Download Vision with Macular Degeneration

Fall Prevention
What’s New?
Mary McDougall RN MSN
Clinical Nurse Specialist
Caritas Norwood Hospital
© 2008
Objectives
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2008
Identify fall risk
Identify changes of aging that increase risk
Identify patients at increased risk for fracture
Describe how fall risk is assessed
Identify elements of Caritas Norwood Hospital
fall prevention plan
Demonstrate knowledge of the CNH fall policy
What is fall risk?
Fall risk is measured by several different
nursing fall assessment tools.
 The basic elements of each tool ask the
nurse to check:
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patient’s age, diagnoses, history of falls,
gait, and mental status
 some tools ask for medications that may
place patient at increased fall risk
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2008
People of any age can fall,
but….
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Changes of aging increase risk of falling
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1/3 persons 65 and older fall yearly
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Nearly half these falls are recurrent
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½ of persons 80 and older fall each year
Risk is greatly increased in hospital
 Strange environment
 Medications
 Illness
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© 2008
Changes of Aging and Falls
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Vision:
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decreased ability to focus
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sensitive to glare
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Patient safety teaching; keep areas well lit
less peripheral vision
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contrasting colors helpful
slower light to dark accommodation
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pull shades when glare is present
use direct task lighting
colors more washed out
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larger print helpful
Patient safety teaching
Changes of Aging and Falls
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Hearing:
Distortion of normal sounds
 Inability to hear softer sounds
 Inability to hear beginning of words
 Difficulty hearing when background noise
present
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Patient teaching
 Caregiver awareness
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Changes of Aging and Falls
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Muscle strength
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Joint mobility
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Difficulty changing position
Shuffling gait
Difficulty climbing stairs
Using knobs and handles
 Patient/family teaching
 Assistance when needed
Changes of Aging and Falls
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Nerve conduction
Slower response time
 Less ability to regain balance
 Altered pain perception
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Patient teaching
 Caregiver awareness
 Assistance when needed
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© 2008
Changes of Aging and Falls
Decreased thirst sensation
 Increased risk of dehydration which can
lead to confusion, dizziness
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Patient/family teaching
 Caregiver awareness
 Encourage fluids, within prescribed diet
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2008
Changes of Aging and Falls
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Less body insulation
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Increased risk of hypothermia can lead to
confusion and falls. Consider:
Warmth through layering
 Warm blankets
 Patient family teaching
 Caregiver awareness
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2008
Changes of Aging and Falls
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Nutrition and Elders:
 Prone to dehydration, and also malnutrition
due to changing sense of thirst and taste
 Adequate nutrition and hydration key to
better balance and reduction of confusion
 Nutrition consults important
 Elders may have issues with swallowing
 Safe feeding techniques
Changes of Aging and Falls
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Decreased kidney glomerulofiltration rate
 More risk of drug reactions
 Accurate heights and weights in meditech, so pharmacy
can calculate creatinine clearance for geriatric dosing of
meds
 Pharmacy consults
Decreased bladder tone
 Frequent need to use the bathroom
 Consider caffeine free diet
 Consider timing of meds ex. Lasix
 Toilet Q2 hours
© 2008
Changes of Aging and Falls
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Decreased cardiac output
Decreased exercise tolerance, easy to tire
with stairs and long hallways
 Activity as ordered and within patient’s
tolerance level
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2008
Summary
Changes of Aging
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As patients age, they are more and more at
risk to fall, because of the changes of aging.
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In addition to normal changes of aging, there
are also disease processes that increase risk
for falling, which is covered next.
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© 2008
Changes that are NOT necessarily
aging…
 Confusion
 Dementia:
slow, insidious mental
status change
 Delirium: acute, sudden, abrupt
mental status change, triggered by
physical factors such as sepsis,
bladder infection, medication etc
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© 2008
JCAHO
Joint Commission on Accreditation
of Hospitals and Organizations
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JCAHO safety standard 2007:
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© 2008
“Reduce the risk of patient harm resulting
from falls”
Who is at Risk:
Fall Related Fractures?
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Risk for fracture
Vision loss
 Osteoporosis, smoking , steroids
 Weakness, poor balance
 Medicines: sedatives, pain meds
 Diabetes
 Stroke
 Arthritis
 HISTORY OF FALLS
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A BIG PROBLEM
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© 2008
“We are looking a train wreck in the
face,” Dr. Joseph Melton III an
epidemiologist at the Mayo Clinic in
Rochester, Minnesota, as quoted in
Boston Globe 12.10.06
Vision Problems
Increase Risk to Fall
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Elders with vision loss are more than
THREE times more likely to have a fall
resulting in a hip fracture.
Macular degeneration
 Glaucoma
 Diabetic Retinopathy
 Cataract
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© 2008
Macular Degeneration
Leading cause of vision loss in people
age 60 and older
 Destroys sharp, central vision needed
for reading and driving
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© 2008
Vision with Macular
Degeneration
© 2008
Glaucoma
Glaucoma damages the
optic nerve when normal
fluid pressure inside the
eyes slowly rises.
© 2008
Vision with Glaucoma
Initially, glaucoma
affects peripheral
vision causing "tunnel
vision;" gradually
advances into central
vision resulting in
vision loss and
blindness.
© 2008
Diabetic Retinopathy
Leading cause of blindness
 Two types diabetic retinopathy:
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Blood vessels in the back of the eye, swell
and leak fluid
 Abnormal new vessels grow on the surface
of the retina
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© 2008
Vision with Diabetic
Retinopathy
© 2008
Cataract
-Clouding of the lens
which affects vision
-Very common in older
adults
-By age 80, more than
half have had a
cataract
© 2008
Cataracts
Vision with Cataracts
© 2008
Medications
Increase the risk to fall
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More than 4 prescription medications
increase patient risk to fall
Nurses, physicians, and pharmacists
should review the list and recommend
stopping or lowering some doses
 Pharmacy consult: enter in Meditech
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Tinetti, M., Preventing Falls in Edlerly Persons, NEJM, 1.2.03
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2008
Medications increase the risk to
fall continued
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Certain medications greatly increase risk to
fall
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Antidepressants
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Tricyclics like amitriptyline
Serotonin reuptake inhibitors like Zoloft, Prozac , Paxil
Antiarrhythmics/antihypertensives
Anticonvulsants
Benzodiazepines like Ativan, Valium, Xanax
Neuroleptic agents like Risperidone, Haldol
(haloperidol)
Tinetti, M., Preventing Falls in Edlerly Persons, NEJM,
1.2.03
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2008
Medication Surprises
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Patients taking sedatives/hypnotics are
FOUR times more likely to fall than
others
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Patients taking diabetes medication are
THREE times more likely to fall than
others
Krauss et all, J.General Internal Medicine 2.05
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© 2008
Older Adults and Medications
Absorption: delayed gastric emptying may
decrease the rate of absorption of some
drugs
 Distribution:
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Increase in fat stores may increase effect of lipid
soluble drugs and increase risk of toxicity
Decrease in total body water may change the
onset of water bound drugs like morphine
Decrease in serum albumin may change action of
protein bound drugs like warfarin, phenytoin, sulfa
antibiotics and NSAIDs
Medications and Older Adults
Metabolism: decreased hepatic blood
flow causes some drug actions to be
prolonged.
 Excretion: reduced renal clearance of
drugs due to reduced renal mass and
glomerular filtration rate causes
decreased excretion of drugs
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© 2008
Fall Risk Assessment
New Scale w/Computerized Charting
 Marita Titler, U of Iowa
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Top score 21
 Over score 7 considered fall risk
 Includes age, medications along with
mobility, vision, hearing, mental status
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Fall Risk Assessment
continued
If patient has a Fall Risk Scale of 7 or
above, he/she is placed on fall
precautions
 Know your
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Fall precautions policy
 Fall precautions equipment
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© 2008
Fall Risk Assessment
HIGH Risk to Fall
If, in addition to risk on the scale
 The patient is/has
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Age over 80
Confused
History of falls
The patient is HIGH RISK TO FALL and placed
close to the desk on Q15 minute safety
checks. All on the team should be aware of
this patient’s high risk status.
Patient Selection for
High Fall Risk Room
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Patients will be selected based on
High Fall Risk scale
 Presence of confusion
 Gait disturbance
 History of falls
 Over age 80
 Female only (for now room 3209 will be
the only high risk to fall room)
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2008
Your patient is at risk to
fall…now what?
KNOW YOUR PATIENT
 Confusion, age over 80, history of falls
makes him/her a high fall injury risk
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Poor vision increases risk
 Unsteady gait increases risk
 Long lists of medications, especially certain
classes of meds increases risk
 Bowel or bladder problems increase risk
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© 2008
Fall Prevention Plan key points
PATIENT TEACHING: key
 Good lighting
 Non skid slippers/shoes
 Toileting every 2 hours..BR or commode
 Helpful equipment/supplies
 New beds with bed exit alarms
 New Fall/Safety equipment Carts
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Non Skid Slipper Socks
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Shoes
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Toilet Riser
Many falls occur in bathrooms..
Toilet riser with handles or extra
grab bars planned for bathroom
in 3209.
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Non restraint Items We Have
from Posey and Alimed
Skin sleeves
 Busy Apron
 Velcro “Posey SR Wrap Around” (different
sizes)
 Wedge Pommel Cushions
 Posey “Quick-Release Soft Belt”
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© 2008
Posey Quick Release Soft Belt
Not a restraint,
as long as
Patient KNOWS
how to
remove and
clip is in the
front…
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Posy Busy Apron
‘Busy Apron’
may be just
the activity
that your
distracted
elder female
patient
needs…
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Posey Skin Sleeves
Ideal for
‘hiding’ the
IV for
patient
who is
pulling and
tugging at
lines
Skin color choices
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Posey SR Wrap Around
Not a restraint
as long as
patient KNOWS
how to remove
and the velcro
opening is in
the FRONT…
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Posey Wedge Pommel Cushion
… for
Helpful
patients
Who ‘scoot’ to
the
edge of the
chair,
and at risk to
fall off the edge
of the chair…
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2008
Hill Rom: Versa Care AIR Beds
These new
beds have
many
features and
also have
bed exit
alarms.
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TAB Monitor
Place
patient clip at back of clothing
Patient gown must be tied
TAB must be secured to bedrail or
chair
Double ‘TAB’ patients as necessary
Always TAB patients who are in
restraints
Do not use TAB monitor on patient who
is skilled at removing it
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2008
How to move patients who
don’t move very well?
 Gait
belts
 Liko lift
 ‘Easy Move’
 Wheelchairs
 Geri chairs
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Gait Belt
View film on unit
Re: Safe use
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Liko Lift
-Check
body mechanics
-View film for safe use
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Wheelchair
Safe patient
Transfer
Technique;
Locked brakes
Check body
mechanics
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Wheelchair Safety
1.
Always lock the brakes before getting in or
out of the wheelchair.
2.
Lift the footplates up before getting in or
out of the chair.
3.
If you have a wheelchair with removable
arms or leg rests, make sure they’re secure
by lifting the arms and gently trying to
swing the leg rests away from the chair. Do
this before each use.
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2008
Wheelchair Safety
3. Avoid putting heavy loads on the back of the
wheelchair. It may tip backwards.
4. Keep loose objects or lap covers away from wheel
spokes.
5. Avoid going up or down steep inclines. You may lose
control or tip over.
6. Beware of caster flutter. This is the side-to-side
motion of the caster usually at high speeds. If the
casters flutter, repair immediately.
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2008
Geri Chair
-Safe
patient
-Transfers
-Locked brakes
-Check body
mechanics
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Less Restrictive Restraints
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Elbow Immobilizer
Still a restraint
But
could be helpful…
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“Peek A Boo” Mitt
Still a restraint…but
could be helpful
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2008
Caritas Norwood Hospital Fall
Prevention Plan
Fall risk assessment by nurse
 If at fall risk:
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Orange bracelet, orange stickers
 Toileting Q2hours
 Room near station
 Pharmacy consult for patients at risk who
have 4 or more prescription medications
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2008
Caritas Norwood Hospital Fall
Prevention Plan
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PATIENT TEACHING: key
Micromedex fall prevention teaching
 CDC brochure: fall prevention at home
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Helpful equipment/supplies
 New beds with bed exit alarms
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2008
Caritas Norwood Hospital Fall
Prevention Plan
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Transport, test and return fall risk patients to
units quickly
Do not leave fall risk patients unsupervised
on stretchers; send nursing staff when
necessary
Stretcher/bed locked; bed in low position;
side rails up
Call bell, tissues, phone etc within reach
Orient to surroundings; teach to call for help
getting out of bed
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2008
Caritas Norwood Hospital Fall
Prevention Plan
Toilet patients at least Q2 hours
 Non slip slippers or shoes and
use canes, walkers etc.
 Glasses/hearing aide/listenator in use
 Room close to nursing station; bring
patient to station in recliner if necessary.
 Do not use Tab monitor on patient who
is skilled at removing it
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2008
Caritas Norwood Hospital Fall
Prevention Plan
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Q15 min rounds for fall risk patients who are: over
age 80, confused and /or have history of falls
 Place pharmacy consults to evaluate fall risk meds
 Place geriatric consults to evaluate sudden confusion
 Provide activities such as folding, sorting, walking,
singing, talking, playing cards, magazines, picture
books
 Ask volunteer services for a Friendly Visitor volunteer
or a Caring Touch volunteer
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2008
Caritas Norwood Hospital Fall
Prevention Plan
Avoid sleep meds; use warm milk, back rub
 Document patient/ family teaching about
fall prevention
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2008
Summary
Communicate and Prioritize Prevention of
Falls
 Many patients are older, more at
risk
 Know the risks; protect your
patients
 Patient Safety is every employee's
responsibility
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©
2008