NEO 111 Melanie Jorgenson, RN, BSN

Primary Causes of Falls Change in balance or gait disturbance Muscle weakness Dizziness, syncope, and vertigo Cardiovascular changes Vision changes Physical environment Acute illness Neurologic disease Language disorders impairing communication Multiple medications

Preventing Falls Identifying at-risk patients Assess for a history of falls Assess for additional risk factors Combining an assessment tool with a care plan Accurate assessment and use of appropriate fall intervention

Interventions for a Patient Who Experiences a Fall Immediately assess the patient’s condition Provide care and interventions appropriate for status/injuries Notify patient’s physician or primary caregiver of incident and your assessment of the patient Ensure prompt follow-through for any test orders Evaluate circumstances of the fall and the environment; institute preventive measures Document the fall and complete an event report

Alternatives to Restraints Determine whether a behavior pattern exists Assess for pain and treat appropriately Rule out physical causes for agitation Involve family members Reduce stimulation, noise, and light Check environment for hazards and modify, if necessary Use therapeutic touch Investigate discontinuing bothersome treatment devices

Factors to Assess for Pain Management Potentially painful conditions and procedures The patient’s self-report of pain The report of family members or caregivers Cultural beliefs related to pain Behaviors and physiologic measures that indicate pain Blood pressure Pulse rate

FLACC Behavioral Scale Faces Legs Activity Cry Consolability

Sedation Assessment Scale Sleeping, easy to arouse – S Awake and alert – 1 Slightly drowsy, easily aroused – 2 Frequently drowsy, arousable, drifts off during conversation – 3 Somnolent, minimal or no response to physical stimulation – 4

Pain Management Therapies Administration of analgesics Emotional support Comfort measures Nonpharmacologic interventions

Therapeutic Effects of Nonpharmacologic Methods of Pain Management Diminish the emotional components of pain Strengthen coping abilities Give patient a sense of control Contribute to pain relief Decrease fatigue Promote sleep

Effects of Heat on Pain Management Stimulates specific nerve fibers; closes the gate allowing the transmission of pain stimuli to the brain Accelerates the inflammatory response to promote healing Reduces muscle tension to promote relaxation and help to relieve muscle spasms and joint stiffness

Effect of Cold on Pain Management Reduces blood flow to tissues Decreases the local release of pain-producing substances such as histamine, serotonin, and bradykinin Reduces the formation of edema and inflammation and muscle spasms Alters tissues sensitivity producing numbness Slows transmission of pain stimuli

Therapeutic Benefits of Back Massage Provides an opportunity for the nurse to observe the skin for signs of breakdown Improves circulation Decreases pain, symptom distress, and anxiety Improves sleep quality Provides a means of communicating with the patient through the use of touch Provides cutaneous stimulation for pain relief

Effects of Immobility on the Body Decreased muscle tone, size, and strength Decreased joint mobility and flexibility Limited endurance and activity tolerance Bone demineralization Lack of coordination and altered gait Decreased ventilatory effort and increased respiratory secretions, atelectasis, respiratory congestion

Effects of Immobility on the Body (cont.) Increased cardiac workload, orthostatic hypotension, venous thrombosis Impaired circulation and skin breakdown Decreased appetite, constipation Urinary stasis, infection Altered sleep patterns, pain, depression, anger, anxiety

Principles of Body Mechanics Maintaining correct body alignment Facing the direction of movement without twisting body Maintaining balance Using body’s major muscle groups and natural levels for coordinated movement Planning to use good body mechanics Using large muscle groups in legs for movement Performing work at the appropriate height for your body Using mechanical lists to ease movement

Principles of Effective Traction Countertraction must be applied. Traction must be continuous. Skeletal traction is never interrupted except in emergency. Weights must not be removed unless intermittent traction is prescribed. The patient must maintain good body alignment in bed. Ropes must be unobstructed; weights must hang free.

Assessments Made Prior to Moving a Patient Check the medical record for any conditions or orders limiting mobility. Perform a pain assessment prior to the time for the activity. If the patient reports pain, administer medication. Assess the patient’s ability to assist with moving and the need for assistants or equipment. Assess the patient’s skin for signs of irritation, redness, edema, blanching.

Expected Outcomes When Performing Range-of-Motion Exercises The patient maintains joint mobility. Muscle strength is improved or maintained. Muscle atrophy and contractures are avoided.

Performing Range-of-Motion Exercises on the Leg

Equipment and Assistive Devices for Moving Patients Gait belts Stand-assist and repositioning aids Lateral-assist devices Friction-reducing sheets Mechanical lateral-assist devices Transfer chairs Powered stand-assist and repositioning lifts Powered full-body lifts

Supporting the Patient by the Gait Belt or Waist

Assessments Made Prior to Transferring a Patient From Bed to Stretcher Review the medical record and nursing plan of care for contraindications to moving the patient. Assess for tubes, intravenous lines, incisions, or equipment that may alter the transfer process. Assess the patient’s level of consciousness and ability to follow directions and assist with the transfer. Assess the patient’s weight and your strength to determine if a fourth assistant is necessary. Determine if bariatric equipment is needed. Assess the patient’s comfort level; medicate if needed.

Documentation of the Transfer of a Patient From Bed to Chair The activity and the length of time the patient sat in the chair Any observations The patient’s tolerance of and reaction to the activity The use of transfer aids The number of staff required for transfer

Interventions for a Patient Who Begins to Fall When Assisted to Ambulate Place your feet wide apart, with one foot in front. Rock your pelvis out on the side nearest the patient. Grasp the gait belt. Support the patient by pulling her weight backward against your body. Gently slide her down your body to the floor, protecting her head. Stay with the patient and call for help.

Pneumatic Compression Devices (PCDs) Consist of fabric sleeves containing air bladders that apply brief pressure to the legs Intermittent compression pushes blood from the smaller blood vessels into the deeper vessels and into the femoral veins The sleeves are attached by tubing to an air pump May be used in combination with antiembolism stockings and anticoagulant therapy to prevent thrombosis formation

PCD Machine at the Foot of the Bed