NEO 111 Melanie Jorgenson, RN, BSN. Primary Causes of Falls Change in balance or gait disturbance Muscle weakness Dizziness, syncope, and vertigo Cardiovascular.

Patient Safety, Comfort, & Mobility

NEO 111Melanie Jorgenson, RN, BSN

Safety

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

Comfort

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

FLACC Behavioral Scale

FacesLegsActivityCryConsolability

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

Mobility

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.

Performing Range-of-Motion Exercises on the Leg

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

Supporting the Patient by the Gait Belt or Waist

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

PCD Machine at the Foot of the Bed

Questions?