NURS1002-Berman Audrey-Skills in Clinical Nursing-Section 12 Hand Hygiene-Pp6-11

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Course of Study:
(NURS1002) Essentials of Nursing and Care
Title of work:
Skills in clinical nursing, Second Australian edition. (2020)
Section:
Section 1.2: Hand hygiene. pp. 6--11, 16--22, 47--86, 165--186, 377, 428--430,
432--435, 446--448
Author/editor of work:
Berman, Audrey; Snyder, Shirlee; Levett-Jones, Tracy; Burton, Patricia; Harvey,
Nichole
Author of section:
Audrey Berman; Shirlee Snyder; Tracy Levett-Jones; Patricia Burton; Nichole
Harvey
Name of Publisher:
Pearson Australia
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LEARNING OUTCOMES KEY TERMS

On completion of this section you will be able to: alcohol-based hand rub, 7
detergent, 7
1 Define the components of hand hygiene.
hand hygiene, 6
2 Identify the 5 moments for hand hygiene.
3 Identify the barriers to hand hygiene.
4 Demonstrate competency in undertaking hand hygiene.
5 Complete the critical thinking questions associated with the clinical scenario.
One of the most effective ways to control the spread of Hand hygiene provides an opportunity to break
microorganisms is to perform frequent hand hygiene with the sequence of steps in spreading microorganisms
appropriate solutions and an effective technique. The (Gyi, 2018a). The ACSQHC (2019) coordinates the
Australian Commission on Safety and Quality in Health National Hand Hygiene Initiative, which strives
Care (ACSQHC) (2019) indicate that for an organism to to ameliorate infection risks associated with poor
be transmitted from an affected person to a susceptible hand hygiene compliance. It commissioned Hand
person, five sequential steps must occur (Figure 1-3): Hygiene Australia (HHA) to develop a manual to
assist in the implementation of this initiative. The
Organisms are present on the person's skin or have
initiative involves numerous strategies including the
been shed onto inanimate objects immediately
introduction of an alcohol based hand rub within the
surrounding the patient.
clinical areas and the establishment of the '5 moments
2 Organisms must be transferred on the hands ofHCWs. for hand hygiene'.
3 Organisms must be capable of surviving for at least
several minutes on the HCWs' hands.
4 Hand hygiene by the HCW must be inadequate or WHAT IS HAND HYGIENE?
entirely omitted, or the agent used for hand hygiene Hand hygiene is the act of hand washing. It may be
inappropriate. achieved using water and soap which may or may not
5 The contaminated hand or hands of the caregiver must contain antimicrobial properties. Effective hand hygiene
come into direct contact with another person. may also be achieved with the use of an alcohol-based
Source of
organism
_.. Organism
transferred ~
Organism
survives
_.. Lack of
hand ~
Contact with
susceptible
hygiene person
Figure 1-3 Steps required for transmission of microorganisms

Source: Generated using information from Australian Commission on Safety and Quality in Health Care (2019). National hand
hygiene initiative manual. Retrieved from https://www.safetyandquality.gov.au/publications-and-resources/resource-library/
national-hand-hygiene-initiative-manual.
UNIT 1 SECTION 1.2 HAND HYGIENE 7
hand rub. The goal of hand hygiene is to reduce the hand-

borne microorganisms and therefore reduce the risk of
BARRIERS TO EFFECTIVE HAND
transferring these potential pathogens to other individuals or HYGIENE
equipment. When a Surgical Aseptic Non-Touch Technique Historically, health care professionals have contributed to the
(see Section 1.6) is required, further washing is needed before transmission of HAis from poor hand hygiene practices, so
donning sterile gloves and gowns for specific invasive clinical efforts have been made to identify factors contributing to this
procedures. The purpose of the extended wash is to remove
increased risk. Reasons cited for poor hand hygiene include:
microorganisms from the nails, hands and forearms and
prevent microbial regrowth. • poor knowledge or recognition of microbial
contamination risks
Alcohol-based hand rub • poor role-modelling behaviours and lack of positive social
An alcohol-based hand rub is a liquid, gel or foam norms
solution which does not require water to reduce microbial • experience of skin irritation from hand hygiene agents
contamination on hands . Alcohol-based hand rub solutions • perceptions of the person's needs taking precedence over
work by rapidly killing hand-borne pathogens through the hand hygiene
evaporation of alcohol and should contain 60-80% ethanol • perceptions that glove usage negates need for hand
(National Health and Medical Research Council [NHMRC], hygiene. (Belela-Anacleto et al. , 2019; Korhonen et al.,
2019) . The alcohol-based hand rub is considered the 2019; Oncu et al., 2018; Woodward, et al., 2019)
optimum method for hand hygiene (Kingston et al., 2017), Other barriers to effective hand hygiene include the
with the ACSQHC (2019) advocating that this method of wearing of jewellery on fingers and wrists (e.g. rings and
hand hygiene is better than the use of traditional soap and watches) (Gould & Drey, 2013). Wearing jewellery is known
water as it requires less time, is readily accessible, is more to increase the colonisation and caiTiage of gram negative
cost effective and results in a greater reduction of bacterial bacteria (including enterobacteriaceae). Fmthermore, fungal
contamination than using soap and water in many clinical and bacterial growth and transmission are increased with
situations. the application of artificial nails and nail polish, as is the
Water and detergent excessive growth (0.05 cm) of fingernails (ACSQHC, 2019).
The Bare Below the Elbows guideline (Queensland Health,
Hand washing using running water and soap or other 2017) recommends the following:
detergents works by mechanically dislocating
microorganisms and other contaminants from an individual 's • No jewellery to be worn. A single flat ring/band may be
hands. Water and detergent should always be used when worn but cannot impede effective hand hygiene.
hands are visibly soiled, or in ungloved episodes of care with • Long sleeves should be rolled up above the elbow.
a person who has a Clostridium difficile infection (Kingston et • Fingernails should be short and clean, with no nail polish
al., 2017) or non-enveloped virus such as norovirus (NHMRC, or artificial nails.
2019). Pokrywka et al. (2014) found that patient hand washing • All breached skin to be covered with a waterproof dressing.
reduced Clostridium difficile transmission.
11111111111••• 1
CLINICAL SAFETY ALERT
••·••1
THE 5 MOMENTS FOR HAND
HYGIENE • Frequent hand hygiene provides an opportunity to prevent
transmission of infection.
The '5 moments for hand hygiene' are now a national
• Contamination can occur even during brief encounters with
standard and it is imperative that all health care professionals the person.
learn and implement this strategy. The five moments include • People with latex sensitivity or allergy must not be exposed
before and after touching an individual, before and after a to latex gloves (neither the health care professional nor the
procedure, and after touching the person's surroundings (see person). Only nitrile gloves should be used in the vicinity.
I Figure 1-4 ).
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8 SKILLS IN CLINICAL NURSING
5 Moments for
HAND HYGIENE
----- -------- , .., 4-
\
\
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\
... --------
BEFORE TOUCHING
1 A PATIENT
When : Clean your hands before touching a patient and their immediate surroundings.
Why: To protect the patient against acquiring harmful germs from the hands of the HCW
2 BEFORE
A PROCEDURE
When: Clean your hands immediately before a procedure.
Why: To protect the patient from harmful germs (including their own) from entering their body during a procedure.
AFTER A PROCEDURE When: Clean your hands immediately after a procedure or body fluid exposure risk.
3 OR BODY FLUID
EXPOSURE RISK
Why: To protect the HCW and the healthcare surroundings from harmful patient germs.
AFTER TOUCHING When: Clean your hands after touching a patient and their immediate surroundings.
4 A PATIENT Why: To protect the HCW and the healthcare surroundings from harmful patient germs.
AFTER TOUCHING
5 A PATIENT'S
SURROUNDINGS
When: Clean your hands after touching any objects in a patient's surroundings when the patient has not been touched.
Why: To protect the HCW and the healthcare surroundings from harmful patient germs.
~
Adapted from
(&@~l World Health

~ ~~J? Organization
NHHI
Na110rtal Hartel HYSl• n• lnltl•tlva
~
Figure 1-4 The 5 moments for hand hygiene

Source: Reproduced with permission from the 5 Moments for Hand Hygiene from the World Health Organization, developed by the
Australian Commission on Safety and Quality in Health Care (ACSQHC). ACSQHC: Sydney 2019.
UNIT 1 SECTION 1.2 HAND HYG IEN E 9
mno iilWI! jjj@j llllllll lUIIIII jjjflljj iiltw! ®jjjj 11jjjjj1@ 1111 llllllll 3 A nurse is performing hand washing after administering
intravenous medications to Sam. Which action is
CLINICAL SCENARIO inconsistent with proper technique?
Sam Neal is a 30-year-old male with a past history of contracting a The use of warm water to wash
hepatitis B virus (HBV) via intravenous drug taking when he was b The use of firm, rubbing and circular movements to wash
19 years of age. He has been admitted to the emergency department c The use of a paper towel to scrub hands dry
with a chief complaint of right lower quadrant abdominal pain. d Asking a colleague to turn the tap off
e Washing for 1O seconds
f Using both hand rub and water because transmission-
based precautions are enacted with this person.
Critical Thinking Questions g The use of a paper towel to turn the tap off
4 A nursing student asks you about the wearing of jewellery

What role does hand hygiene play in Sam's care while in the (dress ring and wrist watch) and fingernail polish in clinical
emergency department? areas. How do these three items affect hand hygiene?
2 Which hand hygiene product should be used while caring for
Sam: alcohol-based hand rub or soap and water?
rrnppjj jrtjrjjj lll/llll jjj,jjjj iiltw! ®jjjj 11111111@ 1111 jjjjjjjr
ACTION EXPLANATION AND RATIONALE

Implement the '5 Moments for Hand Hygiene'. For clean hands use hand rub, and for soiled or dirty hands soap and water are
Consider the appropriateness of either hand rub or required to remove contaminants.
hand wash.
Implement the Bare Below the Elbows guideline. Short, natural nails are less likely to harbour microorganisms, scratch a person
Determine if barriers exist to effective hand hygiene or puncture gloves. Removal of jewellery facilitates proper cleaning of the
(including inappropriate nail length or artificial nails; hands and arms.
presence of jewellery on wrist or fingers).
.
Gather the correct equipment:
For hand rub: select an alcohol-based hand rub
The organisation of equipment promotes time management.
..(that contains 60-80% ethanol)

For hand wash:
Soap (antimicrobial)
• Warm running water
..Paper towels
Domestic waste bin .
Hand rub with alcohol-based solution (procedure Hand rub solution will not kill C. difficile or non-enveloped viruses.
should take 20 to 30 seconds).
Determine whether hands are visibly soiled or care
encounter resulted in potential exposure to C. difficile
infection or non-enveloped viruses; if so, perform
hand wash with water and detergent instead.
Distil the volume of alcohol-based solution as directed Various solutions from various manufacturers require different volumes of
by the manufacturer's instructions into a cupped hand. alcohol-based solution to achieve maximum effect.
Rub the hands together palm to palm . All skin areas must have contact with the solution so as to reduce
microorganisms.
Rub one palm over the dorsum of the other hand All skin areas must have contact with the solution so as to reduce
with interlaced fingers. Repeat the procedure with the microorganisms.
other hand on top.
Rub palm to palm with fingers interlaced. All skin areas must have contact with the solution so as to reduce
microorganisms.
Rub the backs of the distal phalanges to the All skin areas must have contact with the solution so as to reduce
opposing palms, interlocking the fingers. Repeat the microorganisms.
procedure with the other hand on top.
Rub the thumb with the palm of the other hand. All skin areas must have contact with the solution so as to reduce
Repeat the procedure on the other side. microorganisms.
10 SKILLS IN CLI NICAL NURSING
Rub the tops of the fingers on the palm of the other All skin areas must have contact with the solution so as to reduce
hand in a circular motion . Repeat the procedure on microorganisms.
the other side.
The procedure is complete when the hands are dry. Antiseptic effect is complete when hands are dry.
Hand wash with water and soap (procedure should Soap applied directly to dry hands may damage skin.
take 40 to 60 seconds). Water as a medium facilitates soap dispersal across the skin.
Firstly, wet hands.
Distil the appropriate volume of soap as directed by Various solutions from various manufacturers require different volumes of soap
the manufacturer's instructions into a cupped hand. solution to achieve maximum effect.
Rub the hands together palm to palm. The friction of rubbing the skin surface ensures soap contact.
Rub one palm over the dorsum of the other hand
with interlaced fingers. Repeat the procedure with the
other hand on top.
Rub palm to palm with fingers interlaced. The friction of rubbing the skin surface ensures soap contact.
Rub the backs of the distal phalanges to the
opposing palms, interlocking the fingers.
Rub the thumb with the palm of the other hand.
Repeat the procedure on the other side.
Rub the tops of the fingers on the palm of the other Mechanical action and the duration the soap product is on the skin promotes
hand in a circular motion. Repeat the procedure on the removal of microorganisms.
the other side.
Rinse hands with water. The water should run from This ensures that the water moves from a cleaner area to a more contaminated
the wrist down to the fingers. area.
Dry hands thoroughly with single use towel. Drying hands on a multiple-use towel will transfer a large volume of
microorganisms back onto your clean hands.
Use towel to turn off the tap. Touching the dirty tap with clean hands will contaminate yo ur hands again .
Dispose of paper towel in non-hazardous waste bin . Paper towels from hand washing are not considered infectious 'clinical' waste.
Variation: Specific hand wash for Surgical Aseptic

Non Touch Technique
Perform the hand wash with water and detergent steps The hands are cleaner than the elbows. The water should run from the least
as described above with the hands held above elbow contaminated to the most contaminated area.
level (procedure should take 2 to 5 minutes depending
on the detergent manufacturer's recommendation).
Use circular movements to wash the forearm from Circular movements clean effectively.
wrist to elbow.
Rinse fingertips to elbow with running water. Water rinses from the least contaminated area.
Each hand and forearm is dried thoroughly with an A clean towel for each hand prevents the spread of microorganisms from the
individual clean towel. Dry with a rotating motion from elbow to the other hand .
fingertips to elbow. A second new clean towel is used
for the other hand and forearm.
1!!1~1re••
u--lliliu=I'1 ~,9~'••-::11••••~1:1
'"
Early identification of breakage of the skin barrier assists in applying further

barriers to protect the nurse and the person.
Source: Based on information from Australian Commission on Safety and Quality in Health Care (2019). National hand hygiene initiative manual. Retrieved from https://www.safetyandquality.
gov.au/sites/defaulVfiles/2019-11 /nhhi_user_manual_-_october_2019.pdf.
On completion of this section you will be able to: apron, 11
gloves, 11
1 Identify situations where personal protective equipment should be used.
gown, 11
2 Demonstrate competency in the implementation of standard and transmission-
mask, 11
based precautions.
personal protective equipment (PPE), 11
3 Complete the critical thinking questions associated with the clinical scenario. protective eyewear, 11
• A face mask is a barrier which reduces the transmission

Use and removal of personal of microorganisms from the wearer to the patient and
with protective eyewear is worn to protect the wearer
protective equipment (PPE) from splashes or sprays of blood and body substances
from the patient. These:
Personal protective equipment (PPE) is used to ensure • should be worn when there is a risk of splash or spray
adequate protection from pathogenic microorganisms. The into face and eyes
appropriate application sequence (donning) and removal
sequence (doffing) of personal protective equipment is also • may consist of a surgical mask and protective eyewear.
a major consideration in infection prevention and control. The protective eyewear can be in the form of goggles
or wrap-around eye shields.
The Australian Guidelines for the Prevention and Control
of Infection in Healthcare (NHMRC, 2019) recommend the • Gloves are worn to protect contamination of workers '
sequences to be used . hands. These:
• should be worn when there is a risk of exposure to
RECOMMENDATIONS blood , body substances, secretions and excretions
Personal protective equipment (PPE) (see Figure 1-5) should: • may be non-sterile single-use natural rubber latex
• include wearing an apron or gown to protect skin , (NRL) or synthetic (nitrile)
uniforms or clothing • must be changed between patients and after every
• be appropriate to the task episode of care.
• be used for a single procedure or episode of care
(NHMRC, 2019)
• be removed in the area of care.
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On completion of this section you will be able to: standard precautions (SP), 16
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1 Distinguish between indications for standard and transmission-based precautions.
transmission-based precautions, 16
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2 State the guidelines for the management of health care workers with blood-borne
infections. I
3 Discuss the management and disposal of soiled equipment and supplies.
4 Demonstrate competency in the use of standard and transmission-based
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precautions.
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Basic principles of infection control consider that any
person may be a source of or at risk from infectious
2 Transmission-based precautions When the use of
standard precautions alone may not be sufficient to I
agents. The Australian Guidelines for the Prevention
and Control of Infection in Healthcare (NHMRC, 2019)
control the spread of infection. Transmission-based
precautions include a subset of extra strategies specific I
indicate that infection control can be achieved by a two-
tiered approach:
to pathogens that pose an airborne, contact or droplet
transmission risk. These strategies may include I
Standard precautions (SP) The routine establishment
and maintenance of strategies such as appropriate
the wearing of additional specific PPE, restricting
movement of affected individuals and associated I
health care workers, or even allocation of an affected
hand hygiene, the wearing of PPE and the appropriate
disposal of sharps. These strategies should be
person to a single room with a door and, potentially, I
employed when handling blood and body secretions.
Other considerations also include the promotion of
specific air-handling techniques available. Signage
should be utilised to remind individuals approaching I
cough etiquette, adherence to the Aseptic Non Touch
Technique and appropriate handling and management
the affected person of which added precautions should
be undertaken (see Figure 1-6). I
of waste and linen. I
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UNIT 1 SECTION 1.4 STANDARD AND TRANSMISSION-BASED PRECAUTIONS 17
A B
On leaving room
On leaving room
Dispose
of mask Dispose
of gloves
Perform Perform
hand hyg iene hand hygiene
Dispose
of gown
or apron
Perform
hand hygie ne
Keep door closed at all times
Standard Precautions Standard Precautions

A nd always • Pl:!rformh.lnd • Useandd,sposeol • FoNOWf"MPll',ltOfY • Use;.mddisposeof • Followresp,r.:,tory
hyg,cnebcfore sh.irpss.:,fcly hygjcneand
A nd always • Perform hand
hyg!Cf'lebefore sh.lrPSsafcfy hyg1cocand
fo llow these andatte<cv«y • Pwformroutine cough etiquette fol low these andatt«cYCfY · P«formroutine cough etiquette
p;,tlentcont.>et l.ll'IYlronmental cic.inng • UseascptlctcchnlQO<! P.Jtientcont;,ct efivlronmcntlll ckl,)('),ng • Usc.1$Cptlctechr'IIQI.IC
standard • Us.!PPEwhen • Ckslnandf'CPl'C)CC1,S
standard • UscPP£whc:-ll
• ~lvanddi1P0M1 • Cle.:Jnandreproceu · Hand~and~spose
precautions riskofbodyflvid shar«lp;,ticnt otw.isteandusod precautions riskolbodyfluld shar«lp;,~t ofw.»teandUSOO
ClCPOSUll? OQUiplnCl'lt hncnsafcly DCMPlnCl'lt hnc.-nsafely
AUSTRALIAN COMMISSION AUSTRALIAN COMMISSION

OH SAFETY -'No QUALITY IN HEALTH CARE ON SAFETYN<O QUALITY~ HEALTH CARE
On leaving room
Dispose
of mask
Perform
hand hygiene
Standard Precautions
• Use;ind di$poseo(
• Perform hand
hygiene before
andaftwevery
ShafPSsafcty
• Perform routine
..,....,""'
• FollowrnsplratofY
cough etiquette
p;,ucnt cont oct cnvironmcn~clroning • Use.lsepticteichniqt,.,c
• UroPPEwh~ • Clc.in.iridrcproccu • 1-!ilndlc and dispose
nsko(bodyfluid shilrtop.:1tient o(w.:meaodus«I
~""'""' eqt.o;pment knenS.ltel:,o
AUSTRALIAN COMMISSION
OHSAFETYANO QUAUTY1t1 HEALTI-t CARE
Figure 1-6 Posters used to assist in compliance of transmission-based precautions: A, Airborne precautions poster; B, Contact
precautions poster; C, Droplet precautions poster
Source: Australian Commission on Safety and Quality in Health Care, Standardised Infection Control and Prevention Signs (ACSQHC): Airborne Precautions
poster 2016 (February 2012), Sydney.
fl
fl
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18 SKILLS IN CLINI CAL NURS IN G
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The vast number of microorganisms and combination of depending on the organism involved and the stage of the I
precaution types can be confusing to a new graduate (Mitchell
et al. , 2014). Organisations will have policy and procedure
individual's disease (i.e. whether they are still infectious or
not). Table 1-3 identifies the precautions associated with I
documents identifying which type of precaution is required some selected microorganisms.
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Table 1-3 Selected microorganisms and associated precautions
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CONDITION INFECTION TYPE PRECAUTIONS I
Aspergillosis (Aspergillus spp.)
Burkholderia cepacia
Fungal
Bacterial
s
C
I
Chickenpox and shingles (Varicella-Zoster virus)
Chlamydia trachomatis
Viral
Bacterial
C, A
s
I
Clostridium difficile Bacterial C I
Cytomegalovirus (CMV)
Escherichia coli (Shiga toxin-producing E. coli)
Viral
Bacterial
s
C
I
Giardia instestinalis Protozoan s I
Hepatitis A
Hepatitis B
Viral
Viral
C
s I
Hepatitis C
Human immunodeficiency virus (HIV)/AIDS
Viral
Viral
s
s
I
Infectious mononucleosis (glandular fever) Viral s I
Influenza
Lice (pediculosis) - head
Viral
Arthropod
C, D
C
I
Malaria
Meningococcal infection (Neisseria meningitidis)
Protozoan
Bacterial
s
D
I
Norovirus Viral C,D I
Pertussis (whooping cough)
Pneumococcal pneumonia (Streptococcus pneumoniae)
Bacterial
Bacterial
D
D
I
Respiratory syncytial virus (RSV) Viral C I
Rotavirus gastroenteritis
Rubella
Viral
Viral
C
D I
Scabies (Sarcoptes scabier)
Severe Acute Respiratory Syndrome (SARS)
Arthropod
Viral
C
C,D,A
I
Staphylococcal infection (Staphylococcus aureus) Bacterial s
(C if MRSA)
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Streptococcal infection (Group A) Bacterial
Bacterial
D
A
I
Tuberculosis
Vancomycin-resistant enterococcus (VRE) Bacterial C I
A= Airborne; C = Contact; D = Droplet; MRSA = Multiple resistance Staphylococcus aureus; S = Standard
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Source: Based on material provided by the National Health and Medical Research Council (2019). Australian guidelines for the prevention and control of infection in healthcare,
Appendix 2, 6.4 Type and duration of precautions for specific infections and conditions. I
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UNIT 1 SECTION 1.4 STANDARD AND TRANSMISSION-BASED PRECAUTIONS 19
for the Management of Healthcare Workers Known to be

IIIIIii iiwlii 1111 1111111 /1111111110! 11111111@11]1 ®iii! 1jj@1rn 111 011 111 rn Infected with Blood-Borne Viruses (Department of Health and
CLINICAL SCENARIO Ageing [DOHA] , 2018) provides principles for the infected
health care worker to assist in the protection and detection,
Back to Sam, the 30-year-old male with a past history of contracting
HBV. Sam has been diagnosed with appendicitis and is now being
and the management and restrictions necessary to safeguard
prepared for surgery. consumers of health care in Australia.
Some important principles regarding health care workers
identified in this guideline include:
• comprehensive surveillance and reporting of possible
Critical Thinking Questions blood-borne virus transmission
• access to confidential testing, counselling and treatment
What precautions should both the emergency department of blood-borne viruses
and operating theatre staff take in relation to Sam?
• voluntary annual blood-borne virus testing of individuals
2 How should body secretions, bed linen, equipment used who undertake exposure-prone procedures
for vital signs, one-use disposable equipment, sharps and • blood-borne virus testing of individuals following sharps
laboratory specimens be handled?
injury or body fluid exposure
3 As part of Sam's postoperative care he will be transferred to • understanding of the professional and ethical
the ward until he is discharged to his home. In the nursing responsibility to be tested for blood-borne virus and the
care plan transmission-based precautions will be used in
compliance with restrictions to their working practices as
addition to standard precautions. Which of the following
required
precautions would the nurse use in order to be consistent
with infection control guidelines? Select all that apply.
by law
• abstinence from exposure-prone procedures* for workers
a A surgical mask is worn at all times while in the person's
with HIV, HCV-RNA positive or HBV-DNA positive
room
b A P2 mask/respirator when within 1 metre of the person
• support for workers known to be infected with a blood-
c Gloves for all contact with the person borne virus including:
d Hand hygiene before applying and after removing gloves • providing a work environment which minimises risk of
e A gown when performing a physical examination of the cross-infection
person • opportunities for retraining
• maintenance of the rights of the individual in relation
4 The nurse is assigned to care for a person on contact
precautions. Which action by the nurse would require
to anti-discrimination, privacy, industrial relations and
immediate intervention on the part of the supervisor? equal employment opportunity.
a The nurse changes gloves after contact with infectious
material.
b The nurse places used disposable sharps directly into
FURTHER INFECTION CONTROL
designated sharps containers. CONSIDERATIONS
c The nurse removes the used gown outside the person's
Unless otherwise stipulated by the organisation's policy
room.
and procedure the following information reflects common
d The nurse places a laboratory specimen in a plastic
container which has a secure lid, and the plastic
management and disposal of soiled equipment and supplies.
container is placed in a sealed plastic bag.
Management and disposal of soiled
mnii iilmii lllliOl 111 lllll ljjjllll lllfjjjj jjjtll]j jll111jj 11111jj jjjjjjjj lllllllf equipment and supplies
Many pieces of equipment are supplied for single use only
and are disposed of after use. Some items, however, are
HEALTH CARE WORKERS INFECTED reusable. Determine which equipment is single use and which
equipment requires sterilising.
WITH BLOOD-BORNE VIRUSES
As previously mentioned, health care workers have a duty of *Invasive procedures in wh ich there is a risk of direct skin contact of the health care
care to protect the health and safety of individuals for whom worker with sharp instruments, needles or sharp tissue (e.g. bones and teeth or in poorly
visual ised body cavities).
they care. Occasionally, health care workers may, themselves,
be infected with blood-borne pathogens, either from (HIV 5 human immunodeficiency virus; HCV 5 hepatitis C; HBC 5 hepatiti s B; DNA
workplace accidents or from exposure to pathogens outside 5 deoxyribonucleic acid ; RNA 5 ribonucleic acid)
of the work environment. The Australian National Guidelines (DOHA, 2018; NHMRC, 20 19)
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20 SKILLS IN CLIN ICAL NURSING
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Bagging Linens I
Articles contaminated, or likely to have been contaminated,
with infective material - such as pus, blood, body fluids, faeces
Handle soiled linen as little as possible, hold it away from
your body and, with the least agitation possible, place it in
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or respiratory secretions - need to be enclosed in a sturdy bag
that is impervious to microorganisms before they are removed
the linen skip. This prevents gross microbial contamination
of the air and contamination of persons handling the linen.
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from the person's room. Biohazardous waste is placed in
a container with special labelling, such as that shown in
Close the bag before sending it to the laundry in accordance
with organisational practice. Bag soiled clothing before
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Figure 1-7. A single bag can be used, if it is sturdy and
impervious to microorganisms, and if the contaminated articles
sending it home. I
can be placed in the bag without soiling or contaminating its
outside surface.
Laboratory specimens
Laboratory specimens must be placed in a leak-proof
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Double-bagging is required if the above conditions are
not met.
container with a secure lid. In most organisations specimens
are then placed in a biohazard bag. Use care when collecting
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specimens to avoid contaminating the outside of the container. I
Dishes
Dishes require no special precautions. Soiling of dishes can
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largely be prevented by encouraging persons to cleanse their
hands before eating. Use of detergent and warm water safely
I
removes microorganisms. I
Blood pressure equipment I
Blood pressure equipment needs no special precautions
unless it becomes contaminated with infective material. If
it does become contaminated, follow organisational policy
I
for decontamination. Cleaning procedures vary according to
whether the equipment is a wall unit or a portable unit. In some
I
Figure 1-7 Biohazard alert
Source: tuulijumala. Shutterstock.
agencies, a disposable cuff is used for people placed on isolation
precautions or even for all persons. Stethoscopes should be
I
cleaned after auscultation and after use with each person in
order to remove gross contamination. Dedicated stethoscopes
I
Disposal
Place disposable sharps instruments, such as scalpels, needles
are used when the individual is under transmission-based
precautions.
I
and lancets, directly into a hard plastic sharps container.
Place garbage and soiled disposable non-sharps equipment,
Thermometers I
including dressings and tissues, in the plastic bag that lines
the waste container and tie the bag. If the bag is sturdy
Many organisations use tympanic thermometers with
disposable tips. It is common for dedicated thermometers
I
and impermeable (waterproof or solid enough to prevent
microorganisms from moving through the barrier even when
to remain in the room with the individual who is under
transmission-based precautions.
I
the waste is wet), a single bag is adequate. If not, place the
Disposable needles, syringes and I
first bag inside another impermeable bag. Some organisations
separate dry and wet waste material. sharps
Place needles, syringes and sharps (e.g. lancets, scalpels
I
Place non-disposable or reusable equipment that is visibly
soiled in a labelled bag before removing it, and send it to a and broken glass) into a puncture-resistant container (Waste I
central processing area for decontamination. Disassemble
special procedure trays into component parts. Some
Management Association of Australia, 2010). To avoid
puncture wounds, use approved safety or needleless systems
and do not detach needles from the syringe or recap needles
I
components are disposable; others need to be sent to the
laundry or central services for cleaning and decontaminating. before disposal. I
I
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I
UNIT 1 SECTION 1.4 STAN DARD AN D TRANSM ISS ION-BASED PRECAUTIONS 21
WHAT IF ...
Identify level of infection control procedures
THEN
Consult signage
IF CORRECT
THEN You need to seek assistance from

WHAT IF I forgot something another staff member, or remove PPE
Gather all equipment
entering the room? and perform hand hygiene, then locate
the equipment, then don a new set of PPE
Remove personal items that can be contaminated
Discuss the need of PPE with the person
Perform hand hygiene
Apply PPE in order of gown , mask,

eyewear and gloves
Undertake care
THEN If you have been exposed

WHAT IF I accidently remove to a pathogen for all contaminated
Remove PPE in correct order
the PPE in the wrong order? areas, articles and yourself, follow
institutional policy
Perform hand hygiene
Perform hand hygiene. Hand hygiene is performed as an infection control precaution.

Determine the level of precaution required. SP apply when the nurse may come into contact with body fluids,
including blood, excretions and secretions (excluding sweat).
Consider the procedures about to be performed and determine The planning of a procedure promotes nursing practice that is
which aspects require SP. Gather all necessary equipment. effective in delivery, in terms of the person's comfort, use of
resources and health care outcomes. This will determine which
equipment is required .
Gather the correct equipment: The organisation of equipment promotes time management.
• Gown
• Mask. Surgical masks are generally adequate. However,
for people suspected of having certain conditions, such as
tuberculosis or H1 N1 influenza, a P2 mask/respirator may be
requ ired .
• Goggles
• Gloves.
Remove or secure all loose items such as name tags or jewellery. Reduces the exposure to contamination.
If PPE w ill be used , explain to the individual why this is necessary People may feel alienated, fearful or even ashamed when staff
and that SP are performed with all people. members use this equipment. Masks block facial expressions,
and being touched by gloved hands feels different. The
explanation will help the individual to understand that SP are used
to protect both the individual and health care workers.
Perform hand hygiene and observe appropriate infection control Hand hygiene reduces the transmission of microorganisms.
procedures.
Wear gloves during contact that could involve blood, body Prevents skin contact with body fluids and wastes.
fluids , secretions, excretions and contaminated objects (see
Section 1 .3).
Perform hand hygiene after contact with blood, body fluids, Gloves can develop invisible holes during use. Moisture
secretions, excretions and contaminated objects {linen, dressings, that collects on hands under gloves promotes the growth of
equipment or any items which may have come into contact with microorganisms.
potentially infective material) whether or not gloves are worn . Prevents the spread of microorganisms.
Wear a mask, eye protection or a face shield , and a clean, Prevents facial contact with body fluids and wastes.
waterproof gown during the person's care that could involve Protects personal clothing from body fluids and wastes.
splashes or sprays of blood, body fluids, secretions or excretions
(see Section 1 .3).
Ensure that objects that have come in contact with blood , body Reduces the exposure to contamination.
fluids , secretions or excretions are disposed of or cleaned
appropriately. Check the organisation's infection control policy
and procedure manual for details regarding proper disposal or
decontamination.
Place used needles and other 'sharps ' directly into puncture- Recapping can result in a needlestick injury.
resistant containers as soon as their use is completed . Do not
attempt either to recap needles or to place sharps back in their
sheaths, even using two hands.
Handle all soiled linen as little as possible. Do not shake it. Bundle Reduces the exposure to contamination .
it up with the clean side out and dirty side in , and hold it away
from yourself so that yo ur uniform or clothing is not contaminated
(soiled).
Place all human tissue and laboratory specimens in leak-proof Reduces the exposure to contamination.
containers. If the outside of the container becomes contaminated,
place the container inside another sealable container prior to
transport.
Perform hand hygiene. Prevents the spread of microorganisms.

Contact between potentially infective material and intact skin
is not normally considered a risk for transmission of infection.
When there has been an exposure to infective materials it is
important that the nurse follows protocol to ensure that they can
I
If accident or failure to sufficiently uphold basic principles of
SP results in exposure, the nurse must immediately follow the
organisation's policies on management of the exposure incident.
be monitored for a potential infection , and also be able to protect
individuals, their family members and the health care team from
being inadvertently exposed to infective microorganisms.
I
■
I
I
I
I
:__a.
I
I
1-....-
1 LEARNING OUTCOMES KEY TERMS
I On completion of this section you will be able to:
1 Discuss the prevalence of falls and harm from falls in Australia.
falls prevention, 48
falls risk assessment, 48
I 2 Explain measures to prevent falls in hospitals, and in long-term care and

ambulatory settings.
falls risk screening, 48
functional mobility, 48
1~ - ~ 3 Demonstrate appropriate documentation and reporting of falls prevention,
mobility assessment, 48
screening, assessment and management.

I 4 Identify the steps in completing a mobility and falls risk assessment on a person.
I 5 Outline the process to follow if a person experiences a fall.

I ......
I~~ ~ Injuries related to falls is one of the leading causes of facility (ACSQHC , 2018). In response to incidents such
morbidity and mortality in older Australians (ACSQHC, as these, theACSQHC developed the National Safety and
I 2018; Australian Institute of Health & Welfare [AIHW] ,

2018; AIHW, 2019). In the older population (over
Quality Health Service (NSQHS) Standards to improve
the quality and safety of health care in Australia. Even
I 65 years old), the most common injuries that require

hospitalisation include head injuries (26%) and hip and
though people can experience a fall at any age, falls are
most prevalent in the older adult age group. Therefore
I thigh injuries (22%) (AIHW, 2019). Femoral neck (hip)

fractures are by far the most severe with approximately
ACSQHC developed a document entitled Preventing
falls and harm from falls in older people: Best practice
I 25 per cent of cases resulting in the person dying. Of

those who survive, about one-third will never regain
guidelines for Australian hospitals 2009. Some of the
terms commonly referred to in this document are defined
in Table 2-2.
normal or complete mobility (Australian and New
le.----- Zealand Falls Prevention Society [ANZFPS] , 2019).
llllllllll~IIIIIIIJ
1 The financial cost of falls on the health care system
is great; the hospital beds needed to care for people
I following a fall is expected to double by 2051. This
places an enormous burden on Australia's health care
'Transfer tags' placed on beds are now recommended for
I system (ANZFPS, 2019).

Falls can occur in any health care facility or setting
use when the bed is positioned in an ultra-low (or low-low)
position (see Figure 2-6 on page 48). This is to assist with
I and can cause significant harm (ACSQHC, 2018). Harm

such as intracranial injury and fractured neck of femur
safer transfers and to reduce the risk of falling. The transfer
tag indicates the suitable height of the bed, specific to the
person, for safe transferring. The person's 1egs are measured
I result in prolonged hospital stays, increased pain and
discomfort for the injured person and also the increased using the 'stick-to-stand' measurement system so that the
bed can be adjusted to meet the needs of the person.
I likelihood of being discharged to a residential aged care
I
I
Table 2-2 Common terms with definitions
TERM DEFINITION
Falls risk screening Falls risk screening is a brief process used to estimate a person's risk of fal ling; people are classified as
being at either low or increased risk. Falls risk screening usually involves reviewing a few key items and
can be used to identify a person who requires a high level of supervision and a more detailed falls risk
assessment.
Falls risk assessment Falls risk assessments aim to identify factors that increase falls risks. This assessment is a more detailed
process than falls risk screening and is used to identify underlying falls risk factors for tailored intervention .
Risk factors There are a number of risk factors among older people. A person's risk of falling increases both with age
and with the number of risk factors. Risk factors may be divided into intrinsic and extrinsic risk factors.
Intrinsic risk factors relate to a person's behaviour or condition (i.e. previous fall, postural instability, muscle
weakness, person living with dementia may forget their level of mobility and try to walk without their mobility
aid). Extrinsic risk factors relate to a person's environment or their interaction with the environment (i.e. time
of day, cluttered environment).
Tailored interventions An intervention is an evidence-based therapeutic procedure or treatment strategy designed to cure, alleviate
or improve a certain condition. Interventions can be in the form of medication, surgery, early detection
(screening), dietary supplements, education or minimisation of risk factors .
Falls interventions may include:
• environmental risk assessment and modification (placing the bed in an ultra-low position)
• balance and gait training with appropriate use of assistive devices
• medication review and modification
• managing visual concerns
• addressing orthostatic hypotension and other cardiovascular problems
• physical activity (strength and balance)
• orientating the person to the bed area, room or ward facilities
• placing high-risk individuals with in view of or close to the nursing station
• encouraging good nutrition and hydration.
Falls prevention Falls prevention is:
• preventing and minimising the risk of tripping, slipping, stumbling and then falling by identifying what
causes falls and what can protect people from falling
• identifying how to minimise the physical and psychological effects that result from falling.
The basis of falls prevention is 'prevention is better than cure' . However, not all falls can be prevented , unless
you totally take away a person 's independence.
Source: Based on Australian Commission on Safety and Quality in Healthcare (2009). Preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals.
Canberra, Australia: Commonwealth of Australia.
I~1I111._IUDiiii.i.IJJj
Co-morbidities and advancing age increase frailty and make
it more likely for an older person to fall. Encourage the person
to have regular check-ups with their doctor, keep as active as
possible, eat a well-balanced diet, take care when standing up
from a lying or sitting position, be sensible and recognise their
own limitations, ask for help as needed and have a plan of how
to get help in an emergency. There are a number of digital/smart
devices available; for example, the Apple Watch, which can alert
emergency services if the person has fallen and needs assistance.
MOBILITY ASSESSMENT
There are a number of mobility assessment tools available
to assess a person's mobility. These can take between a few
minutes and 30 minutes to conduct. Ideally, a team approach
to conducting a balance and mobility assessment is best and
referral to a physiotherapist for further assessment may be
Figure 2-6 Transfer tag to indicate the suitable height of the bed required. Consideration should be given to the environment
for safe transfers
© Nichole Harvey and the person's physical and cognitive health status when
selecting a tool. Functional mobility is a term used to
UNIT 2 SECTION 2.2 MOBILITY AND FALLS RISK ASSESSMENT 49
describe a person who can move from one position to another to a seated position on the side of the bed and then shake
(i.e. lying to sitting, sitting to standing) to perform activities your hand . If the person is successful, proceed to the second
of daily living (ADLs) such as getting out of bed, walking level of assessment. If the person fails level one, the nurse
and being independent (Department of Health, Victorian will need to choose the most appropriate manual handling
Government, 2014). People who do not have functional devices to assist the person. Level two involves assessing
mobility will require a falls risk assessment. the person's lower extremity strength and stability by asking
TheTimedUpandGo(TUG)Testisaquick,reliablemobility them to stretch their leg out while sitting on the side of the
assessment that allows the nurse to observe the person' s bed, and then flex and extend their ankle. Once again, if they
posture, gait, stability, stride length and balance (Lusardi are able to do this, proceed to the third level of assessment.
et al., 2017; Marin, 2018). The nurse instructs the person Level three involves assessing the lower extremity strength
to stand up from the chair or bed; walk to a predetermined for standin g by asking the person to stand up; they may
line on the floor (3 metres away); turn around; walk back use a cane or the bedrail to help. If they are able to stand
to the chair or bed at their normal pace; and sit down again. up successfully, ask them to march on the spot, taking a
The person wears regular non-slip footwear and can use a step forward and backward while marching. If the person
walking aid if needed. The person commences the test when is un able to do this or shows signs of an un steady gait they
the nurse says 'Go ' and the nurse times how long it takes will need to be assessed for an appropriate manual handling
for the person to stand up, walk the 3 metres and return to device (Boynton et al. , 2014).
their sitting position. An older adult who takes longer than
15 seconds to complete the test is at high risk of falling
(Waldron et al. , 2012). RISK FACTORS AND
The Banner Mobility Assessment Tool (BMAT) has
been recommended as an effective resource for performing PREVENTATIVE MEASURES
a bedside mobility assessment (Boynton et al. , 2014). It Key strategies that health care facilities can implement to help
consists of three levels of assessment. The first level is with reducing falls , incidents and injuries are policies in areas
assess in g the person's trunk strength and seated balan ce. such as risk prevention, falls screening and assessment and
This is done by asking the person to sit upright and rotate risk management (ACSQHC, 2018). Table 2-3 outlines some
Table 2-3 Risk factors and preventative measures for falls

RISK FACTOR PREVENTATIVE MEASURES
Poor vision Ensure glasses are fun ctional and the right prescription; ensure appropriate lighting; mark
doorways and edges of steps as needed ; keep the environment tidy; ensure the nurse cal l buzzer
and night light are within easy reach .
Older adult Consider vitamin D and Calcium supplementation for mobile older adults; consider hip protectors
and alarm devices.
Cognitive dysfunction (confusion, Set safe limits to activities; remove unsafe objects; orient the person to their surroundings and
disorientation, impaired memory or explain the nurse call system; minimise the use of chemical and physical restraints and bedside
judgement) rails; consider alarm devices.
Impaired gait or balance and Ensure shoes or well-fitted slippers with non-slip soles are worn; check that ambulatory
difficulty walking because of lower devices are used as necessary (cane, crutches , walker, braces, wh eelchair); provide assistance
extremity dysfunction (e.g . arthritis) with ambulation as needed; monitor gait and balance; adapt living arrangements to one floor
if necessary; enco urage exercise and activity as tolerated to maintain muscle strength , joint
flexibility and balance; massage limb/ s with or without anti-inflammatory cream ; manage pain;
ensure uncluttered environment with securely fastened rugs; organise routine physiotherapy
review.
Difficulty getting in and out of chair Encourage the person to request assistance; keep the bed in the low position ; install grab bars in
or in and out of bed the bathroom; provide a raised toilet seat.
Orthostatic hypotension Instruct the person to rise slowly from a lying to sitting to standing position, and to stand in place
for several seconds before walking; measure postural blood pressure.
Urinary frequency or receiving Provide a bedside commode; assist with voiding on a frequent and scheduled basis; organise
diuretics screening urinalysis as needed to identify urinary tract infections.
Weakness from disease process or Encourage the person to summon help; monitor activity tolerance; place bedside table near
therapy the bed or chair so the person does not need to overreach; conduct regular checks of the older
person.
Current medication reg imen Attach side rails to the bed if appropriate; keep the rails in place when the bed is in the lowest
that includes anticonvulsants, position or place a mattress beside the bed; monitor orientation and alertness status; discuss
sedatives, anxiolytics and how alcohol contributes to fall-related injuries; encourage the person not to mi x alcohol and
analgesics medications and to avoid alcohol when necessary; encourage annual or more frequent review of
all medications prescribed; consider alarm devices.
50 SKILLS IN CLINICAL NURSIN G
common risk fac tors, with suggested preventative measures of kin should be notified and informed of the fall and the
for each risk. As people often have multifactorial risk factors it management plan. The hospital workplace health and safety
is important to implement as many interventions as necessary committee or representative also needs to be co mmunicated
to provide person-centred care and to help mi ni mise the risks with about the incident and an incident report to be
as much as possible (ACS QHC, 2018; Lizarondo, 20 18). submitted (Queensland Health , 201 5b). If the facility has
a falls risk committee, any recommendations made by the
Falls screening and assessment committee should be considered and implemented.
Falls screening and assessment are vital to identify people at
risk of falling so that strategies to mitigate the risk can be
implemented (ACSQHC, 2018). As defined in Table 2-2,
falls screening is more of a brief process looking at j ust a few
11111111111••• 1
••·••1
factors, whereas fa lls assessment is a more comprehensive
process looki ng at all factors, both intrinsic (i.e. the person's A person who suffers a fall, with or without a resulting injury,
health status) and extrinsic (i.e. the environment) to the person can develop a loss of confidence in walking. It is important for
(Fong, 20 18). There are a number of falls risk assessment nursing staff to observe and assess the person 's behaviour
and management tools available. It is important to discover and discuss, in a reassuring and gentle manner, any concerns
what tool is used at the health care facility where you work the person may have. Offering emotional as well as additional
physical support may be needed. This will help identify if
and to fami liarise yourself with it. Figure 2-7 is an example the person has a fear of falling and, if so, what strategies to
of an 'i n-patient falls assessment and management' tool implement to help with resolving this fear (ACSQHC, 2018).
(Queensland Health, 201 5a). This example demonstrates
the recording of risk factors and identifying the appropriate
actions or preventative measures to implement against each
risk factor. Page 2 of the tool is to document a falls prevention 1111@1 111 II0 11111jjjj 111i101 !!IUlli ®Oli 1111jjj1@1111 ii 111 ili 1
management plan (see page 52).
CLINICAL SCENARIO
Post fall assessment and management You are caring for Sally Abraham, a 37-year-old woman who has
Nurses need to know what to do in the unfortun ate event metastatic breast cancer (Van Der Riet & Pitt 2018). Sally has been
that someone they are caring for does have a fall. The living with breast cancer for the past 12 years. She has undergone
imm ediate action is to check for DRS ABCD (Danger, a total mastectomy and had multiple courses of radiotherapy and
Response, Send for help, Airway, Breathing, Compressions, chemotherapy. Her last course of chemotherapy was two years
Defi brillate) . If the person does not require res uscitatio n, ago after being told by the doctor that she only had six months to
live. Sally is a single mother and lives with her 13-year-old daughter
call fo r assistance in case a seco nd person is req uired. It is
in a small caravan . For the past two years Sally has been using
best not to move the person until an assessment has been
a lot of complementary therapy and seeing a psychotherapist
completed to determin e what injuries , if any, the person and a herbalist. She enjoys meditating and creating a positive
may have sustained. If the person has any symptoms th at environment around her. It is for this reason t hat she is currently
indi cate a head or mu sculoskeletal injury the medical estranged from her parents who do not agree with her choice to
officer mu st be notified and requested to review the person have no further courses of chemotherapy and are quite negative to
urgently. If th e person shows any signs of deterioration be around. Sally takes MS Cantin 120 mg BO and morphine elixir 40
following a fall, an urgent medi cal review is also req uired mg for breakthrough pain.
(Queensland Health, 20 15b).
Most health care facilities will have established clinical
pathway s or protocols in place for staff to implement if a
person experiences a fall. These clinical path ways share
Critical Thinking Questions
similar treatment and management processes. Within
You are working with the community palliative care team
the firs t 15 minutes following the fall the nurse should
and visit Sally in her home. As part of your comprehensive
perfor m an assessment, documenting the person's vital
assessment today, you need to complete a falls risk
signs, blood glucose level, Glasgow Coma Scale (see Unit
assessment. Given the information you have about Sally, are
13), and any obvious injuries. The nurse should contact there any factors that put Sally at risk of having a fall? If so,
th_e medical officer to arrange a medical assessment of what are they?
the person. Following the medical review, an appropriate 2 What preventative measures could you suggest to minimise
management plan will be implemented for the person. This Sally's risk of having a fall?
may include a co mbination of interventions, observations
3 What other assessment would be important to do along with
and investigation s; for example, hourl y neurol ogical the falls risk assessment to help identify risk factors for falls?
observations, ice pack, x-ray or blood tests. The perso n
should be monitored for at least 24 hours to •ensure that
there are no late manifes tations of head injury. The next I@1111 1111 @111111111111 0il !Oifili @111111111111 1111111111111 ili
I
I UNIT 2 SECTION 2.2 MOBILITY AND FALLS RISK ASSESSM ENT 51
I
I
I ~ Queensland
(Affix identification label here)
~ Government
I In-patient Falls Assessment
URN:
Family name:
I and Management Plan

Given name(s):
Add ress:
I Facility: _
• Complete assessment within eight (8) hours of admission
Date of birth: Sex: O M O F 0 1
I •
•
•
Reassess at a minimum of weekly, when there is a change in condition, medication, after a fall and on discharge
Care plans never replace clinical judgement. Care outlined must be altered if it is not clinically appropriate for the individual patient
Every person documenting on the form must supply a sample of their initials in the signature log page2
I Falls Risk Assessment

Identify risk factors I I
I I
Tick ( ✓ )Yes or No
(if Yes to any, patient is 'at risk ' of a fall) I
If YES to any
I
Initiate actions
Tick when actioned (if indicated)
I
I Risk Factors
Date
Time Actions
Date
Time
I Initial Initial
I Screen:
The patient has had a fall in the last 6 months
□Y □Y D Y
►
O N O N O N
z • Refer patient to physiotherapist for gait and
I c:5
0::
<I:
::E
The patient is observed to be unsteady
□Y □Y □Y
O N O N O N
►
balance assessment
•
('.)
I 0
z
z
ai
The patient requires supervision or assistance
with transfer
□Y □Y □Y
O N O N O N
► Conduct pre-activity screening prior to off
bed transfer
I (/)
◄ f-
:i:
The patient is visually impaired
□Y □Y □Y ► •Ensure glasses / visual aid is within reach
.I
• Consider referral (e.g. ophthalmologist,

~ O N O N O N
I w
f-
a'.
s: The patient has new onset incontinence
□Y □Y □Y ► •
optometrist)
Initiate ward urinalysis
z
~
I
I b
z
0
O N O N O N
□Y □Y □Y ►
• Notify MO and facilitate tests as ordered
•
(e.g. MSU)
Initiate toileting routine
::::!
m
z
I 0 The patient has existing incontinence, frequency
or requires assisted toileting
O N O N O N
• Consider use of continence aids
• Refer for continence assessment
--I
~
r
I The patient reports postural symptoms
□Y □Y □Y
►
(as appropriate)
• Measure lying and standing BP

r
(/)
)>
I The patient has a recent history of syncope

O N O N O N
□Y □Y □Y ► •Notify MO and facilitate tests as ordered

(/)
(/)
m
(/)
I The patient is on one of the following medications: □ Y □ Y □ Y

O N O N O N
►
(e.g. ECG, CT, ECHO, EEG, halter monitor) (/)
s:
m
I (antihypertensive, antidepressant, sedative,
antipsychotic, benzodiazepine) O N O N O N • Refer to MO / Pharmacist for medication
review/ simplification
z
--I
)>
□Y □Y □Y
► z
I The patient is on more than 4 medications
O N O N O N
► •Facilitate tests ordered by MO (e.g. TFT,
0
s:
I The patient has a minimal trauma fractu re
and / or history of osteoporosis
□Y □Y □Y
O N O N O N
calcium, vitamin D assay, PTH , sEPP)
• Refer to Dietitian (as appropriate)
)>
z
)>
I
I
--~
iiiiiii
i iiiiii
_ ;,;
The patient has new onset or increased
confusion / delirium
D Y D Y
O N O N O N
□Y
► • Notify MO and facilitate tests as ordered
(e.g. MSU, folate, CT, E/LFT, FBE, TFT)
• Conduct/ refer for cognitive assessment
(if appropriate)
G)
m
s:
m
z
=(/) The patient is usually confused
□Y □Y □Y ► •Conduct or refer for cogn itive assessment --I
"O
I
iiiiiii
- O N O N O N
(if appropriate)
Following assessment, proceed to management plan (page 2) ~

z
I Page 1 of 2
I Figure 2-7 An example of an in-hospital falls assessment and management tool (Continues)
I
I
~
~
I
(Affix identification label here)

~ Queensland
~ Government URN:
Family name:
In-patient Falls Assessment
and Management Plan
Given name(s): dult
Address:
Date of birth: Sex: OM OF 0 1

• Complete within eight (8) hours of admission
• Review management plan at a minimum daily and document as per local policy
• Initial when strategies are implemented
• V indicates a variance from clinical care and must be documented in the clinical notes
All care givers who initial are to sign signature log h Key ♦ Allied Health ■ Medical A Nursing (I!) Pharmacy
Category .... Date
nme
Communication A In partnership with patient and / or carer discuss falls risk factors and develop falls prevention plan
♦
Provide written falls prevention information (e.g. Stay On Your Feet- BE SAFE brochure)
Communicate patients 'at risk' status at bedside handover
Instruct patient to call for assistance when getting out of bed I mobilising (if required)
Environment/ A Orientate patient to surroundings, routine and location of bathroom and toilet
Equipment 0
0
Ensure clutter free and safe environment (e.g. night time lighting) z
0
Ensure the bed height and position are suitable for the patient's needs -i
~
Apply bed brakes correctly ;:o
=i
m
Ensure bed rails are at appropriate height for patient's needs
z
-i
Keep buzzer in reach; educate patient on buzzer usage I
iii
Keep patient's routine belongings within reach OJ
Keep patient's mobility aid in reach if applicable

z0
Review patient footwear and / or foot problems
z
G)
Observations
;;::
A Ensure frequent rounding and surveillance )>
;:o
G)
Consider supervision during toileting/ showering / mobilisation
z
Ensure suitable toileting protocols are in place
Other Care
(specify)
...
♦
■ --------------------------------i--i--i--i
(I!)
Discharge
Planning/
! Provide information on falls risk factors and prevention strategies
Education Refer to OT for AOL and home assessment
Complete nursing discharge summary and facilitate referrals
I
Page 2 of 2
I
Figure 2-7 An example of an in-hospital falls assessment and management tool (Continued )
I
Source: Adapted and reproduced by Pearson Australia with permission. © The State of Queensland (Queensland Health) 2015. Permission to
reproduce should be sought from <[email protected]>.
I
I
J
UNIT 2 SECTION 2.2 MOBI LITY AND FALLS RISK ASSESSMENT 53
LIFESPAN CONSIDERATIONS . :1~

Falls can occur at any age, but infants and older adults are at higher ■ In the home or community setting, assess for potential
risk of falling and causing serious injury. environmental causes of falls:
■ Lighting: inadequate amount, inaccessible or inconvenient
Infants
switches
■ Assess risk for falls (age, mental status, medications, physical ■ Floors : presence of electrical cords, loose rugs, clutter,
and mental impairments). slippery surfaces
■ Encourage parents to change the infant's nappy on a soft towel ■ Stairs: absent or unsteady railings, uneven step height or
placed on the floor.
surfaces
■ Use changing tables and cribs with properly padded sides and
■ Furniture: unsteady base, lack of armrests, cabinets too high
rails and never leave the baby/infant unattended.
or too low
■ Use home safety devices, such as stair gates and guard rails, to
■ Bathroom: inappropriate toilet height, slippery floors or tub,
help keep an active child from taking a dangerous fall.
absence of grab bars.
Older adults ■ In the home, consider alternatives to a hospital or regular bed if
■ Assess for potential personal causes of falls: hypotension, the person is extremely prone to fall out of bed:
unsteady gait, altered mental responsiveness (such as from ■ Place the mattress directly onto the floor or keep bed in the
medications), poor vision, foot pathology, unsafe footwear low position.
(loose, poorly fitting, slippery bottoms, high heels, rough edges), ■ Place padding on the floor next to the bed or between the
cognitive changes and fear (Pamaiahgari, 2018; Podder, 2019). person and side rails.
---....,- ~ ~ ~....._,.. __,......._,,.. ~ ..........,-......,,,,,,-.~....._,.. ...........,,,, ....._.... ~~~
THE 3Ps TABLE Mobility and falls risk assessment

PREPARATION AND PLANNING
Identify indication for performing a mobility and falls Conducting a mobility and falls risk assessment will help determine if someone
risk assessment. is at risk of falling , especially the older adult. One of the best practice strategies
for falls and injury prevention is firstly identifying someone's risk of falling . The
mobility assessment will allow the nurse to see how well the person can perform
normal tasks, such as sitting up from a lying position or standing up from a
sitting position. If the person shows signs of an unsteady gait or is unable to
do these tasks, the nurse can select an appropriate manual handling device
to assist the person in a safe and effective manner. The falls risk assessment
screens the person for potential risk factors and allows the nurse to put
preventative measures into place to minimise the person falling and harming
themselves. The falls risk assessment should be repeated whenever there is
a change in the person's health, medications, when the person's environment
changes, after a fall and when the person is to be discharged.
Perform hand hygiene. Hand hygiene is an essential skill to remove microorganisms and prevent cross
contamination .
Introduce yourself to the person using full name This is a professional expectation and helps to promote a therapeutic
and designation . Verify the person's identity and ask relationship. Checking how the person prefers to be addressed also helps to
how they would like you to address them, i.e. their promote rapport and demonstrates respect.
preferred name.
Determine the person's physical and mental 'Mobility' and 'falls risk assessment' may be unfamiliar terms to the older
capabilities and willingness to participate in a person and they may need you to explain what is required and why. Ensure it is
mobility and falls risk assessment. framed in a positive way, such as, ' Identifying and putting strategies into place
to reduce your risk of falls will help you stay independent longer'.
Collect the Falls Risk Assessment Tool (FRAT) that is There are several FRATs available in Australia. The ACSQHC (2009)
applicable to your health care facility. recommends using FRATs that include both intrinsic and extrinsic risk factors .
Provide for privacy by drawing curtains around the Privacy is required to protect the person's dignity and modesty during
bed or closing the door to the room. assessment procedures.
PERFORMING THE PROCEDURE
contamination. Hand hygiene is performed before touching or examining an
individual to comply with the '5 moments for hand hygiene'.
54 SKILLS IN CLIN ICAL NURSING
Provide a clear explanation of the mobility and falls Knowing what is about to happen can help reduce anxiety. Consent should be
risk assessment and obtain consent. obtained as it is a legal requirement and complies with ethical standards for a
registered nurse.
Use the FRAT to assess/ ask about intrinsic and In any falls risk assessment, both intrinsic and extrinsic risk factors related to a
extrinsic risk factors. person's health, functional status and environment need to be considered .
..
Intrinsic factors:
Mobility
Medications
• Vision
. Blood pressure
. Incontinence, frequency
. History of syncope (fainting), dizziness
. History of osteoporosis
. Confusion , orientation .
Extrinsic factors:
. Environment, lighting
• Appropriate bed height
. Nurse call bell accessible
. Walking aids, devices
. Condition of floor.
Initiate relevant actions by documenting them on the If risk factors have been identified for the person , then certain actions or
FRAT and complete a management plan . interventions may be required to help reduce risk. For example, refer to
physiotherapist, ensure glasses are within reach , refer to pharmacist for a
medication review. It is believed that effective falls prevention programs have
combined risk assessment with interventions (ACSQHC, 2009).
-
Conduct a mobility assessment. Give clear A quick and simple mobility test is the TUG test. An older adult who takes
instructions, e.g. 'On the word GO please stand up longer than 15 seconds to complete the test is at high risk of falling (Waldron
and walk to the line on the floor, turn around and et al. , 2012). From the results, a comprehensive management plan can be
walk back and sit down. Walk at your normal pace'. developed .
-
Conclude the mobility and falls risk assessment The call bell should always be within reach in case of an emergency. The
by doing a final check to ensure the person is nurse should always check the person's comfort level in case the mobility test
comfortable and feels safe (i.e. call bell in reach , aggravated the person's pain or illness. Hospital can be overwhelming ; clarifying
brakes are locked). Prior to leaving, check if they or checking if the person has questions are both effective communication skills.
have any questions.
-PR IORITIES POST PROCEDURE
•,... ·-•-·;;1,-_,-,_. •:·-•··-·,·,_.,. ., ..
, ,., .::_..:.~-- .,. ',-_' .,-:
-.-, ... --1re1~ ,,.,
.. ,,.:.. ·,a:,{;,.-: ,,• ,;•:.:.'. ;t {~?r/,.; -•~ •• IUn,H•ll~f·)~"•1~U••·••lll[•J~Jf1 ■ ::::I ,'° .. '.
.··'•'.< '
.. ' ·. ' ' .
•' .-.:-
. ,.. -\:'
contamination . Hand hygiene is performed after touching a person or the
person's surroundings, to comply with the '5 moments for hand hygiene' .
Determine, from the results of the falls risk In order to provide person-centred care, interventions specific to the person's
assessment and mobility assessment, what assessment need to be determined. For example, if the person experiences
interventions, manual handling devices and incontinence, specific interventions to help promote continence would
assistance are required to ensure safe movement for be implemented . This might include access to individualised continence
the person. assessment and continence advisors; collaboration with multidisciplinary team;
offer toileting assistance regularly; establish toileting protocols and practices;
- Document in care plan and progress notes.

encourage habit retraining; consider the use of continence aids.
Documenting is a legal and professional requirement of a registered nurse.
Documentation ensures that essential information is transferred to other relevant
health professionals to ensure that the care plans are accurate, updated and
appropriate to meet the needs of the person .
Collaborate with the multidisciplinary team to ensure Mobility and falls risk assessment involves health professionals from many
a holistic and safe management plan has been disciplines. The treating medical officer, physiotherapist, occupational therapist,
developed. and the nurse specialist for manual handling may all be able to contribute to the
person 's management plan.
Evaluate care plan and complete ongoing A person's risks of falling will likely change throughout their stay and will require
assessments at regular intervals or as required . reassessment.
Communicate any changes in the findings to the Communication among health professionals ensures that prompt review
treating doctor and/or allied health professionals (i.e. and management can be undertaken and further tests/treatments ordered , if
physiotherapist, occupational therapist) as required. necessary.
I
On completion of this section you will be able to: gait belt, 55
sliding board, 55
1 Describe three manual handling devices that could be used to help a person out
of bed. transfer belt, 55
walking belt, 55
2 Describe the process to use if a person weighing over 90 kg is unable to assist with
the transfer.
3 Outline the general guidelines to use when helping a person out of bed.
4 Identify the steps involved when helping a person out of bed.
Many people require some assistance in transferring transferring a person. It can also be used when assisting
between bed and chair or wheelchair, between a person to ambulate. A transfer belt may have handles
wheelchair and toilet, and between bed and stretcher. that allow the nurse to control movement of the person
Before transferring any person , however, the nurse must during the transfer or during ambulation (see Figure 2-9).
determine the person 's physical and mental capabilities A transfer belt offers dignity with mobility. Nurses or
to participate in the transfer skill. In addition, the nurse others are not tempted to grab the person 's clothing while
must analyse and organise the activity. assisting the person with mobility. A sliding board is
A transfer belt provides the greatest safety (see another device that can be used for transferring a person
Figure 2-8). A transfer belt (also called gait belt or between a bed and a chair (see Figure 2-10).
walking belt) is a safety device used for moving or A stretcher is used to transfer supine individuals from
one location to another. Whenever the person is capable
of accomplishing the transfer from bed to stretcher
independently, either by lifting onto it or by rolling
onto it, the person should be encouraged to do so. If the
person cannot move onto the stretcher independently and
weighs less than 90 kg, a friction-reducing device and/or
a lateral transfer board should be used and at least two
staff are needed to assist with the transfer. Some friction-
reducing devices have handles or long straps to avoid
awkward stretching by the staff when pulling the person
during the lateral transfer (see Figure 2-11). A ceiling
Figure 2-8 Transfer belt
lift with supine sling, or a mechanical lateral transfer
© gidney/123RF
device or air-assisted device and three staff should be
used if the person weighs more than 90 kg (Figure 2-12) .
Figure 2-9 Transfer belt with handles

© Nichole Harvey
Figure 2-12 An electric lift transfers the person from bed, chair,
toilet or fl oor.
© Sian Bradfield, Pearson Austral ia.
GENERAL GUIDELINES FOR

TRANSFER TECHNIQUES
There are a number of steps that should be followed to ensure
the safe transfer of a person.
• Plan what to do and how to do it. Determine the
space in which the transfer manoeuvre will take place
(bathrooms, for instance, are usually cramped), the
number of assistants (one or two) needed to accomplish
the transfer safely, the skill and strength of the nurse(s) ,
and the person's capabilities.
• Obtain essential equipment before starting (e.g. transfer belt,
Figure 2-10 Plastic transfer board sliding boards, wheelchair) and check that all equipment
© Nichole Harvey is functioning correctly. The transfer belt is meant only to
increase control of the person's movements; if the person
requires lifting, a mechanical lifting device should be used.
• Remove obstacles from the area used for the transfer.
• Explain the transfer to the person, including what the
person should do.
• Explain the transfer to the nursing personnel who are
helping; specify who will give directions (one person
needs to be in charge).
• Always support or hold the person rather than the
equipment, and ensure the person 's safety and dignity.
• During the transfer, explain step by step what the
person should do ; for example, ' Move your right foot
forward'.
• Document the plan of the transfer, including the person's
tolerance (e.g. pulse and respiratory rates).
Figure 2-11 Friction-reducing device with handles
© Rick Brady/Pearson Education, Inc.
UNIT 2 SECTION 2.3 HELPING A PER SON OUT OF BED 57
Assess: Person's
mobility status
t
WHAT IF the person THEN provide standby
can fu lly bear weight? -- assistance for safety
as needed.
THEN assess person's ability

WHAT IF the person can to assist and participate
partially bear weight? -- (e.g. cooperate; follow
directions).
'-
WHAT IF the person can

assist moderately
(< 50% by caregiver) -
and can participate?
- THEN assess the person's

upper extremity strength.
WHAT IF the person requires
maximum assistance
(>50% by caregiver)
and can participate?
- t '
' WHAT IF the person has WHAT IF the person has
inadequate upper adequate upper
extremity strength? extremity strength?
t
THEN use a lift or an
WHAT IF the person
appropriate manual handling THEN use a sit-to-stand
requires maximum
assistance and is not -- device, with at least two
careg ivers, depending on
assistance device.
able to participate?
the person's weight.
Source: Adapted from S. Harrington & C. Brigham (2013). Navigating the New Safe Patient Handling & Mobility lnterprofessional National Standards (ANA webinar).
Retrieved from http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/SafePatient/SPHM-Standards-Media; A. L. Nelson, K.
Motacki, & N. Menzel (2009). The illustrated guide to safe patient handling & movement. New York, NY: Springer; and Algorithms for safe patient handling & movement,
U.S. Dept Veterans Affairs.
58 SKILLS IN CLINI CAL NU RS IN G
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CLINICAL SCENARIO
_
cr_it_ic_a_lT_h_in_k_in_g_a_u_es_t_io_n_
s_____
How would you respond to this request and why?
ii
You visit Sally (the 37-year-old woman with metastatic breast
cancer) in her caravan (home) the following week to reassess her 2 Are there any manual handling devices that could be helpful
mobility and falls risk assessment (Van Der Riet & Pitt 2018). Sally in this situation? If so, which one(s)?
tells you that she has had to take the morphine elixir 40 mg four 3 What strategies could you employ to make this transfer as
times in the past 24 hours for breakthrough pain. When you arrive safe as possible for both you and Sally?
you find Sally lying in bed. She asks if you could help her to the
toilet, which is outside the caravan, as she is feeling very tired and
is worried she may not make it on her own. mno nWjjj /jjlllll Hllllll llllllll illlj/jj )jjQIJI ®jjjj 111@1 llllllli lllllll[
TRANSFERRING PEOPLE ■ Use special caution with older adults to prevent skin tears or
bruising during a transfer or when using a hydraulic and
Infants electric lift.
■ An infant who is lying down, on the side or supine, can be ■ Document the method used to transfer each person - equipment
placed in either a bassinet or cot for transport. If the bassinet used, best position, and number of people needed to assist in
has a bottom shelf, this can be used for carrying the IV pump or the transfer. This can be part of the care plan and can also be
monitor. available in the person 's room as a guide to all staff caring for the
Children person.
■ Avoid sudden position changes. They can cause orthostatic
■ The todd ler should be transported in a high-top cot with the side
hypotension and increase the risk of fainting and falls.
rails up and the protective top in place. Stretchers should not be
used because the active toddler may roll or fall off.
Older adults
■ Because the conditions of older adults can change from day to
day, always assess the situation to ensure that you have the right
equipment and enough people to assist when transferring a person.
~
11111111111••• 1
••·••1
Air, foam and gel cushions (see Figure 2-13) that distribute
weight evenly (not doughnut-type cushions) are essential for
people confined to a wheelchair and must be checked frequently
to ensure they are intact. Strict continence management is
also important for preventing skin breakdown. Maintaining
wheelchair tyre pressure will prevent added resistance and
energy expenditure. Periodically monitor the person's upper
extremities for pain and overuse syndromes. Figure 2-13 A chair cushion designed to mimic the floatation
effects of water
© Nichole Harvey
UNIT 2 SECTION 2.3 HELPING A PERSON OUT OF BED 59
THE 3Ps TABLE Helping a person out of bed
Identify indication for helping a person out of bed. When a person is unable to transfer themselves due to physical, cognitive,
life span or illness considerations. There are many reasons for helping a
person move from their bed to either a standing position or to sitting down
in a chair; for example, eating meals, hygiene or toileting needs. Whatever
reason, ensure the person 's health status allows for them to be out of bed at
this time.
Perform hand hygiene. Hand hygiene is an essential skill to remove microorganisms and prevent
cross contamination.
Check the person's care plan or notes to confirm what Most facilities will have a falls risk assessment tool or management plan that
equipment or how many people are required for the has been completed for the person. This document will provide information
transfer. about the person (i.e. whether they suffer from postural hypotension) and
also what manual handling aids may be necessary.
Introduce yourself to the person using full name and This is a professional expectation and helps to promote a therapeutic
designation. Verify the person's identity and ask how relationship. Checking how the person prefers to be addressed also helps
they would like you to address them , i.e. their preferred to promote rapport and demonstrates respect. During this time you can
name. ascertain from the person what level of help they believe they require and
whether they are comfortable for you to assist them .
Determine the person 's physical and mental capabilities A person 's physical and mental status will have an important bearing on
to participate in this activity (i.e. undertake a risk how much the person will be able to assist themselves in getting out of
management process). bed. It is essential to determine whether the person is mainly independent,
requiring minimal assistance from one person , or whether they are largely
dependent, requiring assistance from two or more people and whether
mobility aids will be needed.
Plan what you will do and what equipment you will To ensure the transfer is done as safely as possible the environment needs
need to gather. Arrange the environment and space to to be prepared prior to the move. Ensure that there are no loose items on
allow sufficient room for the transfer. the floor, lighting is sufficient, there is a clear path to where you want to go
and the person is prepared for the transfer. For example, if the person is in
pain, administer pain relief prior to the transfer, if possible, to increase the
person 's comfort.
Gather and check the necessary equipment and The equipment needs to be checked and ready to use to ensure the
request another person if required. Possible aids that person's and the nurse 's safety at all times. Check the Safe Working
can be used are: Load (SWL) of the chair/wheelchair to ensure it is appropriate for the
• Walking stick, crutches person's weight. Ensure brakes are in place for devices that have wheels.
• Transfer belt Additionally, having all the equipment available and ready to use avoids
• Walking frame/ Rollator interrupting the procedure or leaving the person unattended while the nurse
retrieves the missing items. It also improves time management as having to
• Wheelchair
stop and start to retrieve equipment will cause the procedure to take longer.
• Monkey bar
• Slide board
• Additional pillows.
Provide for privacy by drawing curtains around the bed Privacy is required to protect the person's dignity and modesty during
or closing the door to the room . Place a 'privacy' sign manual handling activities.
on the curtain or door to prevent anyone accidentally
entering .
Hand hygiene is an essential skill to remove microorganisms and prevent

cross contamination . Hand hygiene is performed before touching or
examining an individual to comply with the '5 moments for hand hygiene'.
Provide a clear explanation of the transfer procedure Know ing what is about to happen can help reduce anxiety. This can be a
and what the person wi ll need to do. Obtain consent. very anxious time for some people, especially if they have had a previous
fall or are unsteady on their feet due to their current health status. Consent
should be obtained as it is a legal requirement and complies with ethical
standards for a registered nurse.
Explain what your role will be and if there is another It is important that everyone knows what role is expected of them and that
person helping, what their role will be during the transfer one person takes a lead role and gives directions throughout the transfer.
procedure. This will ensure that everyone is working together and will minimise the
potential for injury for all parties.
60 SKILLS IN CLINICAL NURSIN G
Adjust the bed height to the appropriate height for the It is important to position the person 's feet in the direction of the move
person so that the person will be able to place their feet once they are sitting. This will ensure good body alignment and allows the
on the floor once they are sitting on the edge of the bed. person to use their feet and legs to push off from the bed. Ensuring the
Ensure the brakes on the bed are locked. brakes are on prevents the bed from moving unexpectedly.
Assist the person to a lateral lying position facing you This decreases the distance that the person needs to move to sit up on the
and raise the head of the bed slowly to the highest side of the bed.
position the person can tolerate.
Position the person's feet and lower legs at the edge of This enables the person 's feet to move easily off the bed during the
the bed . movement, and the person is aided by gravity into a sitting position .
Stand beside the person 's hips. Face the far corner of It is important to use good body mechanics to prevent musculoskeletal
the bottom of the bed (the angle in which movement will injuries to yourself.
occur). Assume a broad stance, placing the foot nearest
the person forward. Lean your body forward from the
hips. Flex your hips, knees and ankles.
Move the person to a sitting position by placing one arm Supporting the person 's shoulders prevents them from falling backwards
around their shoulders and the other arm beneath both during the movement. Supporting the person 's thighs reduces friction of
of their thighs near the knees. O the thighs against the bed surface during the move and increases the force
of the movement.
Tighten you r gluteal , abdominal , leg and arm muscles, The use of good body mechanics will help prevent injury. Lifting the thighs
and lift the thighs slightly. slightly will reduce friction.
Pivot on the ball of your feet in the desired direction Pivoting prevents twisting of the nurse's spine. The weight of the legs
facing the foot of the bed while pulling the person's feet swinging downwards increases downward movement of the lower body
and legs off the bed. f) and helps make the person's upper body vertical.
Keep supporting the person until they are well balanced This movement may cause the person to feel some dizziness and/or to feel
and comfortable. faint.
Check if the person would like to put on a dressing It is safer for the person to mobilise with non-slip shoes on. The person
gown or non-slip slippers/shoes and assist them as may feel more comfortable with wearing a dressing gown to protect their
required. modesty and also to help keep them warm.
There are a number of variations to how this transfer Variations include one- or two-person assist with the use of different
can proceed, because it depends on the health status of manual handling aids, such as a transfer belt, wheelchair, slide board,
the person . For the purpose of this example the person rollator, walking stick, hoist and sling. It is vital that every health
requires a one-person assist with no manual handling professional involved in manual handling undergo education and training
aids. on the use of each device. It is the nurse's responsibility to ensure that
they have completed the mandatory manual handling training in their own
workplace and know how to use each device safely.
If using a transfer belt, place it around the person's This is not essential , but can be helpful depending on the person 's gait and
waist. balance and the degree of assistance required.
UNIT 2 SECTION 2.3 HELPING A PERSON OUT OF BED 61
Speak clearly and ask the person to move forward and This brings the person 's centre of gravity closer to the nurse's.
sit on the edge of the bed (or surface on which the
person is sitting) with their feet placed flat on the floor.
Ask the person to lean forward slightly from the hips and This brings the person 's centre of gravity more directly over the base of
place their foot of the stronger leg beneath the edge of support and positions the head and trunk in the direction of the movement.
the bed and put the other foot forward. e The person can use their stronger leg muscles to stand and power the
movement. The broader base gives the person more stability.
c::::::::) {C:::)
xPerson
r.--..----
c::::::> "---' I
Nurse's Person's
feet feet
8 Note that placement of the nurse's

feet mirrors that of the person's feet.
Ask the person to place their hands on the bed surface This provides additional force for the movement and reduces the potential
(or surface on which the person is sitting) so that they for strain on the nurse's neck/back. The person should not grasp the
can push while standing. nurse's neck as this can injure the nurse.
Stand close and directly in front of the person and place Moving the person close to you is good body mechanics.
one hand on the person's shoulder blade and the other
over the pelvis.
Lean the trunk forward from the hips (keep back Good body mechanics is essential to prevent musculoskeletal sprains/
straight). Flex hips, knees and ankles. Place one foot injuries and to maintain balance throughout the transfer.
in front of the other, shoulder-width apart - mirror the
placement of the person 's feet.
Assist the person to stand - communicate clearly with This provides support and reassurance to the person and allows them to
the person so they know exactly what to expect. For know what actions they are required to perform to stand safely. Never rush
example, 'On the count of three please push down with the person - allow the person to take the time they need to stand safely.
your hands against the bed and lean forward towards The nurse should not have to lift the person and pulling should be minimal.
me as you stand. I will be here to help you as you If more help is needed, a second person should be requested and the use
stand' . of a manual handling device (i.e. hoist and sling) should be considered .
Support the person in an upright standing position for a This allows all parties to extend their joints and provides the nurse with the
few moments. opportunity to check the person is stable before moving away from the
bed .
When the person is ready, slowly start to take a few Moving too soon, too quickly or if the person is not ready may result in the
steps towards the chair/ wheelchair, which you prepared person becoming anxious and losing their balance. Good communication
earlier in the preparation phase. is essential.
Manoeuvre the person towards the chair/wheelchair, Always move at a comfortable pace for the person to increase their
moving at a comfortable pace for the person. Have the confidence and comfort throughout the transfer. Having the person place
person back up towards the chair/wheelchair until they their legs against the chair/ wheelchair seat minimises the risk of the person
feel the edge of the chair seat against their legs. falling when sitting down.
Ask the person to reach back and feel for the arms of This will help the person support themselves as they lower themselves into
the chair/wheelchair. the seat of the chair.
I Stand close and directly in front of the person and place

one hand on the person's shoulder blade and the other
over the pelvis as you guide them into the chair. If using
Moving the person close to you is good body mechanics. The use of good
body mechanics will help prevent injury.
I a transfer belt, you can hold this as the person lowers

themselves into chair.
I Ensure you tighten your gluteal, abdominal, leg and arm

muscles and flex your hips and knees as the person sits.
Tightening muscles and flexing at the hips and knees will protect your back
and minimise risk of strains/ injuries.
I
I
I
I
62 SKILLS IN CLI NICAL NURSING
Once the person is sitting, ask them to push themselves Sitting well back on the seat provides a broader base of support and
back using the arm rests. greater stability and minimises the risk of falling from the chair/ wheelchair.
A wheelchair or commode can topple forward when the person sits on the
edge of the seat and leans forward.
Remove the transfer belt if one was used. If transferring Now that the transfer is completed, ensure the person is left comfortable
to a wheelchair put the footplates down for the person and has all items that they need within easy reach.
to rest their feet. Check if additional blankets or pillows
are required to promote comfort and also if the person
would like any personal items (i.e. reading glasses,
book).
Check if the person has any pain. If concerned perform Movement may increase a person's pain so checking their pain levels and
a set of vital signs. vital signs should also be done when the transfer is completed , if there is
concern.
Do a final check for proper body alignment of the person To prevent the person experiencing any musculoskeletal pain or injuries
and ensure all safety precautions are in place (i.e. call from misalignment. The call bell should always be within reach in case of
bell in reach, brakes are locked). an emergency.
PRIORITIES POST PROCEDURE
Perform hand hygiene. Hand hygiene is an essential skill to remove microorganisms and prevent
cross contamination . Hand hygiene is performed after touching a person
or the person 's surroundings, to comply with the '5 moments for hand
hygiene'.
Check documentation has been completed accurately Documenting is a legal and professional requirement of a registered nurse.
and that you have printed your name, designation and Documentation ensures that essential information is transferred to other
the date, and have signed the relevant documents. relevant health professionals to ensure that the care plans are accurate,
updated and appropriate to meet the needs of the person.
Evaluate care plan and complete ongoing assessments To determine if there has been any worsening or improvement in the
at regular intervals or as required. person 's health status and mobility requirements . Regular evaluation will
alert you to whether the person wishes to return to bed or change position .
Communicate any changes in the findings to the Communication among health professionals ensures that prompt review
treating doctor, nurse coordinator and/or allied health and management can be undertaken and further tests/ treatments ordered
professionals (i.e. physiotherapist) as required . if necessary.
On completion of this section you will be able to: ambulation, 64
hemiplegia, 65
1 Define the key terms used in the skill of assisting with mobilisation.
rol lator, 66
2 Describe appropriate safety measures to use when assisting people to ambulate. walker, 66
3 Describe the different mechanical aids used to help someone with walking and the
indications for choosing one above another.
4 Identify the steps used in assisting a person to mobilise safely.
The importance of body movement to a person's health Manual wheelchairs come in different sizes and
cannot be overemphasised. The overall benefits of weights. The lighter the wheelchair, the easier the person
exercise and the ability to carry outADLs by walking and can manoeuvre it around. The cost, however, increases
moving are often taken for granted by a healthy person. as the weight of the wheelchair decreases. Folding
Being ill and confined to bed weakens the body and can wheelchairs have an X-shaped brace under the seat that
result in serious impairments not only to movement but allows the seat to fold arm to arm. Although the ability to
I also to the functioning of other body systems (Ackley
et al., 2020). Individuals should be encouraged to keep
fold the wheelchair for placement in a car or for compact
storage may be desirable, folding wheelchairs have
I moving, and they may require assistance through the 'use
of walkers, rollators, walking sticks/canes and crutches
drawbacks. The brace makes the wheelchair heavy and
possibly too heavy for one person to lift. In addition, the
L in order to do so. Some people may require the use of
a wheelchair for a short or an extended period of time.
frame is not as strong as the rigid frame, and the moving
joints are subject to wear. The rigid frame usually has a
I Individuals and their families often need to learn how to
use equipment that enhances mobility.
seat back that folds down and easily removable wheels.
Armrests can be removed from most wheelchairs.
l~ - - ASSISTING PEOPLE TO USE
Footplates (footrests) and leg rests may be rigid or
adjustable. Adjustable leg rests are more common in
r WHEELCHAIRS
wheelchairs found in hospitals since they are used when
the feet need to be raised to aid in circulation or for people
I There are two general types of wheelchairs: manual
and electric/power. It is important to evaluate a person's
who cannot bend their knees. Wheel locks are generally
side-mounted with short or long lever arms that are used
I ability to propel themselves manually by means of the
wheelchair if independent use is desired. Otherwise, an
to manually move the brake arm against the wheel. The
size and type of the wheelchair's smaller front caster
I electric wheelchair that can be manipulated by the person
with the physical abilities available to do so, must be
wheels are selected according to the expected use. Larger
caster wheels roll over bumps more easily but are heavier,
I chosen. Manual wheelchairs may be either folding or
rigid-framed and come in a variety of sizes (see Figure
are harder to turn and take more room to turn . Tyres may
be air-filled (pneumatic) or solid (airless). Air-filled tyres
I 2-14A). Another type of chair on wheels is a toilet chair
(see Figure 2-14B). These chairs can be very helpful in
are light, smooth and durable. Solid tyres do not go flat,
which makes them more reliable for power wheelchairs
I reducing the number of transfers the person has to do. and the extra weight is less of a concern.
I
64 SKILLS IN CLINI CAL NURSING
sling seats can cause internal rotation of the hips, flexion of

the pelvis and inadequate neck support. They may also cause
skin breakdown ifused for extended periods of time. For long-
term use, a rigid back and a solid seat platform with a foam,
air, gel or honeycomb cushion are required. It may also be
desirable to use a tilt, multi-positioning chair with the ability
to assume a reclining position when the person is expected to
remain in a wheelchair for lengthy amounts of time.
IJ.1.I.11.l_l..lllJ-II-1-LIUJj
· CLINICAL SAFETY ALERT
Always lock the brake on both wheels of the wheelchair when
the person transfers in or out of it. Raise the footplates and
move the calf rests out of the way before transferring the person
into the wheelchair. Lower the footplates after the transfer, put
the calf rests back in place, and place the person's feet on the
footrests. Wheelchairs should be serviced regularly and if any
damage is noted (e.g. footplates falling down), organise prompt
repair. This will help prevent skin tears, bruising and other
A injuries .
. LIFESPAN CONSIDERATIONS 11111 ~ l

USING A WHEELCHAIR
Be sensitive to the significance that the wheelchair may have
for the person. For some, it may mean an opportunity for some
much-desired mobility. For an older adult, it may signify a negative
milestone of increasing dependence. For a young person who is
undergoing a temporary lack of mobility (such as with a fractured
femur) , it might be necessary to emphasise safety precautions, as
the temptation to try 'tricks' with the wheelchair may arise.
Children
■ Children learn quickly how to manoeuvre themselves in an
appropriately sized wheelchair. They may view the wheelchair
almost as a special 'toy' and disregard the dangers involved
in, for instance, trying to balance the wheelchair on its back
wheels only wh ile moving rapidly. Ensure that proper education
is performed and supervision is sufficient until it is clear that
the ch ild will be safe in the wheelchair.
Older adults
■ Some older adults may have incomplete sensation or control in
their extremities. People who have had strokes may have lost
their sense of what is truly 'upright'. Ensure that arms and legs
are appropriately supported and protected from injury.
...._,.. ~
~
AMBULATION
Ambulation (the act of walking) is a function that most people
take for granted. However, when people are ill, they are often
Figure 2-14 A, Standard wheelchair; B, Toilet chair on wheels confined to bed and are non-ambulatory. The longer someone
A, © Rick Brady/Pearson Education, Inc; B, © Nichole Harvey. is in bed, the more difficulty they have walking. Even one or
two days of bed rest can make a person feel weak, unsteady
and shaky when first getting out of bed. A person who has
For people who spend a great deal of time in a wheelchair, had surgery, is elderly or has been immobilised for a longer
proper seating is of utmost importance. If the seat does not time, will feel pronounced weakness. The potential problems
adequately support the person, skin breakdown and adverse of immobility are far less likely to occur when the person
effects of poor posture can result. For temporary use, the sling becomes ambulatory as soon as possible. The nurse can assist
seat that comes with most wheelchairs is acceptable. However, the person to prepare for ambulation by helping them become
UN IT 2 SECTION 2.4 ASSISTING WITH MOBILISATION 65
as independent as possible while in bed. Nurses should

encourage the person to perform ADLs, maintain good body
alignment and carry out active range-of-motion exercises
to the maximum degree possible yet within the limitations
imposed by their illness and recovery program.
People who have been in bed for long periods often need
a plan of muscle tone exercises to strengthen the muscles
used for mobilising before attempting to walk. One of the
most important muscle groups is the quadriceps femoris,
which extends the knee and flexes the thigh . This group is
also important for elevating the legs; for example, for walking
upstairs. These exercises are frequently called quadriceps
drills or sets (see Figure 2-15). To strengthen these muscles,
the person consciously tenses them, drawing the kneecap
upward and inward. The person pushes the popliteal space
Figure 2-15 Tensing the quadriceps femoris muscles before
of the knee against the bed surface, relaxing the heels on the ambulating
bed surface. On the count of 1, the muscles are tensed; they © Rick Brady/Pearson Education, Inc.
are held during the counts of 2, 3, 4; and they are relaxed
at the count of 5. The exercise should be done within the
person's tolerance; that is, without fatiguing the muscles.
Carried out several times an hour during waking hours, this
simple exercise significantly strengthens the muscles used for
11111111111,••····••1
walking. CLINICAL SAFETY ALERT
Common problems that affect walking include pathology
When making a home visit, assess carefully for safety issues
of the muscles, disease or injury of the bones of the lower
concerning ambulation. Educate the person and family about
extremities, and impaired balance, such as from an inner ear inadequate lighting, unfastened rugs, slippery floors and loose
infection or due to a stroke that produces hemiplegia (loss of objects on the floors. Check the environment for adequate
movement on one side of the body). Nurses frequently need to supports, such as railings and grab bars (Joanna Briggs Institute
assist individuals in walking and in using a variety of devices [JBI], 2016). If required, refer to an occupational therapist for
further assistance with home set-up needs.
such as a walking stick, walker or rollator, and crutches.
LIFESPAN CONSIDERATIONS ;·. :- ' 11

ASSISTING THE PERSON TO AMBULATE ■ If assistive devices such as a walker or cane are used, make
OR MOBILISE sure the person is supervised as they begin to learn the proper
method of using them. Crutches may be much more difficult for
Children older adults due to decreased upper body strength. In general,
■ Children and adolescents who have sustained a sports injury older people do much better with walkers than with crutches.
(e.g . sprained ankle) may want to be more active than they ■ Be alert to signs of activity intolerance, especially in older adults
should be. A cast, splint or boot may be put in place to limit who have cardiac and lung problems.
activity and assist in healing. Teach children the importance ■ Break up the eventual desired mobility goal into shorter, more
of appropriate activity and the use of assistive devices (e.g. easily attained but progressively more ambitious goals. Increase
crutches) if necessary. Help them focus on what they can do slowly to build endurance, strength and flexibility.
rather than what they cannot do (e.g. 'You can stand at the ■ Be aware of any fall risks the older person may have, such as
free throw line and shoot baskets'). the following :
Older adults ■ The normal effects of ageing on the body's mobility abilities
■ Inquire how the person has ambulated previously and/or check ■ Effects of medications
any available chart notes regarding the person's abilities, and ■ Neurologic disorders
modify assistance accordingly. ■ Orthopaedic problems

■ Presence of equipment that must accompany the person
■ Take into account a decrease in speed, strength , resistance to
fatigue, reaction time and coordination due to a decrease in when mobilising
nerve conduction , muscle strength and the effects of ageing on ■ Environmental hazards
baroreceptors and proprioceptors. ■ Orthostatic hypotension.
■ Be cautious when using a transfer belt with a person who has ■ In older adults, the body's responses return to normal more
osteoporosis. Too much pressure from the belt can increase the slowly. For instance, an increase in heart rate from exercise may
risk of vertebral compression fractures. stay elevated for hours before returning to normal.
......_,............__,,...... ~~
I
I
Using mechanical aids for walking forearm (see Figure 2-17). On the Lofstrand crutch, the metal I
Mechanical aids for ambulation (wallcing) include wallcing
sticks, walking frames and crutches.
cuff around the forearm and the metal bar stabilise the wrists
and thus make walling easier, especially on stairs. The platform i
WALKING STICKS
or elbow extensor crutch also has a cuff for the upper arm (see
Figure 2-17). The platform crutch is helpful for persons who I
The standard straight-legged walking stick and the quad walking
stick are the two walking sticks that are used today. (see Figures
have damaged not only a lower extremity but also an upper one.
All crutches require suction tips, usually made of rubber, which I
2-16 A and B). Walling stick tips should have rubber caps to
improve traction and prevent slipping. The standard walking stick
help to prevent slipping on a floor surface. In crutch walling,
the person's weight is borne by the muscles of the shoulder I
is 91 cm long; some aluminium walking sticks can be adjusted
from 56 to 97 cm. The length should permit the elbow to be
girdle and the upper extremities. Before beginning crutch
walking, exercises that strengthen the upper arms and hands are I
slightly flexed. The person using the aid may use either one or
two walking sticks, depending on how much support they require.
recommended.
I
11111111111••• 1 i11111
CLINICAL SAFETY ALERT I
'
Crutches need to be measured to ensure they fit the person I
safely. Crutches that are too long or too short may put the
person at risk of falling or developing poor body posture. The
weight of the body should be borne by the arms rather than by
I
the axillae (underarms). Continual pressure on the axillae can
injure the radial nerve (Moxham & Reaburn, 2018). (See 'Useful
I
A B
weblinks' for newer styles of crutches.)
I
Figure 2-16 A, Standard straight-legged walking stick; 8, Quad
walking stick
WALKING FRAMES
Walkers are for people who need more support than a walking
I
A, © Vector pro, Pearson Education Ltd; B, © 257 4523/Shutterstock. stick provides and lack the strength and balance required for
crutches. Walkers come in many different shapes and sizes, with
I
CRUTCHES
Crutches may be a temporary need for some people and a
devices suited to individual needs. The standard type is made of
polished aluminium. It has four legs with rubber tips and plastic
I
permanent one for others. The most frequently used lands of
crutches are the underarm crutch, or axillary crutch with hand
hand grips (see Figure 2-18A). Many walkers have adjustable
legs. The standard walker needs to be picked up to be used. The
I
bars, and the Lofstrand crutch, which extends only to the person therefore requires partial strength in both hands and wrists,
strong elbow extensors and strong shoulder depressors. The person
I
also needs the ability to bear at least partial weight on both legs.
Two-wheeled (see Figure 2- 18B) and four-wheeled (see
I
Figure 2-19) models of walkers , also referred to as rollators,
do not need to be picked up to be moved, but they are less
I
stable than the standard walker. They are used by people who
are too weak or unstable to pick up and move the walker with
I
each step. Four-wheeled walkers allow the user some added
stability as compared to using no assistive device, and have
I
the capability of rapid ambulation, but they are not suitable
for people who need a walker to bear weight; walkers with no
I
wheels are safer for these people. The four-wheeled walker
may also have hand brakes and a seat at the back for the
I
person to sit down to rest when desired (see Figure 2-20). An
adaptation of the standard and four-wheeled walker is one
I
that has two tips and two wheels. This type provides more
stability than the four-wheeled model yet still permits the
I
person to keep the walker in contact with the ground all the
time. The legs with wheels allow the person to easily push
I
the walker forward, and the legs without wheels prevent the
walker from rolling away as the person steps forward.
I
The nurse may need to adjust the height of a person's walker
so that the hand bar is below the person's waist and the person 's
I
Figure 2-17 Types of crutches: axil lary, Lofstrand and platform
elbows are slightly flexed. This position helps the person assume
a more normal stance. A walker that is too low causes the person
I
to stoop; one that is too high makes the person stretch and reach. I
I
UNIT 2 SECTION 2.4 ASSISTING WI TH MOBILISATION 67
A 8
Figure 2-18 A, Standard walker; 8, Two-wheeled walker
© Rick Brady/Pearson Education, Inc.
Figure 2-19 Four-wheeled walker or rollator with padded armrests

© Nichole Harvey.
Figure 2-20 Four-wheeled walker or rollator with brakes and
padded seat
© glenda. Shutterstock.
IIIIIIIIIIlIIIIIIIJJJ
When rising from a bed, chair or bedside commode and intending
to use a walker, people sometimes overestimate the stability of
the walker, which typically has a lightweight aluminium frame
and sometimes wheels. Teach people to use the more stable
surface of the bed or arms of the chair from which they are
getting up and to use the walker only for stabilising balance
once they are upright.

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What are the components of hand hygiene?

What are the components of hand hygiene?

What are the 5 moments for hand hygiene?

What are the 5 moments for hand hygiene?

COMMONWEALTH OF AUSTRALIA

This material has been reproduced and communicated to you by or on behalf of

Do not remove this notice

LEARNING OUTCOMES KEY TERMS

Figure 1-3 Steps required for transmission of microorganisms

hand rub. The goal of hand hygiene is to reduce the hand-

(&@~l World Health

Figure 1-4 The 5 moments for hand hygiene

4 A nursing student asks you about the wearing of jewellery

ACTION EXPLANATION AND RATIONALE

..(that contains 60-80% ethanol)

Variation: Specific hand wash for Surgical Aseptic

Early identification of breakage of the skin barrier assists in applying further

• A face mask is a barrier which reduces the transmission

Keep door closed at all times

Standard Precautions Standard Precautions

AUSTRALIAN COMMISSION AUSTRALIAN COMMISSION

for the Management of Healthcare Workers Known to be

THEN You need to seek assistance from

Remove personal items that can be contaminated

Discuss the need of PPE with the person

Perform hand hygiene

Apply PPE in order of gown , mask,

THEN If you have been exposed

Perform hand hygiene

Perform hand hygiene. Hand hygiene is performed as an infection control precaution.

Perform hand hygiene. Prevents the spread of microorganisms.

I 2 Explain measures to prevent falls in hospitals, and in long-term care and

screening, assessment and management.

I 5 Outline the process to follow if a person experiences a fall.

I 2018; Australian Institute of Health & Welfare [AIHW] ,

I 65 years old), the most common injuries that require

I thigh injuries (22%) (AIHW, 2019). Femoral neck (hip)

I 25 per cent of cases resulting in the person dying. Of

I system (ANZFPS, 2019).

I and can cause significant harm (ACSQHC, 2018). Harm

I likelihood of being discharged to a residential aged care

Table 2-2 Common terms with definitions

Table 2-3 Risk factors and preventative measures for falls

I and Management Plan

I Falls Risk Assessment

• Consider referral (e.g. ophthalmologist,

• Measure lying and standing BP

I The patient has a recent history of syncope

□Y □Y □Y ► •Notify MO and facilitate tests as ordered

I The patient is on one of the following medications: □ Y □ Y □ Y

Following assessment, proceed to management plan (page 2) ~

(Affix identification label here)

Date of birth: Sex: OM OF 0 1

Category .... Date

Communicate patients 'at risk' status at bedside handover

Keep patient's mobility aid in reach if applicable

Complete nursing discharge summary and facilitate referrals

LIFESPAN CONSIDERATIONS . :1~

THE 3Ps TABLE Mobility and falls risk assessment