neo 111 melanie jorgenson, rn, bsn. primary causes of falls change in balance or gait disturbance...
TRANSCRIPT
Primary Causes of Falls
Change in balance or gait disturbanceMuscle weaknessDizziness, syncope, and vertigoCardiovascular changesVision changesPhysical environmentAcute illnessNeurologic diseaseLanguage disorders impairing
communicationMultiple medications
Preventing Falls
Identifying at-risk patientsAssess for a history of fallsAssess 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 conditionProvide care and interventions appropriate for
status/injuriesNotify patient’s physician or primary caregiver of
incident and your assessment of the patientEnsure prompt follow-through for any test ordersEvaluate circumstances of the fall and the
environment; institute preventive measuresDocument the fall and complete an event report
Alternatives to Restraints
Determine whether a behavior pattern existsAssess for pain and treat appropriatelyRule out physical causes for agitationInvolve family membersReduce stimulation, noise, and lightCheck environment for hazards and modify, if
necessaryUse therapeutic touchInvestigate discontinuing bothersome
treatment devices
Factors to Assess for Pain Management
Potentially painful conditions and proceduresThe patient’s self-report of painThe report of family members or caregivers Cultural beliefs related to painBehaviors and physiologic measures that
indicate painBlood pressure Pulse rate
Sedation Assessment Scale
Sleeping, easy to arouse – S Awake and alert – 1Slightly drowsy, easily aroused – 2 Frequently drowsy, arousable, drifts off
during conversation – 3Somnolent, minimal or no response to
physical stimulation – 4
Pain Management Therapies
Administration of analgesicsEmotional supportComfort measuresNonpharmacologic interventions
Therapeutic Effects of Nonpharmacologic Methods of Pain Management
Diminish the emotional components of painStrengthen coping abilitiesGive patient a sense of controlContribute to pain reliefDecrease fatiguePromote 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 ManagementReduces 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 numbnessSlows transmission of pain stimuli
Therapeutic Benefits of Back Massage
Provides an opportunity for the nurse to observe the skin for signs of breakdown
Improves circulationDecreases pain, symptom distress, and
anxietyImproves sleep qualityProvides a means of communicating with the
patient through the use of touchProvides cutaneous stimulation for pain relief
Effects of Immobility on the Body
Decreased muscle tone, size, and strengthDecreased joint mobility and flexibilityLimited endurance and activity toleranceBone demineralizationLack of coordination and altered gaitDecreased 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 breakdownDecreased appetite, constipationUrinary stasis, infectionAltered sleep patterns, pain, depression,
anger, anxiety
Principles of Body Mechanics
Maintaining correct body alignmentFacing the direction of movement without twisting
bodyMaintaining balanceUsing body’s major muscle groups and natural
levels for coordinated movementPlanning to use good body mechanicsUsing large muscle groups in legs for movementPerforming work at the appropriate height for
your bodyUsing 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 PatientCheck 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.
Equipment and Assistive Devices for Moving PatientsGait beltsStand-assist and repositioning aidsLateral-assist devicesFriction-reducing sheetsMechanical lateral-assist devicesTransfer chairsPowered stand-assist and repositioning liftsPowered full-body lifts
Assessments Made Prior to Transferring a Patient From Bed to StretcherReview 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 ChairThe activity and the length of time the patient
sat in the chairAny observationsThe patient’s tolerance of and reaction to the
activityThe 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 legsIntermittent 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