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
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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
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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
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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,
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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
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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
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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.
Performing Range-of-Motion
Exercises on the Leg
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
Supporting the Patient by the Gait
Belt or Waist
Assessments Made Prior to
Transferring a Patient From Bed to
Stretcher
 Review the medical record and nursing plan of care for
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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
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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
PCD Machine at the Foot of the Bed