ch. 15 - falls

Question 1

• 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

Answer 1

falls and fall reduction

Question 2

they are Termed Sentinel Events and they have to be reported to Medicare and Medicaid services

Answer 2

Falls in nursing homes

Question 3

consequences of falls

Answer 3

• hip fracture
• Traumatic Brain Injury (TBI)
• Fallophobia

Question 4

• 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

Answer 4

hip fracture

Question 5

• 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

Answer 5

Traumatic Brain Injury (TBI)

Question 6

• 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

Answer 6

Fallophobia

Question 7

risk factors for falls

Answer 7

• 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

Question 8

unique to each person

• reduced vision/hearing
• unsteady gait
• cognitive impairment
• med side effects

Answer 8

Intrinsic factors

Question 9

related more to your environment

• lack of supportive equipment
• inappropriate height of bed
• unleveled flooring
• stairs
• poor lighting
• improper use of devices
• improper footwear

Answer 9

Extrinsic factors

Question 10

• 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.

Answer 10

Peripheral Vascular Disease (PVD)

Question 11

• 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

Answer 11

Homan’s Sign

Question 12

• fracture (pelvis, femur, and tibia)
• Hip or knee replacement:
• major general surgery
• major trauma
• spinal cord injury

Answer 12

Homan’s Sign: increased risks for DVT

Question 13

A decrease of 20mm Hg or more in systolic or decrease of 10mm Hg or more in diastolic with position change

Answer 13

Orthostatic hypotension

Question 14

• Decreased blood pressure following eating a meal
• Increase fluid intake, eat smaller more frequent meals, move slowly

Answer 14

Postprandial hypotension

Question 15

• dementia or AMS? Automated fall risk

Answer 15

cognitive impairment

Question 16

Poor visual acuity, cataracts, difficulty hearing = FALL RISK

Answer 16

vision and hearing impairment

Question 17

To determine the patient’s fall risk score. Based on their score, we implement certain interventions

Answer 17

Morse Fall Scale

Question 18

• 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

Answer 18

Postfall assessment

Question 19

Fall risk reduction and safety measures

Answer 19

• Environmental modifications
• Assistive device use
• Safe patient handling
• Wheelchairs
• Alarms
• Vitamin d and calcium -supplementation

Question 20

• 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

Answer 20

safety patient transfers

Question 21

• 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

Answer 21

restraints

Question 22

• 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

Answer 22

foot deformities