FUNDAMENTALS – SAFETY/INFECTION are similar to food proteins.

Latex
CONTROL sensitivity increases with exposure and
PPE DONNING should be suspected in the following
situations:
• Allergic contact dermatitis (rash, itching,
vesicles) developing 3–4 days after
exposure to a rubber latex product. This is
a type IV hypersensitivity reaction (delayed
onset).
• Anaphylaxis - many cases of anaphylaxis
have been reported in both medical and
non-medical settings. These represent a
type I hypersensitivity reaction and should
be treated with intramuscular epinephrine
injections. Some common settings include:
o Glove use
o Procedures involving balloon-tipped
catheters (eg, arterial
catheterization)
o Blowing up toy balloons
o Use of bottle nipples, pacifiers
o Use of condoms or diaphragms
during sex
• Clients with severe allergies should wear a
PPE REMOVAL Medic Alert bracelet and carry an injectable
epinephrine pen due to cross-sensitivity
with many food and industrial products that
can be impossible to avoid.

CELLULITIS
• Cellulitis is inflammation of
the subcutaneous tissues that is typically
caused by bacterial infection
(eg, Staphylococcus aureus, group
A Streptococcus) resulting from an insect
bite, cut, abrasion, or open
wound. Cellulitis is characterized by
redness, edema, pain, and fever.
• Nurses caring for clients with cellulitis
should ensure that the affected
extremity is elevated when the client is
sitting or lying down to promote lymphatic
drainage. Flat or dependent positioning
may worsen edema, which delays recovery
LATEX ALLERGY and contributes to pain
• People with latex allergy usually have a • In addition, clients with weeping or draining
cross-allergy to foods such as bananas, wounds must be protected from prolonged
kiwis, avocados, tomatoes, peaches, and exposure to moist or soiled linens as this
grapes because some proteins in rubber
 exposure promotes tissue injury and
infection. • Clopidogrel (Plavix) is an antiplatelet
• Applying warm compresses promotes medication that should be discontinued 5-
circulation to the area of infection, alleviates 7 days before surgery to decrease the risk
discomfort, and helps reduce edema. for excessive bleeding. The client took this
• Daily marking and dating of reddened areas drug 48 hours ago. Therefore, the nurse
assist with monitoring improvement or must notify the HCP. The surgery may be
worsening of the infection. Redness that postponed due to the increased risk for
progresses past the marked areas indicates intra- and post-operative bleeding
ineffective antibiotic therapy and should be • All clients should try not to smoke for at
reported to the health care provider. least 24 hours before surgery to help
• Although standard precautions are typically prevent oxygenation problems.
sufficient for cellulitis, a gown and gloves • The client takes gingko biloba to relieve
are worn when contact with body fluids (eg, symptoms of intermittent claudication; it
urine, stool) or potentially infectious was discontinued 2 weeks ago because it
drainage is expected, such as during can increase the risk for excessive
bathing. bleeding.
• Nonsteroidal anti-inflammatory drugs
(NSAIDS) such as naproxen (Naprosyn)
PRE-OP NURSING RESPONSIBILITIES should be discontinued 7 days before
scheduled surgery as they can increase the
• Nursing responsibilities prior to risk for excessive
surgery include assessment, client bleeding. Acetaminophen can be taken to
teaching, and communication with the control pain up until surgery.
health care provider. Client allergies and
history are confirmed while baseline vital
signs are collected. Other nursing
NEUTROPENIC PRECAUTIONS
preoperative responsibilities include:
The following neutropenic precautions are
o Confirming that informed consent has indicated:
taken place and signed documents are
placed in the client's chart o A private room
o Encouraging the client to void to reduce o Strict handwashing
the risk of retention in the immediate o Avoiding exposure to people who are
recovery period sick
o Ensuring that the client has been o Avoiding all fresh fruits, vegetables,
on NPO status to avoid aspiration and flowers
during surgery and documenting when o Ensuring that all equipment used with
it started the client has been disinfected
o Witnessing and documenting
preoperatively that the correct
surgical site is marked by the surgeon
AIRBORNE PRECAUTIONS
with a permanent marker. Verify this
with the client, ensuring that surgery will
take place on the correct side/site

• If an IV line has not been started, an 18-

gauge catheter is preferred. However, if a
functioning IV line is already present, a 20-
gauge is acceptable. Blood products, if
needed during surgery, can be transfused
through a 20-gauge catheter if necessary.
• Varicella (chickenpox) is a highly CONTACT PRECAUTIONS
contagious infection characterized by a
generalized rash of itchy, vesicular lesions.
• Both chickenpox and shingles are caused
by the varicella-zoster virus (VZV), which
is transmitted through airborne particles or
contact with open vesicles.
• For chickenpox and disseminated
(widespread) shingles, the nurse should
use precautions for both airborne
• Clients with a health care-associated
isolation (ie, N95 respirator mask),
infection, such as methicillin-
negative air pressure room) and contact
resistant Staphylococcus aureus, are
isolation (eg, gown, gloves, disposable
placed on contact precautions to prevent
equipment)
transmission of microorganisms.
• Once the vesicles have crusted, the client is • Contact precautions include standard
no longer contagious, and isolation precaution measures in addition to use of
precautions may be discontinued a gown and gloves and single-client-use
equipment (eg, stethoscopes, blood
• Rooms with negative air pressure are pressure cuffs, thermometers).
equipped with specialized air equipment • Disposable or single-client-use equipment
that continuously filters air out of the room must not be shared between clients or
and creates a negative pressure gradient transferred to other care areas.
that prevents infectious airborne particles • Dedicated equipment should be kept in
from escaping through the doorway the room for client care, and then
• Pregnant health care workers should not be disinfected or discarded when no longer
exposed to clients with TORCH infections needed
(Toxoplasmosis, Other [VZV/parvovirus • The urine specimen should be placed in a
B19], Rubella, Cytomegalovirus, Herpes leak-proof specimen cup and then sealed in
simplex virus), as these infections can a biohazard bag before transport to the
cause fetal abnormalities laboratory.
• To prevent specimen contamination and the
introduction of bacteria into the client's
urinary tract, the nurse should scrub the
• Infectious agents that are spread by air Foley collection port with alcohol or
currents are among the most contagious of chlorhexidine for 15 seconds before
pathogens. Therefore, clients withdrawing a specimen.
with airborne infections (measles, • Hand hygiene with an alcohol-based hand
tuberculosis, varicella, severe acute rub is recommended, unless there is visible
respiratory syndrome) should be isolated soiling of the hands with body fluids, or after
first using airborne precautions. contact with Clostridium difficile. In both
• These infections are spread via very small situations, hand hygiene must be performed
particles that circulate in the air. with soap and water to thoroughly remove
• Clients with airborne infections are placed contaminants left behind by alcohol-based
in an isolation room with negative pressure rubs.
that provides air exchange or with a high-
efficiency particulate air filtration system.
• Clostridium difficile is a highly
infectious bacteria causing severe colitis in
infected clients. When caring for a client
 with C difficile, it is critical that the nurse o Wearing gloves when entering room
implement contact isolation o Perform proper hand hygiene before
precautions to prevent transmission of exiting room (use soap and water or
microorganisms between clients, including: alcohol-based hand rubs for MRSA and
VRE, but only soap and water for C
o Placing the client in a single-client difficile and scabies)
room, if possible, or in a cohort with o Wearing gown with client contact and
other clients infected with C difficile removing before leaving room
o Wearing a single-use, disposable o Place door notice for visitors
gown and clean gloves during all client o Having client leave room only for
care and discarding the equipment essential clinical reasons (ie, tests,
before leaving the room procedures). If an x-ray is needed, try
o Performing hand hygiene before and to arrange for a portable one.
immediately after client care with soap
and water
o Using dedicated medical equipment
(eg, stethoscope, blood pressure cuff) • C difficile poses a unique hazard in health
that is not shared between clients and care settings. This infection of the colon
always remains in the client's room may develop/spread through contact with
the organism or after prolonged antibiotic
• Clean, rather than sterile, gloves are therapy alters normal bowel flora, allowing
required during care of a client with C for C difficile overgrowth.
difficile to prevent transmission of infection
to other individuals. • Clients with C difficile infection should be
placed on strict contact precautions in
• Surgical masks are required when caring
private rooms. These precautions require
for a client prescribed droplet isolation
staff to wear protective gowns and
precautions but are needed only in clients
gloves when entering the client's room
with contact isolation precautions if
performing activities with the possibility of • Hand hygiene using soap and water is the
body fluid splashing (eg, suctioning, wound only effective method for removing C
care). difficile spores
• When caring for clients with C difficile, it is
critical to perform hand hygiene with soap • In addition, alcohol is not an effective agent
and water, rather than alcohol-based for killing C difficile spores; therefore,
sanitizers. Alcohol-based sanitizers are a diluted bleach solution must be used to
unable to effectively kill spore-forming disinfect contaminated equipment and
bacteria (eg, C difficile, anthrax). surfaces
• Contact precautions require the caregiver to
• Infections caused by methicillin- wear a gown and gloves. A face mask
resistant Staphylococcus aureus(MRSA), C must be worn as personal protective
difficile, vancomycin- equipment if an organism is spread via
resistant Enterococcus (VRE), droplets. However, it is not required to
and scabies require contact prevent the spread of a contact-
precautions to be used. transmissible infection.
• Contact precautions include: • The nurse should not wear a mask solely to
avoid the unpleasant odor associated
o Placing client in private room with C difficile diarrhea as this may be
(preferred) or cohorting clients with the offensive and embarrassing to the client.
same infection
o Using dedicated equipment (must be
disinfected when removing from room)
CONTACT AND AIRBORNE PRECAUTION 5. Remove and discard the N95
respirator mask and then perform final
hand hygiene.
• Negative pressure rooms continuously filter
air out of the room, creating a lower
pressure gradient that prevents airborne
microorganisms from escaping through the
doorway.
• To prevent exposure to infectious airborne
microorganisms, nurses should remove
N95 respirator masks only after
exiting the room.

DROPLET PRECAUTION

• The order of removal for personal

protective equipment (PPE) should be
from most to least contaminated,
because this reduces the risk of
contaminating the nurse's skin and clothes.
• When exiting the room of a client on
both contact and airborne precautions,
the nurse should perform the following • Bacterial meningitis (eg, Neisseria
actions in order: meningitidis) and many respiratory illnesses
(eg, influenza) are transmitted
1. Place the call light within the client's through large droplets of secretions
reach and ensure that the client's bed is spread into the air by coughing, sneezing,
locked and in the lowest position. or talking.
2. Remove the gown and gloves (ie, • These droplets can land on surfaces up to 6
contact isolation PPE) in order of most to feet (1.8 meters) away from the client.
least contaminated. The nurse can • Droplet precautions for routine care (eg,
remove gloves and then gown, or medication administration) require the use
alternately, can remove gown and gloves of a surgical mask, as the highest risk of
together. transmission is through inhalation of
droplets
3. Discard the gown and gloves and then • Wearing a face shield, gown,
perform hand hygiene. and gloves is required if there is a risk of
4. Exit the negative pressure room and splash or contact with body fluids from
immediately close the door to prevent procedural client care (eg, suctioning,
infectious airborne microorganisms from wound care).
escaping into the hallway or isolation • Dedicated medical equipment (eg,
anteroom. stethoscope, blood pressure cuff) should
remain in the room to limit spread of
infection.
PERTUSSIS • Sending letters home to parents is
premature at this point. After professional
• Paroxysms of rapid coughing that lead
pest control personnel evaluate the
to vomiting are a key feature
classroom/school, letters can be sent to
of pertussis infection.
inform parents of the findings and any
• Pertussis is a highly contagious disease precautions that should be taken.
and requires droplet precautions.
• Sending the child home is unnecessary and
• It can be deadly if contracted in infancy may be perceived as punitive and
before vaccination is started. This client stigmatizing. Bed bugs do not inhabit
should be placed in isolation immediately to humans; this child is not "infested" (seen in
prevent the spread of disease. children with head lice).
• It is a common misconception that bed
PHYSICAL RESTRAINT
bugs are drawn only to dirty
• A physical restraint that restricts body environments. They can inhabit any
movement should be the last resort to environment and can travel and spread
keep a client from interfering with medical easily in clothing, bags, furniture, and
treatment. bedding. Although they do not pose
• Restraints can cause bodily injury such as significant harm, bed bugs can cause an
pressure ulcers, neurovascular and itchy red rash that can be uncomfortable
peripheral circulatory deficits, and and affect sleep. Bed bugs should be
psychological trauma. Therefore, less exterminated, especially in a home with
restrictive methods should always be tried children.
first. • It is important to treat the entire house for
• Concealing the IV site and tubing by bed bugs. Washing a single pillowcase or
wrapping the forearm in gauze and an blanket will not stop the infestation. Bed
elastic stockinette can be effective in bugs multiply quickly and can hide in any
keeping a confused client from pulling at crevice.
the IV line. • Once pest control is complete, the home
will need to be monitored for signs of
BED BUG lingering bugs.
• Although full-blown bed bug infestations are • Bed bug bites can cause a rash that clients,
uncommon in a school setting, a bed bug especially children, will be inclined to
brought in on the clothing or possessions of scratch. Precautions should be taken to
one student could easily "hitch" a ride to help alleviate the rash as itching can cause
another student's home and cause an complications such as secondary skin
outbreak there. infections.
• The most important measure to prevent bed • Once a home is infested, the bugs can
bugs from infesting other students' homes travel quickly and occupy spaces and
is to prevent the bugs from entering the crevices. All household members and pets
school in the first place. will be afflicted.
• Laundering clothing in hot water and using
the highest temperature setting on a dryer
will kill any bed bugs attached to LEAVE AGAINST MEDICAL ADVICE (AMA)
clothes. The clothing should then be stored
in tightly sealed plastic bags to prevent • A competent client can refuse medical
additional infestation treatment and leave against medical
• A professional pest control company should advice (AMA). The nurse should inform
be brought in to evaluate the the health care provider (HCP)
classroom/school for bed bugs; treatment immediately.
with an insecticide may or may not be • If the client decides to leave the facility,
necessary. even after the HCP and nurse explain the
consequences (including death), or cannot
 wait until the HCP speaks with the client, • The most common nosocomial infection
the client should be allowed to do so. is urinary tract infection, followed by
• It is most important that the client's IV surgical site infections, pneumonia, and
catheter be removed to prevent bloodstream infections.
complications (eg, infections) and misuse
(eg, access for illicit drug injections). The CHEMICAL RESTRAINTS
nurse should document the fluid infused, • Chemical restraints are medications (eg,
the site's appearance, and the integrity of benzodiazepines, psychotropics) used to
the IV catheter. restrict freedom of movement or to control
• The goal is for the client to always have socially disruptive behavior in clients who
an informed refusal and to sign the legal have no medical indications for them.
form to indicate understanding of that • Although this client is at risk of injury from
information. However, if the client refuses falling, the use of a psychotropic drug is
to sign, the client is still allowed to leave not considered the standard
(failure to do so constitutes false treatment for a client with a history of falls
imprisonment). who keeps getting out of bed without
• The nurse should have witnesses to the assistance.
events and clearly document in the chart • The least restrictive method to ensure client
what happened and that the client refused safety (eg, bed alarm, sitter, assistive
to sign. devices) should be tried first before
• Discharge instructions, results, and administering a chemical
prescriptions can be given despite the client restraint. Therefore, the nurse should
leaving AMA. However, it is not essential to question the prescription for haloperidol
provide the clients with results. Removing (Haldol) in this client
the catheter is the priority. • Benzodiazepines (eg, lorazepam [Ativan],
• Reassuring that a client can return is ethical diazepam, chlordiazepoxide) are
as the desire is for the client to receive considered standard treatment to control
needed care. However, it is not a priority agitation in the client in alcohol withdrawal.
over removal of the catheter. • Antipsychotics (eg, olanzapine [Zyprexa],
ziprasidone [Geodon], haloperidol) are
considered standard treatment to control
NOSOCOMIAL INFECTION violent behavior in the client with
schizophrenia.
• A nosocomial infection occurs in a • Propofol (Diprivan) is considered standard
hospital (hospital-acquired) or other health treatment to sedate the client receiving
care setting and is not the reason for the mechanical ventilation to provide ventilator
client's admission. control, prevent accidental extubation, and
• Many nosocomial infections are caused by promote comfort.
multidrug resistant organisms. These
infections occur 48 hours or more after
admission or up to 90 days after
discharge.
• Clients at greater risk include young
children, the elderly, and those
with compromised immune systems.
• Other risk factors include long hospital
stays, being in the intensive care unit, the
use of indwelling catheters, failure of health
care workers to wash their hands, and the
overuse of antibiotics.
CENTRAL VENOUS ACCESS • Most CVC lumens require anticoagulation
in the form of a heparin flush to maintain
patency and prevent clotting when not in
use. The nurse should check the
institution's protocol and the HCP
prescription to determine the correct dose.
• Doses of 2–3 mL containing 10 units/mL–
100 units/mL are the standard of care for
flushing a CVC.
• Doses of 1000–10,000 units are given for
cases of venous thromboembolism;
therefore, this prescription is an error and
should be clarified by the nurse.
• The Centers for Disease Control and
Prevention (CDC) recommend that a single-
dose vial or prefilled syringe be used to
• In adult clients, central venous access sites reduce infection risk.
in the upper body (internal jugular or • Heparin is a high-alert medication (at high
subclavian) are preferred to minimize the risk for causing significant harm to the client
risk of infection. if given in error).
• Access sites in the inguinal area (femoral) • TPN should be administered through
are easily contaminated by urine or feces, a CVC. Because of its viscosity and high
and it is difficult to place an occlusive glucose, lipids, electrolytes, vitamins and
dressing over these sites. minerals, it is safest when administered
• A central venous catheter (CVC) should be through a CVC or peripherally inserted
placed where aseptic technique can be central catheter.
applied. The site should be assessed daily • According to the CDC, an occlusive
for signs/symptoms of infection (eg, dressing should be changed every 7
redness, swelling, drainage). days. The nurse should check the
• The duration of CVC placement should be institution's protocol for frequency of
based on clinical need and judgment that dressing changes.
there is no evidence of infection. • The distal port of a triple lumen CVC is the
• Internal Jugular Line – Although this site largest lumen (tube) and should be used
has been in use for 6 days, it is a preferred for CVP (right atrium pressure)
site; the CVC was inserted in the operating monitoring. The distal end of the CVC is in
room, where surgical asepsis was easily reverse as regards the client; therefore, the
accomplished. The site can be used as distal end is at the tip of the catheter in the
long as there is a clinical need and no superior vena cava vein, closest to the right
evidence of infection. atrium of the heart.
• Peripherally inserted central
catheter (PICC) lines can be left in for
weeks or months. The occlusion of one MOUTHWASH INGESTION
lumen does not necessitate removal of the • Many mouthwashes have an ethanol
catheter. (alcohol) content ranging from the
• The subclavian vein is a preferred site for a equivalent of wine to half the strength of
CVC. Although slight redness is present at hard liquor. Because children's bodies
the suture sites, it is not located at the absorb alcohol quickly, the symptoms of
insertion site. The femoral line is still at alcohol poisoning can occur within 30
higher risk for infection. minutes or less after consumption.
• Clinical indications include confusion, • If dislodgment occurs, the nurse
vomiting and seizures, difficulty breathing, should first use long-handled forceps to
flushed or pale skin, and coma secondary place the implant in a lead-
to low blood sugar. lined container to contain radiation
• The exact amount of alcohol that this child exposure. The nurse should also notify the
presumably ingested is unknown. It is health care provider (radiation oncologist).
most important to assess the child's • (Containing the source quickly is a priority
condition (eg, behavior, mental status, as the implant continues to emit radiation
physical signs and symptoms) to determine that could be dangerous to the staff coming
if immediate emergency measures (eg, to evaluate the client and clean the room.
calling 911, cardiorespiratory support) are • The nurse should not handle dislodged
necessary or if the parent should be radiation implants without the use of
instructed to contact the poison control forceps. Furthermore, device reinsertion
center should be performed only by the health
• It is the nurse's professional responsibility care provider.
to provide instruction and guidance to the • Wrapping the implant in linens and placing
parent. Although caregivers should have it within a biohazard bag does not reduce
the number of the poison control center radiation exposure.
readily available, referral might delay care
and place the child at further risk of a
negative outcome if the child is already FALL
deteriorating.
• If the child's condition is stable, the nurse
should instruct the parents to contact the
center for further evaluation and
instructions.
• Giving the child water or any other liquid will
not change the amount of alcohol
ingested. In addition, alcohol can impair
swallowing, placing the child at risk for
choking and aspiration.
• Parents should be advised not to perform
any interventions before contacting the
poison control center.

INTERNAL RADIATION IMPLANT

• An internal radiation implant (ie, • Falls can occur with any client; however,
brachytherapy) emits radiation in or near a advanced age, incontinence, confusion,
tumor to treat certain malignancies. and presence of lines, tubes, and drains
• When caring for clients undergoing increase the risk for falls and
brachytherapy, the nurse should monitor injury. Interventions to reduce falls in high-
closely for evidence of implant risk clients include:
dislodgment. The dislodged implant emits
radiation that can be dangerous to health o Hourly rounding (eg, assessing pain,
care workers at the bedside. offering toileting and nutrition)
• Long-handled forceps and a lead-lined o Moving the client to a room close to
container should be kept in the room of the the nurses' station
client who has a radioactive implant in case o Activating bed alarms to alert staff if
of dislodgment. the client gets out of bed unassisted
 o Asking family members or visitors to falls. Placing a commode by the
stay at the bedside with the client right (stronger) side of the bed decreases
the number of steps and time needed to get
• Falls are a leading predictor of mortality to a toilet . It also decreases the chance of
and morbidity in older adults. tripping on equipment (eg, IV pump,
• General exercise programs, especially tubing).
those including gait, balance, and • Moving the client to a room close to the
strength training, not only reduce the risk nurses' station allows frequent observation
of falls but also prevent injuries from falls and a faster response time to calls for
• Vision impairment can contribute to fall assistance. A bed alarm alerts staff when
risks; most adults need additional light by the client attempts to get out of bed, which
age 50. The nurse should ensure that allows for prompt response
clients are wearing needed prescription
CASE: A client on fall precautions is found
glasses
on the floor by the bed when the unlicensed
• Handrails, particularly in stairwells, assistive personnel make hourly
hallways, and bathrooms, have been shown rounds. Place the actions the registered
to reduce falls nurse should take in the appropriate order.
• Studies show that staff rounds at regular
intervals (hourly or every other hour)
decrease falls and call light use. The
practice allows staff to intervene early in
needs.
• Typically staff checks on the "Ps": potty,
position, pain, and placement/proximity of
personal items (eg, bed height, call light,
water, tissues, urinal). A common reason
clients get out of bed unassisted is to use
the bathroom
• Non-slip rubber-soled shoes are
recommended to prevent falls. • When determining which nursing diagnosis
to address first, the nurse should consider
factors that affect client safety. Risk for
• The client with right-brain falls is an immediate safety concern
damage following a stroke often • Nursing diagnoses that relate to chronic
experiences left-sided weakness, spatial- conditions (eg, anxiety, chronic pain) are
perceptual deficits, and impulsiveness, addressed after risk for falls. The nurse
making this client at high risk for falls. should immediately implement fall risk
• Other factors that increase fall risk for older precautions by placing the bed in the lowest
adults include: position, ensuring that the call light is within
reach, and turning on the bed alarm.
o Unfamiliar surroundings • Interventions for addressing other client
o Unsteady gait, decreased strength and needs may be carried out after measures to
coordination ensure client safety.
o Altered mental status • Advanced age is associated with
o Orthostatic hypotension (related to decreased visual acuity, muscle mass,
dehydration) strength, and reaction time.
o Bowel/bladder urgency and/or frequency • Medications that cause dizziness or
drowsiness increase the risk for
• Application of color-coded, nonslip socks falls. Diuretics (eg, furosemide) increase
helps prevent a client from slipping and urinary frequency and may cause
alerts staff to a client's increased risk for hypotension. Antihypertensive medications
 (eg, lisinopril, metoprolol) may cause ROMBERG SIGN
bradycardia and dizziness.
• Safety needs are addressed before love • The Romberg test, part of a focused
and belonging needs (eg, anxiety). Anxiety neurologic examination, assesses clients'
interventions (eg, therapeutic touch, perceptions of their head in space
medication) may be implemented after (vestibular function) and body in space
safety interventions. (proprioception).
• Safety is the immediate concern for a client • It is used to determine the reason for loss of
with a high fall risk. Arthritic joint changes coordination (ataxia).
are a source of chronic pain. Pain • Clients are asked to stand with the feet
interventions (eg, medication, repositioning) together and hands at the sides of the
may be implemented after safety body. They are then asked to close their
interventions. eyes while ability to maintain balance is
• A client with advanced age in an unfamiliar assessed.
environment may develop acute confusion • A loss of balance is considered to be a
during the hospital course, but a high fall positive Romberg sign and indicates
risk is a more immediate concern on that ataxia is sensory in nature rather than
admission. cerebellar.
• Clients demonstrating a positive Romberg
test are likely to have ataxia, or be prone to
lose balance, and would
require assistance with ambulation.

CRUTCHES
• Interventions to promote safety when
using crutches in the home include the
following:

• To prevent injury to the nurse and the client o Keep the environment free of
if the client is falling, the nurse uses good clutter and remove scatter rugs to
body mechanics to try to break the fall and reduce fall risk
guide the client to the floor if o Look forward, not down at the feet,
necessary. These actions include: when walking to maintain an upright
position, which will help prevent muscle
o Step slightly behind the client and and joint strain, maintain balance, and
place the arms under the axillae or reduce fall risk
around the client's waist o Use a small backpack, fanny pack, or
o Place feet wide apart with knees shoulder bag to hold small personal
bent - creates a broad base of support, items (eg, eyeglasses, cell phone),
provides stability, and reduces the risk which will keep hands free when
for back injury to the nurse walking
o Place one foot behind the other and o Wear rubber- or non-skid-soled
extend the front leg - allows the nurse slippers or shoes without laces to
to bring the client backward by using reduce fall risk
the leg muscles to rock backward while o Rest crutches upside down on the
supporting the client's weight axilla crutch pads when not in use to
o Let the client slide down the prevent them from falling and becoming
extended leg to the floor - lowers the a trip hazard
client gently to the floor while keeping o Keep crutch rubber tips dry. Replace
the client's head protected from injury them if worn to prevent slipping.
IMPLIED CONSENT VIOLENCE
• Violence (eg, offensive language, physical
• Implied consent in emergency situations
aggression) may be precipitated
includes the following criteria:
by substance abuse, emotional stress,
mental instability, or altered mentation from
o There is an emergency
medical conditions.
o Treatment is required to protect the
• To de-escalate a violent situation and
client's health
o It is impractical to obtain consent
ensure the safety of the client and others,
the nurse should:
o It is believed that the client would want
treatment if able to consent
o Remove other clients from the area.
o Keep a safe distance from the client
EBOLA (VIRAL HEMORRHAGIC FEVER)
with a clear path to safety.
o Maintain a calm demeanor, keeping the
• Ebola (viral hemorrhagic fever) is an
hands visible.
extremely contagious disease with a high
o Use clear, nonthreatening
mortality rate.
communication focusing on mutual
• Clients require standard, contact, droplet,
goals
and airborne precautions (eg, impermeable
gown/coveralls, N95 respirator, full face
• During periods of extreme anxiety and
shield, doubled gloves with extended cuffs,
stress, clients are prone to irrational
single-use boot covers, single-use apron).
thinking. The nurse should avoid
• The client is placed in a single-client
reasoning (eg, explaining the dangers of
airborne isolation room with the door
refusing treatment) until the situation has
closed
been de-escalated and the client is no
• Visitors are prohibited unless absolutely longer in crisis.
necessary for the client's well-being (eg,
• Bargaining with the client by providing false
parent visiting an infected child).
reassurance (eg, promising not to involve
• For disease surveillance, a log is authorities) is nontherapeutic and may
maintained of everyone entering or exiting cause the client to lose trust in the nurse.
the room, and all logged individuals are
• The client with impaired thinking from
monitored for symptoms
substance abuse is legally incompetent to
• Procedures and use of sharps/needles are leave the hospital against medical advice.
limited whenever possible.
• There are currently no medications or
vaccines approved by the Food and Drug MRSA
Administration to treat Ebola. Prevention is
crucial. • Clients at highest risk for hospital-
• In a private airborne isolation room, the acquired MRSA are older adults and those
client does not require a respirator with suppressed immunity, long history
mask. However, all other individuals of antibiotic use, or invasive tubes or
entering the room must don appropriate lines (hemodialysis clients).
personal protective equipment (PPE). • Clients in the intensive care unit (ICU) are
• The PPE removal process after caring for a especially at risk for MRSA. The 80-year-
client with Ebola requires strict monitoring old client with COPD in the ICU on the
by a trained observer. The outer gloves are ventilator has several of these risk
first cleaned with disinfectant and factors. COPD is a chronic illness that can
removed. The inner gloves are wiped affect the immune system, and clients
between removal of every subsequent experience exacerbations that may require
piece of PPE (eg, respirator, gown) and frequent antibiotic and corticosteroid
removed last.
 use. This client is elderly and also has an • Clients report feeling being pulled to the
invasive tube from the ventilator. ground (drop attacks).
• A student athlete could be colonized with • Fall precautions that should be instituted
MRSA from time spent in locker rooms and include assisting the client when arising and
around athletic equipment. MRSA more ambulating, placing the bed in low position,
often appears as skin infections in this age and raising side rails.
group. Unless this client has an open • However, raising all side rails is
fracture, there is no break in skin integrity. considered a restraint and would be
• This client does have an incision (portal of inappropriate. The nurse would need to
entry) and invasive lines but is younger and intervene and instruct the UAP that 2 or 3
has no evidence of suppressed immunity. side rails lifted up would be sufficient
• This client is older and does have a small • Vertigo may be minimized by staying in
surgical incision but is not as high risk as a quiet, dark room and avoiding sudden
the client with COPD. All clients head movements.
undergoing pacemaker placement will • The client should reduce stimulation by not
receive a prophylactic antibiotic to prevent watching television and not looking at
surgical site infection just before surgery. flickering lights.

LATEX ALLERGY
FIRE EXTINGUISHER • Latex allergy is an exaggerated immune-
mediated reaction when one is exposed to
• A small fire can quickly become very
dangerous. During an emergency situation, products or dusts containing latex, a natural
such as a fire, anxiety can narrow a rubber used in many medical devices (eg,
person's focus, causing hesitation or gloves, catheters, tape).
difficulty in responding to the situation, • Many people, particularly health care
especially when operation of unfamiliar workers and individuals requiring chronic
equipment (eg, fire extinguisher) is invasive procedures (eg, self-
involved. catheterization), develop latex allergy
• The mnemonic PASS is often used to help from repeated exposures.
people remember the steps used in • When assessing for potential latex
operating a fire extinguisher: allergies, the nurse should inquire about the
client's reactions to common latex-
P – Pull the pin on the handle to release the containing objects and potentially cross-
extinguisher's locking mechanism allergenic products.
A – Aim the spray at the base of the fire • Balloons commonly contain latex, and
S – Squeeze the handle to release the reports of lip swelling, itching, or hives after
contents/extinguishing agent contact indicate a high risk for anaphylactic
S – Sweep the spray from side to side until reactions with continued exposure
the fire is extinguished • Many food allergies (eg, avocado, banana,
tomato) also increase the risk for latex
MENIERE DISEASE allergy because the food proteins are
• Meniere disease (endolymphatic hydrops) similar to those found in latex
results from excess fluid accumulation in
the inner ear.
• Clients have episodic attacks of vertigo, PSEUDOHYPERKALEMIA
tinnitus, hearing loss, and aural fullness.
• The vertigo can be severe and is • With the exception of clients in end-stage
associated with nausea and vomiting. renal disease, a serum potassium value
>6.5 mEq/L (6.5 mmol/L) in any client who
is walking and talking should raise the
 suspicion of an erroneously elevated serum
potassium (pseudohyperkalemia) from
poor hematology technique, hemolysis, or
clotting.
• A serum potassium level of 7.0 mEq/L (7.0
mmol/L) would normally constitute a life-
threatening electrolyte imbalance that
would cause severe weakness or paralysis,
unstable arrhythmias, and eventual cardiac
arrest.
• An assessment would focus on evaluating
cardiac symptoms and muscle strength and
be reported to the health care provider
(HCP). In this case, it is likely that a repeat • To determine the most appropriate method
blood draw would be prescribed. to transfer a client safely for the first time,
• Pseudohyperkalemia can be avoided on the the nurse should assess 2 factors:
repeat blood draw by using heparin-
impregnated hematology vials to prevent ➢ Whether the client can bear weight:
clotting, minimal use of a tourniquet and fist
clenching, and use of a larger gauge needle o Neurological deficits (eg, paralysis,
for the sample. paresis [weakness])
o Decreased muscle strength (eg,
prolonged immobility, multiple
CLIENT TRANSFER sclerosis, muscular dystrophy)
o Trauma (eg, amputee, hip fracture)
CASE: The nurse is preparing to transfer a
client from the bed to the chair for the first
• Whether the client is cooperative and able
time. The client has generalized weakness
to follow instructions:
and is unable to follow instructions. Which
would be the most appropriate method for
o Altered mental status (eg, delirium,
the nurse to use to transfer this client safely?
drug intoxication)
o Decreased cognitive ability (eg,
dementia, head injury)

• A 1-person standby assistance is

appropriate for a client with full weight-
bearing ability who is either uncooperative
or at high risk for falls.

• A pivot transfer or standing-assist lift

transfer requires client cooperation with
instructions to promote safety during the
transfer.
 • The client situation, rather than the device,
determines whether it is classified as a
restraint.
• Prescribed orthopedic immobilizers and
protective devices used temporarily during
routine procedures or examinations are not
considered physical restraints and do not
require authorization for use from a health
care provider.
• Restraints should be used only after less
invasive methods have failed and must be
discontinued at the earliest time
possible once it is safe to do so.
• The belt restraint is applied at the waist
and tied to the bed frame under the
mattress with straps using a quick-
release knot. It is used to protect a
confused or disoriented client who is on bed
rest. Although the client can turn, it is
considered a restraint because it restricts
physical mobility and confines the client to
ADVERSE EVENT the bed involuntarily
• An adverse event is an injury to a client
• Soft limb restraints (eg, wrist, ankle)
caused by medical management rather
immobilize one or more extremities and are
than a client's underlying condition. It may
used for the prevention of falls or attempted
or may not be preventable. The Institute of
removal of devices. Following a procedure
Medicine (2000) recognizes 4 types of
requiring sedation, clients may require
errors. They are:
restraints to protect them from disrupting a
surgical site or medical device until they are
o Diagnostic (delay in diagnosis, failure to
alert enough to follow instructions
employ indicated tests, failure to act on
independently
results of monitoring)
o Treatment (error in performance of • Limb restraints should be applied loosely
procedure, treatment, dose; avoidable enough that 2 fingers can be
delay) inserted underneath the secured
o Preventive (failure to provide restraint. The nurse should closely monitor
prophylactic treatment, inadequate the peripheral neurovascular
follow-up/monitoring of treatment) status and skin integrity of a client's
o Other (failure of communication, restrained extremity.
equipment failure, system failure)
• Elbow restraints used as a protective
device to temporarily immobilize a child
PHYSICAL RESTRAINT
(<30 minutes) to perform a medical,
diagnostic (eg, drawing blood), or surgical
• A physical restraint is a device or method
procedure are not considered a physical
used to immobilize or limit physical mobility
restraint.
or body movement to prevent falls, injury to
self or others, or removal of medical • The use of full padded side rails in the
devices. raised position for clients during a seizure
protects them from immediate injury; these
are not considered a restraint.
PREPARING STERILE FIELD seizure. These precautions typically
include:
• The general steps for preparing the sterile
field for a wet-to-damp dressing change 1. Raising the upper side rails on the
include: bed to prevent the client from falling to
the floor during a seizure. The side rails
1. Perform hand hygiene. are also padded to prevent client injury
2. Open a sterile gauze package with due to hitting the hard plastic rails during
ungloved hands. a seizure
3. Hold the inverted opened gauze 2. During a seizure, a client may be unable
package 6" (15 cm) above the sterile to control secretions, increasing the risk
field. for an impaired airway. Suction
4. Place the sterile gauze dressing more equipment and oxygen equipment are
than 1" (2.5 cm) from the edge of the set up at the bedside. Some facilities
sterile field. also encourage the use of a continuous
5. Use sterile NSS from a recapped bottle pulse oximeter.
that was opened <24 hours ago (if policy
permits).
• Clients may experience urinary
incontinence during a seizure, but unless
CHEMICAL CONTAMINATION EMERGENCY
the health care provider prescribes a
urinary catheter, it is not typically used as
• Nursing priorities when implementing a part of seizure precautions. Inserting a
chemical contamination emergency urinary catheter puts the client at risk for a
response plan include the following: urinary tract infection.
• It is not necessary to remove all linen from
1. Restricting other clients, staff, and the client's bed. If a client has a seizure,
bystanders from the victims' vicinity to any blankets or pillows that are in the way
protect non-affected individuals and the or pose a threat can be removed, but the
health care facility from the contaminant client may have linen on the bed while on
2. Donning personal protective seizure precautions.
equipment to protect the nurse when
providing care
3. Decontaminating the clients outside
HEALTH CARE CATHETER ASSOCIATED
the facility before initiating
UTI
treatment. If the chemical is not
removed, it will continue to cause • Health care catheter-associated UTIs are
respiratory distress; contaminated prevalent among hospitalized clients with
clothing is left outside the facility to indwelling urinary catheters. Steps to
reduce the risk of contaminating staff prevent infections in clients with urinary
and other clients catheters include the following:
4. Assessing and providing treatment of
symptoms. Initial treatment is for the o Wash hands thoroughly and regularly
symptoms (eg, wheezing), regardless of o Perform routine perineal hygiene
the specific cause with soap and water each shift and
after bowel movements
SEIZURE PRECAUTIONS o Keep drainage system off the floor or
contaminated surfaces
• Clients with seizures are at increased risk o Keep the catheter bag below the level
for injury during seizure activity. Seizure of the bladder
precautions are nursing interventions that o Ensure each client has a separate,
can help protect a client during a clean container to empty collection
bag and measure urine
 o Use sterile technique when collecting MIDDLE EAST RESPIRATORY SYNDROME
a urine specimen
o Facilitate drainage of urine from tube to • Middle East respiratory
bag to prevent pooling of urine in the syndrome (MERS) is a viral respiratory
tube or backflow into the bladder illness caused by the coronavirus (MERS-
o Avoid prolonged kinking, clamping, or CoV).
obstruction of the catheter tubing • Symptoms include fever, cough, and
o Encourage oral fluid intake in clients shortness of breath that often worsen and
who are awake and if not cause death in many of those afflicted.
contraindicated • The incubation period is 5-6 days but can
o Secure the catheter in accordance with range from 2-14 days.
hospital policy (tape or Velcro device) • How the virus spreads is not fully
o Inspect the catheter and tubing for understood, but it is thought to spread via
integrity, secure connections, and respiratory secretions.
possible kinks • Because it has easily spread to those who
care for infected persons, the Centers for
• Catheter-associated urinary tract infections Disease Control and Prevention
are prevalent in hospital recommends the use of standard, contact,
settings. Only indwelling urinary and airborne precautions with eye
catheters should be used when protection when caring for clients with
appropriate. MERS.
• Appropriate uses include the following:
SHINGLES (HERPES ZOSTER)
o Clients with urinary obstruction or • Shingles (herpes zoster) is a reactivation
retention, or a need for strict intake of the varicella-zoster (chicken pox)
and output in critically ill clients virus. It is more likely to occur when a
o Perioperative use for surgical client's immune system is compromised by
procedures such as urologic surgery or disease (eg, HIV infection) or treatments
prolonged surgeries, or when large (eg, chemotherapy).
doses of fluid or diuretics are given
during surgery • Shingles lesions that are open may
o During prolonged transmit the infection by both air and
immobilization when bedrest is contact.
essential • The client with disseminated shingles that
o To improve end-of-life comfort are not crusted over will require contact
o To facilitate healing of an open precautions, airborne precautions, and
perineal or sacral wound in incontinent a negative airflow room to prevent
clients transmission of the infection to others in the
hospital.
• Inappropriate uses include the following:
• Negative airflow pulls air from the hospital
o Convenience or replacement for environment into the room, and the air from
nursing care when the client is elderly, the hospital room then goes directly to the
confused, incontinent, or voids outside rather recirculating to the rest of the
frequently hospital.
o For obtaining a urine culture when the
• Localized shingles require only standard
client can follow instructions and void
precautions for clients with intact immune
voluntarily
systems and contained/covered lesions.
o Postoperatively for prolonged periods
when other appropriate indications are • Negative airflow and airborne precautions
not present are also required in addition to contact
 precautions. Droplet precautions are not prescribed, open MRI machine can be
necessary. used).
• A colostomy is not a contraindication for
• Positive airflow would pull fresh air from
MRI.
outside into the hospital room, and then the
• Transdermal metal-containing medication
air from the room would circulate
patches (clonidine, nicotine, scopolamine,
throughout the rest of the hospital. It is not
testosterone, or fentanyl) are not a
appropriate for this type of
contraindication for MRI. However, the
infection. Instead, positive airflow would be
nurse should remove the patch beforehand
used for protective isolation in a client who
due to the risk of burns and replace after
is immunocompromised.
testing.
• A semi-private room is not appropriate for
this client with a communicable
illness. Standard precautions are used for PERIPHERALLY INSERTED CENTRAL
localized shingles in clients with intact CATHETER (PICC)
immune systems and contained/covered
lesions. • A peripherally inserted central catheter
(PICC) is a venous access device that is
inserted via the cephalic or basilic vein and
terminates in the superior vena cava. It is
MRI
indicated for administration of noxious
• Clients must be screened for medications (eg, parenteral nutrition,
contraindications before exposure to a chemotherapy), for long-term IV therapy, or
magnetic field (MRI) as it can damage in clients with poor venous access.
implanted devices or metallic implants.
• Proper care and aseptic technique are
• Absolute contraindications can preclude
important to maintain lumen patency and
testing, and relative contraindications can
eliminate the risk of life-threatening central
pose a hazard to the client's devices or
line-associated bloodstream
implants, affect the quality of the images, or
infection (CLABSI).
cause discomfort.
• Absolute contraindications: • The nurse should inspect the insertion site
for signs of infection (redness, drainage)
o Cardiac pacemaker and dressing integrity.
o Implantable cardioverter defibrillator
o Cochlear implant • Routine care includes sterile dressing
o Retained metallic foreign body, changes every 48 hours with a gauze
especially in organs such as the eye dressing or 7 days with a transparent
semipermeable dressing (biopatch) as
well as immediately if dressing is loose/torn,
• Relative contraindications:
soiled, or damp.
o Prosthetic heart valve
o Metal plate, pin, brain aneurysm clip, or • The line should be flushed before and after
joint prosthesis – Some of these medication administration and per facility
devices have nonferrous MRI-safe protocol
materials and should be verified.
o Implanted device (eg, insulin pump, • Blood pressure and venipuncture should
medication port) not be performed on the affected arm as
compression of the vein can alter its
• Other factors that can affect the client's integrity
eligibility include inability to remain supine • All infusing medications (except
for 30-60 minutes and claustrophobia; vasopressors) must be paused before
however, these concerns are often drawing blood from the PICC to prevent
controllable (eg, sedation can be
 false interpretation of the client's serum • The caregiver should not be instructed to
levels stay home to monitor for symptoms due to
the rapid onset of toxicity.
• Dressings that no longer occlude the
insertion site must be changed • An outpatient clinic is not sufficiently staffed
immediately. Loose corners may be or equipped for acute management of
temporarily reinforced with tape. amitriptyline toxicity. The nurse should
refer the client to the nearest emergency
• The nurse should "scrub the hub" with
department, which is the safest
alcohol or chlorhexidine/alcohol for 10-15
environment for monitoring and treatment.
seconds. This should be done before
flushing, drawing blood, or administering
medication.
IDENTIFIERS
• "The right client" is one of the "6 rights" of
TRICYCLIC ANTIDEPRESSANT OVERDOSE medication administration.
• Two identifiers are used to compare client
statements and information on the
identification band with the client's
medication administration record.
• An identifier should be permanent and
unique to the client.
• Acceptable identifiers include first and last
name and date of birth. These two
• Amitriptyline is a tricyclic identifiers are commonly used together
antidepressant (TCA) that can because there is a chance that more than
produce cardiac toxicity and neurological one client may share a similar surname or
disturbances by altering cholinergic date of birth, which increases the risk of
pathways, sodium channels, and calcium administering a medication to the wrong
channels, causing symptoms such as client.
atrioventricular block, hypotension, cardiac • Medical record numbers are also an
arrest, and seizure. acceptable form of identification and may
help further differentiate clients
• TCAs have a narrow therapeutic index
and rapid onset of action, so ingestion of UNCONSCIOUS CLIENT
even a small amount may be life- • The unconscious client requires a
threatening for a toddler. Symptoms of thorough head-to-toe assessment on
toxicity are usually evident within hours of admission to assess for foreign objects,
ingestion, but cardiac failure can develop devices, or belongings that have potential
days after. Neurological and hemodynamic for harm. This includes checking for:
assessments, as well as ECG monitoring in
an emergency department setting, are o Medical alert
recommended bracelets/necklaces: Indicating allergy
• Syrup of ipecac is no longer routinely status, emergency contact, or code
recommended for oral poisonings. The status
uncontrolled vomiting and vagal response o Contact lenses: Remove to prevent
induced can be harmful after ingestion of corneal injury
toxic substances. Treatments such as oral o Medication patches: To prevent drug
activated charcoal may be used in the interactions and determine conditions
inpatient setting to remove the ingested currently being treated
toxin if the client presents immediately after
the ingestion.
 o Tampons (in female clients): Remove o Use caution when giving sedatives and
to prevent toxic shock syndrome or frequently monitor for over-sedation,
infection which can slow gastric emptying and
o Rings and jewelry: Remove to prevent reduce gag reflex
constrictive injury or vascular damage if o Avoid bolus tube feedings for clients
edema develops at high risk for aspiration

• Medication patches should not be removed

without first consulting the health care
provider. Clients are often prescribed OVER THE COUNTER MEDICATIONS
transdermal patches for chronic conditions
(eg, clonidine for hypertension, nitroglycerin • Over-the-counter (OTC) medications are
for angina). Removing and discarding a available without a prescription and are
medication patch without additional used to treat common illnesses. It is
information may harm the client. estimated that nearly four times as many
health conditions are independently
managed with OTC medications as are
ENTERAL FEEDINGS managed under the supervision of a health
care provider (HCP).
• Clients who are critically ill are at
increased risk for aspiration of • Prior to taking OTC medications, the client
oropharyngeal secretions and gastric should talk with an HCP or pharmacist,
contents, particularly when they are particularly if already taking prescribed
receiving enteral feedings. medications
• Nursing interventions to reduce aspiration • Even when taken as directed by the OTC
risk for clients receiving enteral tube medication label, interactions and adverse
feedings include: effects may occur when used in
combination with prescription medications
o Assess client for
gastrointestinal intolerance to • All medications, herbal products,
feedings every 4 hours by monitoring and supplements must be discussed with
gastric residual and assessing for HCPs so that they can be reconciled and
abdominal distension, abdominal pain, considered before changing or adding new
bowel movements, and flatus treatments
o Assess feeding tube placement at • When OTC medications are used to
regular intervals manage symptoms (eg, ibuprofen for back
o Keep head of the bed at ≥30 pain), the diagnosis and treatment of
degrees, with 30-45 degrees being serious underlying medical
optimal to reduce gastroesophageal conditions (eg, malignancy) may
reflux and aspiration risk unless be delayed
otherwise indicated
o Keep endotracheal cuff inflated at • Herbal products and supplements, although
appropriate pressure (about 25 cm H20) they are prepared from plants or "all-
for intubated clients, as low cuff natural" substances, may contain
pressure increases the risk for compounds that interact with prescription
aspirating oropharyngeal secretions medications. These interactions may cause
and/or gastric contents increased or decreased prescription
o Suction any secretions that may have medication effect, serious adverse effects,
collected above the endotracheal tube and medication toxicities.
before deflating the cuff if deflation is
necessary
 NEEDLESTICK INJURY

SEIZURE

• Protecting the ambulating client from injury

is the immediate priority. The nurse assists
the client to the floor, cradles the head, and
places the client in the left lateral position.
• Left lateral position is preferred to avoid the SITTING DOWN WITH CRUTCH
risk of aspiration. Hard or sharp objects
should be removed from the client's
environment to prevent injury.
• The nurse remains with the client until the
seizure is over to assess seizure activity
and postictal symptoms and to minimize
injury.
• Clients prescribed crutches after a
• No objects should be placed in a client's musculoskeletal injury must understand
mouth during a seizure. Following the appropriate device use to facilitate
seizure, the client may require assessment independent ambulation, promote wound
and maintenance of the airway, suctioning, healing, and prevent reinjury.
and oxygen administration.
• When educating a client to rise from sitting,
• Attempting to restrain a client during a the nurse instructs the client to hold the
seizure may cause injury to the client. hand grips of both crutches in the hand
on the affected side, move to the chair's
 edge, and hold the armrest with the hand
on the unaffected side. The client then uses
the crutches, armrest, and unaffected leg
for support when rising.
• To sit, the client backs up to the chair and
moves both crutches into the hand on the
affected side. The client holds the armrest
with the other hand and lowers the body.
• To rise from a chair, the client should move
to the edge of the chair and flex the
unaffected leg for support.
• Before sitting, the client should back up to
the chair until the unaffected leg touches
the chair seat.
• When standing or sitting, clients should
place the hand opposite the injury on the
armrest or chair seat for support.