Transcript Chapter_020_LO

Chapter 20
Falls
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Learning Objectives
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Define falls.
Give the incidence of falls.
Describe factors that increase the risk of falls.
Discuss the relationship between restraint use and falls,
types of restraints, and regulations for restraint use.
• Describe fall prevention techniques.
• Describe nursing interventions to use when a fall occurs.
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Definition
• Definitions vary from “unexpected
displacement” to “unintentional change in
position” to “inadvertent events in which the
subject comes to rest unintentionally on the
ground”
• More useful definition: “a circumstance in
which one unintentionally falls to the ground or
hits an object such as a chair or stair”
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Incidence and Risk Factors
• The risk of injury is highest in people older than age
65; falls are the most frequent cause of accidental
injury and death among older adults
• Older adults constitute only 12%-13% of the total U.S.
population but account for 72% of total deaths from
falls
• Rate of death increases from 5 in 100,000 for between
ages 45 and 64 to 200 in 100,000 for those older than
85 years of age
• The U.S. Public Health Service estimates that two
thirds of deaths due to falls are preventable
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Incidence and Risk Factors
• Intrinsic factors
• Factors related to the functioning of the individual,
such as the aging process or physical illness
• Extrinsic factors
• Environmental factors
• Enhance possibility of falling; extrinsic factors
enhance the opportunity to fall
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Intrinsic Factors
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Age-related changes: reduced vision and hearing
Age-related changes in posture and gait
Confusion or depression
Lack of exercise leads to weakness and decline in
physical vigor
Multiple medications related to the increased incidence
of chronic illness in older adults
Psychotropic medications
Acute infections
Diseases affecting the central nervous system may
affect balance by causing dizziness and gait disorders
Overestimation of abilities
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Extrinsic Factors
• Home environment
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Low-lying and poorly visible tables
Trailing electrical wires
Pets
Steep and unlit stairs
Loose carpeting
Unsafe walking aids
Inconvenient bathroom or kitchen arrangements
• Institutional setting
• Changes in position; transferring to/from bed or chair
• Toileting procedures
• Unstable and defective equipment
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Incidence and Risk Factors
• Injury-causing falls are more likely to occur in long-term
care facilities than in the community
• Among community-dwelling older adults, 30% fall
every year, compared with 50% of those living in
residential care facilities
• In about 75% of all reported falls, no injuries occur
• Contusions, cuts, or lacerations occur in about 25% to
30% of all reported falls
• Deep tissue damage or concussion occurs in about 5%
• 1% to 5% of falls result in fractures
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Incidence and Risk Factors
• Factors known to increase the risk of falling
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A history of previous falls
Osteoporosis
Hemiparesis
Sensory impairment
Diminished muscle strength, balance, reaction time
Diabetes with peripheral neuropathies
Loss of consciousness or falls on a hard surface
Multiple medications
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Restraints
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Physical Restraints
• Anything that restricts movement
• If patient able to apply or release a safety device, it
is not considered a restraint
• Geriatric chairs, side rails, vest, waist, wrist, or
ankle ties
• Common reasons
• To protect the patient or others from harm and
prevent tampering with medical devices
• To prevent falls from the bed or chair
• To prevent wandering
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Physical Restraints
• May actually cause or worsen problems
• Patients often able to untie their restraints and wriggle
out of them, resulting in falls from wheelchairs and
beds
• Accidental strangulation with some restraints,
particularly with a restraint vest
• Using side rails now in question
• Patients have been injured, sometimes fatally, after crawling
over side rails or becoming trapped between side rail bars or
between side rails and the mattress
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Physical Restraints
• May have damaging psychological effects on
older patients
• Patients may experience anger, discomfort,
resistance, and fear of physical restraint
• Poor self-image, growing dependency,
increased confusion and disorientation,
regressive behavior, and withdrawal
• Omnibus Reconciliation Act (OBRA) of 1987
• Protects patients from unnecessary restraint in longterm care facilities
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Physical Restraints
• Physician’s order for restraint use; must specify
duration and circumstances under which
restraint may be used
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Physical Restraints
• According to OBRA regulations, the only
people who are considered restrainable are
those who
• Have a history of severe falls or are at extremely
high risk of taking a fall that is life-threatening
• Are neurologically, orthopedically, or muscularly
impaired; need postural support for safety or
comfort, or both
• Experience mental dysfunctions; may cause them to
be a serious hazard to themselves, objects, or
others
• Have life-threatening medical symptoms; a restraint
is used temporarily to provide necessary treatment
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Physical Restraints
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The least restrictive device is best
Check patient frequently, at least every 15 to 30 minutes
Agitated or combative patient: monitored continually
Make sure that the patient’s condition is good and that the
restraint is used properly and is providing adequate
protection and without impeding circulation or breathing
• Remove and release physical restraints every 2 hours for
10 minutes to provide for range of motion, toileting,
nourishment, and restorative activities such as physical
therapy, ambulation, and mental stimulation
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Alternatives
• Physical therapy
• Sitting and talking with patients for short
periods
• Asking staff to be responsible for wanderers in
small blocks of time
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Chemical Restraints
• Never use psychotropic drugs for the purposes
of discipline or convenience
• Use only when danger of self-injury or injury to
others
• Administration of a psychotropic drug requires
a physician’s written order that specifies the
duration and circumstance under which the
medication is to be used
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Chemical Restraints
• Commonly prescribed psychotropic drugs
• Antidepressants
• Sedatives/hypnotics
• Antipsychotic drugs
• Adverse effects
• Confusion, agitation, increased number of falls
• Orthostatic hypotension
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Fall Prevention
• Most important intervention for falls: prevention
• Best prevention: education of patients and
caregivers
• Prevention aimed toward minimizing intrinsic
and the extrinsic factors causing falls and the
potential for injury
• The first step: determine who is at greatest risk
• Fall prevention strategies are carried out in the
home and institutional environments
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Figure 20-1
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Reducing Fall-Related Injuries
• Hip protectors
• Aims to decrease the severity of fall-related injuries
• Individuals at risk for falling also can be taught
to rotate forward or backward to avoid falling
sideways; reduces the risk for hip injury
• Measures to prevent osteoporosis may reduce
the risk of fractures associated with falls
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When a Fall Occurs
• Hospital or long-term care facility
• Determine circumstances of fall and any injuries
• Document the fall according to agency protocol
• Note what the patient was doing at the time, the
mental and emotional status, and environmental
factors that may have contributed to the fall
• Remove or correct the cause
• Have the patient ambulate as soon as possible and
at least several times a day in order to prevent the
hazards of bed rest and to restore confidence
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When a Fall Occurs
• Home
• Requires cooperation of the person who is at risk,
the family, and possibly neighbors
• Plan of action should include information about
getting up and seeking help
• Devices worn around the neck that can send signals
to a control center are effective and provide feeling
of well-being for the individual
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