Fall Prevention
Morse Fall Scale risk factors: fall history, secondary diagnosis, ambulatory aid, IV, gait, mental status. High risk: ≥45 on Morse. Interventions: call light within reach, bed lowest position, brakes locked, non-slip footwear, hourly rounding, clutter-free environment, night light, mobility aids accessible, fall prevention signage, wristband. Post-fall: assess for injury, vital signs, notify provider, complete incident report.
Restraints
Use only as last resort when patient is at immediate risk of harming self/others. Least restrictive first. Requirements: physician order (q24hr renewal for behavioral; q4hr adults), RN assessment q1–2 hours, circulation/sensation/movement checks, skin care, hygiene, positioning, ROM exercises. Offer fluids, toileting, and reorientation. Protective restraints (mittens) vs. behavioral/violent restraints — different criteria.
Isolation Precautions
Standard Precautions: for ALL patients, always. Includes: hand hygiene, gloves, gown/mask/eye protection based on anticipated exposure. Airborne (N95 + negative pressure room): TB, measles, chickenpox, SARS, COVID (aerosol-generating). Droplet (surgical mask + private room): influenza, pertussis, meningococcal, mumps. Contact (gloves + gown): MRSA, VRE, C. diff, scabies, wound infections. C. diff: soap and water only — alcohol-based hand sanitizer does NOT kill spores.
Hand Hygiene
The single most important infection prevention measure. WHO Five Moments: before patient contact, before aseptic procedure, after body fluid exposure, after patient contact, after contact with patient surroundings. Alcohol-based rub preferred (except C. diff, norovirus, spore-forming organisms). Soap and water if hands visibly soiled. Jewelry (including rings) must be removed. 20-second minimum for soap, 15 seconds for alcohol rub.
Medication Safety
High-alert medications (ISMP list): anticoagulants, insulin, concentrated electrolytes (IV KCl), neuromuscular blocking agents, opioids, chemotherapy. ALWAYS require: two-nurse verification, weight-based dosing when applicable. Never crush enteric-coated or extended-release medications. Confirm allergy status before every new medication. Barcode medication administration (BCMA) is evidence-based for error prevention.
Important Notes
- C. difficile: must use soap and water — alcohol hand sanitizer is ineffective against spores.
- Restraints are a last resort — document all alternatives tried before applying.
Clinical Tips
- N95 respirator requires fit testing — check seal before each use.
- SBAR (Situation, Background, Assessment, Recommendation) is the evidence-based communication tool for safety.
Summary
Patient safety and infection control are NCLEX priorities. Nurses prevent harm through fall prevention, appropriate restraint use, correct isolation precautions, proper hand hygiene, and medication safety protocols.
