, if needed to prevent skin
breakdown.
Apply the padded portion of the
restraint around the ankle or wrist.
Pull the tie of the restraint through the
slit in the wrist portion or through the
buckle.
Using a half-bow or a square knot, as
appropriate, attach the other end of
the restraint to the movable portion of
the bed frame.
5. Document:
Behavior(s) indicating the need for
the restraint
All other interventions implemented
in attempt to avoid the use of
restraints and their outcomes
The time the physician was notified
of the need for restraint
Also record:
The type of restraint applied, the time
it was applied, and the goal for its
application
The client’s response to the restraint
The times that the restraints were
removed and skin care given
Any other assessments and
interventions
Explanations given to the client and
significant others
6. Adjust the plan of care as required.