Patient Safety, Comfort, & Mobility NEO 111 Melanie Jorgenson, RN, BSN
Primary Causes of Falls • Change in balance or gait disturbance • Muscle weakness • Dizziness, syncope, and vertigo • Cardiovascular changes • Vision changes • Physical environment • Acute illness • Neurologic disease • Language disorders impairing communication • Multiple medications
Preventing Falls • Identifying at-risk patients • Assess for a history of falls • Assess 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 condition • Provide care and interventions appropriate for status/injuries • Notify patient’s physician or primary caregiver of incident and your assessment of the patient • Ensure prompt follow-through for any test orders • Evaluate circumstances of the fall and the environment; institute preventive measures • Document the fall and complete an event report
Alternatives to Restraints • Determine whether a behavior pattern exists • Assess for pain and treat appropriately • Rule out physical causes for agitation • Involve family members • Reduce stimulation, noise, and light • Check environment for hazards and modify, if necessary • Use therapeutic touch • Investigate discontinuing bothersome treatment devices
Factors to Assess for Pain Management • Potentially painful conditions and procedures • The patient’s self-report of pain • The report of family members or caregivers • Cultural beliefs related to pain • Behaviors and physiologic measures that indicate pain • Blood pressure • Pulse rate
FLACC Behavioral Scale • Faces • Legs • Activity • Cry • Consolability
Sedation Assessment Scale • Sleeping, easy to arouse – S • Awake and alert – 1 • Slightly drowsy, easily aroused – 2 • Frequently drowsy, arousable, drifts off during conversation – 3 • Somnolent, minimal or no response to physical stimulation – 4
Pain Management Therapies • Administration of analgesics • Emotional support • Comfort measures • Nonpharmacologic interventions
Therapeutic Effects of Nonpharmacologic Methods of Pain Management • Diminish the emotional components of pain • Strengthen coping abilities • Give patient a sense of control • Contribute to pain relief • Decrease fatigue • Promote 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 Management • Reduces 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 numbness • Slows transmission of pain stimuli
Therapeutic Benefits of Back Massage • Provides an opportunity for the nurse to observe the skin for signs of breakdown • Improves circulation • Decreases pain, symptom distress, and anxiety • Improves sleep quality • Provides a means of communicating with the patient through the use of touch • Provides cutaneous stimulation for pain relief
Effects of Immobility on the Body • Decreased muscle tone, size, and strength • Decreased joint mobility and flexibility • Limited endurance and activity tolerance • Bone demineralization • Lack of coordination and altered gait • Decreased 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 breakdown • Decreased appetite, constipation • Urinary stasis, infection • Altered sleep patterns, pain, depression, anger, anxiety
Principles of Body Mechanics • Maintaining correct body alignment • Facing the direction of movement without twisting body • Maintaining balance • Using body’s major muscle groups and natural levels for coordinated movement • Planning to use good body mechanics • Using large muscle groups in legs for movement • Performing work at the appropriate height for your body • Using 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 Patient • Check 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.
Equipment and Assistive Devices for Moving Patients • Gait belts • Stand-assist and repositioning aids • Lateral-assist devices • Friction-reducing sheets • Mechanical lateral-assist devices • Transfer chairs • Powered stand-assist and repositioning lifts • Powered full-body lifts
Assessments Made Prior to Transferring a Patient From Bed to Stretcher • Review 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 Chair • The activity and the length of time the patient sat in the chair • Any observations • The patient’s tolerance of and reaction to the activity • The 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 legs • Intermittent 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