NURSE 3101 Lecture 10: Chapter 26 Safety, Security, and Emergency Preparedness

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6 Oct 2016
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Chapter 26 Safety, Security, and Emergency Preparedness
Fall Risk Assessment
Leading cause of injury fatality among adults over age 65.
Most common reason for admissions to hospitals for injuries in older adults.
Types of falls:
oAccidental
Clutter
Grandma’s throw rug at home.
oPhysiological cause
Gait imbalance
Drug effect
Dementia.
oUnanticipated physiological cause
Stroke
Seizure
Cardiac dysrhythmia.
oIntentional
Behavioral acting out
Patient does it on purpose.
High Risk for Falls
Documented history of falls
oBest predictor of fall risk is someone who already fell!
Age older than 65 years.
Impaired vision; impaired balance.
Altered gait or posture.
Drugs
oDiuretics
oBenzodiazepines
oOpioids
oLaxatives.
Postural (orthostatic hypotension).
Slowed reaction time.
Confusion or disorientation.
Impaired mobility.
o“Get up and go test”
Can patient get up off bed and walk?
Weakness; physical frailty.
Unfamiliar environment (the hospital!).
Preventing Falls
Fall risk assessment.
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Indicate fall risk on chart, bracelet, on door, in room (usually a color code).
Orient patient to room and environment
oCues for orientation like clock or calendar.
Bed in low position.
oWheels on bed/wheelchair locked.
Call light within reach
oInstruct patient in use
Return demonstration.
Answer call light promptly.
Hourly rounds.
oOffer assistance while you’re there.
Non-skid footwear.
Leave water, tissues, urinal, etc. within reach.
Report cognitive changes to doctor, at shift change, etc.
Room near nurses’ station
oFrequent observation.
Take to bathroom at regular intervals.
oMany falls rushing to bathroom
Ask family members to stay with patient.
No substitute for frequent observation.
Preventing Falls: Alternatives to Restraints
Sitter or increased staffing.
Put patient in wheelchair and place them near nurses’ station.
Diversionary activities: music, TV, folding towels.
Be careful who is in the room next to the elevator or stairs.
Ambulation and physical therapy (tire them out!).
Hide IV lines with IV sleeve
oChange to saline lock
oSwitch to G-tube from NGT
oHide G-tube with abdominal binder
oRemove Foley catheter.
Rule out physiological cause for agitation.
oAssess respiratory status, fluid/electrolyte issues, blood glucose, neurologic status,
and drugs.
Reduce stimulation, noise, and lights.
Use a calm voice and simple instructions.
Night light at night.
Bed alarm or position-sensitive alarm.
Low-height bed (“Hi-low” bed).
Floor mats/pads on both sides of bed.
Bed alarm
oWeight sensors in/under mattress
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oAlarms if patient gets OOB.
Ambu alarm
oAttaches to leg
oAlarms if leg position changes and patient gets OOB.
Wheelchair alarm
oAlarm attached to w/c
oCord from alarm attached to patient
oIf patient moves, cord pulls tab out of alarm
oAlarm sounds.
When these alarms go off, everybody comes running!
Side Rails
Useful
oPatient grabs while turning or holds for support when getting up.
Usually all raised if patient unconscious.
All side rails up usually considered a restraint.
Typical policy
oOne side rail down at all times.
Leave side rail down closest to bathroom.
Side rails worsen falls.
Climbing over a side rail adds 1-2 feet to the height of a fall.
CAUTION, ENTRAPMENT RISK
oPatients can get caught between the mattress and the side rail or between side
rails.
oCan result in injury or death from asphyxiation.
oRare.
oRisk factors
Frail; elderly; confused; uncontrolled body movements.
Restraints: The Last Resort
Physical devices used to limit patient movement.
Goal is a restraint-free environment.
Multiple risks from restraints
oSkin breakdown; contractures; incontinence; depression; delirium; anxiety;
aspiration; respiratory difficulties; death.
Use the least restrictive alternative.
oExample: restrain one wrist; not both
Physician order required.
oFace to face assessment by physician.
Order states
oType of restraint; location; behaviors for which it should be used.
Restraints
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