ch. 15 - falls Flashcards
1
Q
- leading cause of morbidity and mortality for ppl older than 65
- leads to physical and psychosocial consequences
- nursing-sensitive quality indicator
- Considered a geriatric syndrome
- Most common cause of hospital admissions for trauma
- This is the most common incident reported in hospitals
- Joint commission set goals for fall reduction
- Hospitals will not be reimbursed for treatment related to a fall
A
falls and fall reduction
2
Q
they are Termed Sentinel Events and they have to be reported to Medicare and Medicaid services
A
Falls in nursing homes
3
Q
consequences of falls
A
- hip fracture
- Traumatic Brain Injury (TBI)
- Fallophobia
4
Q
- most are caused by falls when it comes to older adults
- 50-60% will recover to their pre-fracture functional ability
- Increased risk for mortality after a fall
A
hip fracture
5
Q
- major cause of falls
- definitely more concerned about older adults who take anticoagulants
- CT scan is needed and MUST ASSESS for mental status, gait, and sensory
A
Traumatic Brain Injury (TBI)
6
Q
- fear of falling
- Leads to reduced physical activity, increased dependency, and social withdrawal
- an important predictor of general functional decline and a risk factor for future falls
A
Fallophobia
7
Q
risk factors for falls
A
- Intrinsic factors
- Extrinsic factors
- infection
- previous hx of falling
- meds (sedatives, diuretics)
do a good med REC
(including OTC) - gait disturbances (i.e., arthritis, affects ability to ambulate safely)
- foot deformities
8
Q
unique to each person
- reduced vision/hearing
- unsteady gait
- cognitive impairment
- med side effects
A
Intrinsic factors
9
Q
related more to your environment
- lack of supportive equipment
- inappropriate height of bed
- unleveled flooring
- stairs
- poor lighting
- improper use of devices
- improper footwear
A
Extrinsic factors
10
Q
- slow and progressive circulation disorder
- Narrowing, blockage, or spasms in a blood vessel are the causes
- Can cause issues in the lower extremities impacting a patient’s ability to walk
- A lack of foot assessment can lead to amputations that maybe we could have prevented
- most common cause is atherosclerosis, the buildup of plaque inside the artery wall.
- Plaque reduces the amount of blood flow to the limbs. It also decreases the oxygen and nutrients available to the tissue.
- Blood clots may form on the artery walls, further decreasing the inner size of the blood vessel and block off major arteries.
A
Peripheral Vascular Disease (PVD)
11
Q
- pain in calf upon dorsiflexion of foot and may indicated thrombophlebitis
- The patient is supine
- The examiner lifts the affected leg and rapidly dorsiflexes the patient’s foot with the knee extended
- This maneuver is repeated with the patient’s knee flexed while the examiner simultaneously palpates the calf
- patients are at increased risk for DVT
A
Homan’s Sign
12
Q
- fracture (pelvis, femur, and tibia)
- Hip or knee replacement:
- major general surgery
- major trauma
- spinal cord injury
A
Homan’s Sign: increased risks for DVT
13
Q
A decrease of 20mm Hg or more in systolic or decrease of 10mm Hg or more in diastolic with position change
A
Orthostatic hypotension
14
Q
- Decreased blood pressure following eating a meal
- Increase fluid intake, eat smaller more frequent meals, move slowly
A
Postprandial hypotension
15
Q
- dementia or AMS? Automated fall risk
A
cognitive impairment
16
Q
Poor visual acuity, cataracts, difficulty hearing = FALL RISK
A
vision and hearing impairment
17
Q
To determine the patient’s fall risk score. Based on their score, we implement certain interventions
A
Morse Fall Scale
18
Q
- must be performed after EVERY fall
- ALWAYS assess patient first and ensure they are stable
- fill out incident report (don’t put it on chart)
- figure out why the fall occurred so we can try to prevent future falls
- If it’s not performed, then there is a chance the fall will occur again
A
Postfall assessment
19
Q
Fall risk reduction and safety measures
A
- Environmental modifications
- Assistive device use
- Safe patient handling
- Wheelchairs
- Alarms
- Vitamin d and calcium -supplementation
20
Q
- the staff person w/ heaviest load coordinates efforts of team involved by counting to three when moving patient
- staff person positions self-close to patient (or object being lifted)
- staff person keeps back, neck, pelvis, and feet aligned and avoids twisting; arms and legs are used (not back), and knees are kept flexed and feet are kept wide apart
- staff person sets (tightens) abdominal and gluteal muscles in prep for move
A
safety patient transfers
21
Q
- always attempt to use other measures before applying this method
think about patient’s emotional status is affected by being placed in restraints - an order must be obtained to use one; must involve type of restraint, time frame, and why it’s needed
- policy will dictate when the order will be renewed - a new order is needed each calendar day
- CANNOT be prescribed as PRN basis
- client and family should be taught on why this method is being used on patient
- should NOT interfere w/ any treatments
- HALF-BOW, SLIP KNOT; secure device to the bed frame and not to the part of bed that is moveable
- should be enough slack to allow slight movement
- Skin integrity and neurovascular and circulatory status must be assessed EVERY 30 min and the device must be removed EVERY 2 hrs to permit muscle exercise and promote circulation
- offer fluids EVERY 2 hrs as well as bedpan
- proceed to assess for opportunity to remove the device
A
restraints
22
Q
- ensure to assess patient’s feet to see if there’s any wounds to care for
- explain the importance of wearing proper fitting shoes b/c they are more important to be able to ambulate
- feet are easy to neglect but it’s also to check feet w/ every head-to-toe
- assess their nails to see if they need to see a podiatrist
A
foot deformities
