Quiz 2: Causes and Risk Factors for Falls PDF

**Quiz 2** **Causes and risk factors for fall** -- the falling risk of falling [increases with age.] Persons [older than 65 years old are at risk]. A [history of falls increases the risk of falling again]. Falls are the [most common accidents in nursing centers] **box 12-1** **Bed rails**- device...

**Quiz 2** **Causes and risk factors for fall** -- the falling risk of falling [increases with age.] Persons [older than 65 years old are at risk]. A [history of falls increases the risk of falling again]. Falls are the [most common accidents in nursing centers] **box 12-1** **Bed rails**- device that [serves as a guard or barrier along the side of bed]. [Nurse and the care plan tells you when to raise bed rails]. [Maximum bed rails you can raise is 3] **\*4 rails raised= restraints** **Entrapment** -- person [gets caught, trapped, entangled, or strangled] - Cannot be used unless needed to treat medical symptom. - Person or legal representative must give written consent for raised bed rails **Handrails** -- in [hallways and stairways]. Give support to persons who are weak or [unsteady when walking] **Grab Bars** -- in [bathrooms and shower/tub rooms]. Provide support to [sit down or get up from toilet] **Transfer (Gait) belt** - [device applied around the waist] and [used to support a person who is unsteady or disabled**. ALWAYS FOLLOW MANUFSCTURER'S INSTRUCTION**] - The buckle is off-center - Excess strap is tucked into the belt - Nursing assistant grasps the belt from underneath with an upward grasp - CNA's stand behind the person and on their weaker side **Transfer (Gait) belt -- promoting safety and comfort**  **Helping the falling person** -- **do not try to prevent the fall.** - Stand behind the person with your feet apart. Keep your back straight - Bring the person close to your body as fast as possible. Use transfer gait belt or wrap your arms around the person's waist in necessary - Move your leg so the person's buttocks rest on it - Lower the person to the floor. The person slides down your leg to the floor. Bend at your hips and knees as you lower the person - Call a nurse to check the person. Stay with the patient - Help the nurse return the person to bed. Ask other staff to help if needed. **Body alignment** - the way the [head, trunk, arms, and legs align with one another]; posture **\*Good body alignment lets the body move and function with strength and efficiency -- standing, sitting, and lying down**. **Ergonomics** -- the [**science of designing a job to fit the worker.**] It involves [changing the task, work station, equipment, and tools to help reduce stress on the worker's body]. **[Goal is to eliminate a serious work-related MSD ]** - Always report work-related injury as soon as possible **Positions:** - **Supine (dorsal recumbent) --** [back]-lying - **Prone** -- lies on [abdomen], head turned on 1 side - **Lateral (Side lying)** -- person lies on [1 side] or the other - **Fowler --** [semi] sitting, head of the bed is raised between [45-60 degrees] - **Semi fowler** -- head of the bed is raised at [30 degrees] - **High fowler --** head of the bed is raised at [60 -- 90 degrees] - **Left semi prone position** - lies on the [left side of the abdomen]. [Upper leg] (right leg) is [sharply flexed] (bent) so it is not on the lower leg (left leg). The [lower arm] (left arm) is [behind the person] (**procedures involving bowel**) **A good base of support** -- **[Balance]** (needed for balance). [An area on which object rests] **Rules of Body Mechanics Box 16-1** A paper with text on it Description automatically generated **Safely Positioning a person** -- whether in bed or a chair, [person is re-positioned every 2 hours] or more often. Follow the nurse's instruction and the care plan. To safely position a person: - use good body mechanics - follow the care plan for use of assist device - ask a co-worker to help you if needed - explain the procedure to the person - provide for privacy - be gentle when moving the person - use pillows as directed by the nurse for support and alignment - provide for comfort after positioning - place the call light and other needed items within reach - complete a safety check before leaving the room **Positioning the person- focus on communication**  **Support device** -- sliding down in the seat, leaning forward, and leaning to the side cause [poor alignment]. Some persons need [postural support devices], [special cushions], [back support], [side (lateral) supports], and [padded footrests] are examples. [Weak or paralyzed arms are supported.] [Pillows or elevated armrests are used]. Some persons have positioners. The nurse may have you position the wrists at a slight upward angle. The health team selects the [best products for the person's needs.] [Safety, dignity, and function are considered. The nurse or therapist teaches how to use devices properly]. **OSHA recommendations** -- **minimizing manual lifts in all cases** and **eliminating manual lifting when possible** **Logrolling** - [turning the person as a unit, in alignment, with 1 motion] - head, neck, and spine are kept straight - used to turn: older persons with painful joints or arthritis of the spine, hip, knee & persons recovering from hip fractures & persons with spinal cord injury or after spinal cord surgery **Planning a safe move** -- the **[number of staff depends on the person's height, weight cognitive function, and physical abilities]**. The **nurse and care plan tells you what procedure to use and the equipment devices needed**. [Always follow manufacturer's instruction and you should be trained to use the equipment. Ask for needed training]. **Focus on communication** A page of a book Description automatically generated **Friction/Shearing** - [injure the skin. Both cause infection and pressure injuries] - **friction** -- [rubbing of 1 surface against another] - **shearing** -- when the [skin sticks to a surface] while [muscles slide in the direction the body is moving ] **Friction reducing device** -- [protect the person's skin from injury]. They also help [prevent work-related injuries]. Examples: - turning pads/turning sheet - slide sheet - drawsheet/flat sheet folded in half - large re-useable waterproof under-pads - with these devices, **person is moved evenly**. **Shearing and friction are reduced**, at least **2 staff members are needed** to move a person with a friction-reducing device **Moving person in bed** -- some persons can move and turn in bed without help. Others need help from at least 1 person. [Those who are weak, unconscious, paralyzed, or in casts need help. Sometimes 2 or 3 people or a mechanical lift is needed]. Follow guidelines to move persons in bed **Guidelines for Moving person in bed**  **Moving person in bed -- focus on older persons** A white and purple page with text Description automatically generated **Moving the person to side of bed** -- repositioning and care procedures require moving the person to the side of the bed. Example: *bathing in a bed may require reaching over the person you reach less if the person is near you*. [Before turning the person into the lateral position, you move the person to the side of the bed]. [Otherwise, after turning, the person lies on the side of the bed---not in the middle]. in method 1, the [person is moved in segments.] (**upper body** is moved**, lower part** of the body is moved, **legs** are moved) Sometimes you can do this alone if the person is small in size. *[Using a friction-reduced device helps prevent pain, skin damage, and injury to the bones, joints, and spinal cord. Follow guidelines to move the person in bed, mechanical lift may be needed]*. **Turning patient** -- turning persons onto their sides [helps prevent complications from immobility and bed rest.] Procedures and care measures often require the side lying position. You also may turn the person to [position and remove friction-reducing device]. [You turn the person toward you or away from you]. The [direction depends on the person's condition and the situation]. Many **[older persons have painful joints and arthritis in their spines, hips, and knees. Less painful, logrolling is preferred for turning these persons]**. **Turning and positioning the person on the side:** **Turn pt away from you and turn pt toward you** **Repositioning in a chair or wheelchair --** the person can slide down in a chair or wheelchair. For good alignment and safety, the [person's back and buttocks must be against the back of the chair]. If the [person cannot help with repositioning, use a mechanical lift]. [Follow the nurse's directions and the care plan for the best way to reposition a person in a chair or wheelchair]. **Do not pull the person from behind the chair or wheelchair**. If the person reclines: 1. ask coworker to help you 2. lock the wheels 3. recline the chair 4. position a friction-reducing device under the person 5. grasp the device 6. use the device to move the person up **Stand pivot transfer** -- [turn one's body from a set standing position]. It is used if person: - legs are strong enough to bear some or all of the person's weight - person can cooperate and follow directions - person can assist with the transfer **Bed to chair or wheelchair transfer** -**[help the person out of the bed on the person's strong side]**. If the left side is weak and the right side is strong, get the person out of the bed on the right side. [The strong side moves first]. It pulls the weaker side along. [Transfers from the weak side are awkward and unsafe. ] **Promoting safety and comfort**  **Transfer belt** -- they are used to: - support patients and residents during transfers - reposition persons in chairs and wheelchairs - assist with ambulation **Using a mechanical lift** -- before using a lift: - you must be trained in its use - it must work - the sling, straps, hooks, or chains must be in good repair - the person's weight must not exceed the lift's capacity - you need enough help. At least 2 staff members are needed for most lifts. Follow agency policy and the person's care plan **Mechanical lift**- **[training before using, follow the manufacturer's instruction]** **Transferring the person to and from the toilet** -- using the bathroom for elimination [promotes privacy, dignity, self-esteem, and independence]. However, bathrooms are often small with little room for you or a wheelchair. Therefore, transfers with wheelchairs and toilets are often hard. [Falls and work-related injuries are risks]. Sometimes [mechanical lifts are used for toilet transfers]. The following procedure can be used [if the person can stand and pivot from the wheelchair to the toilet] - **Lateral transfer**- the **wheelchair is at right angle (90 degrees) to the toilet** **promoting safety and comfort** **Illness/disease/some drugs often cause:** - a bad taste in the mouth - a whitish coating in the mouth and on the tongue - redness and swelling in the mouth and on the tongue - dry mouth. Dry mouth is common for oxygen, smoking, decreased fluid intake, and anxiety **Oral hygiene equipment** -- [toothbrush, toothpaste, floss or other interdental cleaner, and mouthwash] are needed. A [toothbrush with soft bristles is best]. Using [toothpaste with fluoride helps protect the teeth from decay]. [Sponge swabs are used for sore, tender mouths and for unconscious persons]. Use sponge swabs with care. Make sure the foam pad is tight on the stick. The person could choke on the foam pad if it comes off. You also need a [kidney basin, water cup, straw, tissues, towels, and gloves]. Many persons bring oral hygiene equipment from home. *Electric toothbrushes are common.* **Mouth care for unconscious person** -- [they cannot eat or drink]. Some *breathe with their mouth open, many receive oxygen. These factors cause mouth dryness. They also cause crusting on the tongue and mucous membranes*. [Oral hygiene keeps the mouth clean and moist. It also prevents infection]. [They cannot swallow]. Protect them from choking and aspiration. [It can cause pneumonia and death]. To prevent: - position the person on the side with the head turned - use small amount of fluid to clean the mouth - do not insert dentures - **do not use your fingers to keep the person's mouth open. The person can bite down on them**. - Using a **bite block or plastic tongue depressor is a safe way to open the mouth** - **Sponge swabs are their toothbrush** - **Mouth care is given at least every 2 hours** - **Follow the nurse's directions and the care plan** **Aspiration** -- [breathing fluid, food, vomitus, or an object into the lungs] **Promoting safety and comfort**  **Purpose of Oral Hygiene-Delegation guideline** A white and blue paper with text Description automatically generated **Flossing** -- flossing [cleans between the teeth]. Flossing [removes plaque from areas brushing cannot reach and removes food from between the teeth]. It helps [prevent periodontal disease and cavities.] Dental [floss is commonly used]. It is a [soft thread used to clean between teeth]. Other devices may be used. *[ADA recommends flossing at least once a day]*. Flossing can be [done before or after brushing.] The [person can choose the best time for thorough flossing---in the morning, after meal, at bedtime, or when convenient]. You need to [floss for persons who cannot do so themselves.] **Dentures --** [removable replacement for missing teeth]. [Tooth loss occurs from gum disease, tooth decay, or injury; often called false teeth.] **dentures care equipment --** [denture cleaner], [denture cup], and [denture bru]sh or [toothbrush]. Use [only denture cleaning products to avoid damaging dentures]. Dentures [must be removed for cleaning]. [Do not use denture cleaning products on dentures while they are still in the mouth]. *[Follow manufacturer's instruction how to use the cleaning agent and what water temperature to use]*. **[Hot water causes warping---dentures lose their shape]**. When not worn, [it is stored in a denture cup with cool or warm water or denture soaking solution. Otherwise they can dry out and warp.] **denture care** -- mouth care is given and dentures are cleaned often as natural teeth. Dentures are [slippery when wet]. They [easily break or chip if dropped onto a hard surface.] [Hold them firmly when removing or inserting them]. During cleaning, [firmly hold them over a sink filled half way with water, line the sink with a towel]. This [prevents dentures from falling onto a hard surface]. Dentures are [removed at bedtime]. They are [soaked overnight in a denture cleaning solution or water. Rinse the dentures before they are inserted. If able, person cleans the dentures. You clean it if person is not able to do so. ] **Provider denture care (Pre-procedure/procedure/post-procedure)** A page of a book Description automatically generated Perineal care= Pericare. = cleaning the genital and anal areas - Front to back - Top to bottom - (urethra (top/front) is the cleanest; anal (bottom/back) is the dirtiest clean **Daily hygiene and bathing** -- [follow the person's care plan. It promotes comfort, safety, and health] **Daily care** -- [most people have hygiene routines and habits]. For example: *teeth are brushed, and the face and hands are washed after sleep*. These and other hygiene measures are [common before and after meals and at bedtime]. Routine care is [given during the day and evening]. You also assist with hygiene as needed. Always protect the right to privacy and to personal choice **Early morning(AM) care/morning care/afternoon care/evening (PM) care Box 22-**1  **Bathing** -- cleans the skin and the genital and anal areas. Microbes, dead skin, perspiration, and excess oils are removed. A bath is refreshing and relaxing. Circulation is stimulated. Body parts are exercised. Observations are made. You have time to talk to the person. Complete or partial bed baths, tub baths, or showers are given. The method depends on the person's condition, self-care abilities, and personal choice. In hospitals, bathing is common after breakfast. In nursing centers, bathing is usually before or after breakfast or after the evening meal. The person's choice of bath time is respected when possible. Bathing frequency is a personal matter. Some people bathe daily. Others bathe 1-2 times a week. Some illnesses and dry skin may limit bathing to every 2-3 days. **Rules for bathing ( skin care product, safety.....) Box 22-2** **Bathing- focus on older persons**  **The complete bed bath** (Use mitted washcloth (**Temp 110-115F** / 43.3-46.1C) - Bed baths are for people who are - Unconscious - Paralyzed - In casts or traction - Weak from surgery or illness - Unable to bathe themselves - (older persons with fragile skin. They need lower water temp) **Giving a complete bed bath** - (Pat dry patient, never rub) **Complete bed bath orders**- eyes ( water only ,No soap), face/ears/neck, **far arm, far hand near arm, near hand**, chest, abdomen, shoulders, **far leg, far foot, near leg/near foot ,** back/buttock **procedure step 20-34** A page of a book with text Description automatically generated **Partial bath** - (washing body parts- face, hands, underarms, back, buttocks, and perineal area are washed) **Partial bath position** -- sitting/Fowler -- person is bathing while sitting on the side of the bed. Needed equipment is within reach. figure 22-11 A person in a bed Description automatically generated **Tub bath** - (check pt every 5 mins, lasts no longer than 20 mins) to get in and out of the bath they may use: tub with side entry door, mechanical lift, or bathing lift **Tub bath and shower safety** -- **Risk: falls, burns, chilling from water** **Tub bath and shower safety** - (Temp 105F/ 40.5C, drain the tub before pt get out) **box 22-3**  **Assisting with tub bath/shower**- (clean it before and after use!) P283 **Perineal care -** (warm water, pat dry, wash front to back or top to bottom- Urethra to anal area, Temp 105 -109 F) **Giving female perineal care** - \*wear gloves. 1. Separate the labia with 1 hand. Use mitted washcloth to clean 1 side of the labia with a downward stroke 2. Clean the other side of the labia with a clean part of the washcloth. Use a downward stroke 3. Clean the vaginal area with a clean part of the washcloth. Use a downward stroke 4. Clean rectal area by wiping from the vagina to the anus. Side-lying position allows thorough cleaning of the anal area **Giving male perineal care** (Uncircumcised- retracting foreskin first) \*wear gloves **Retracting foreskin** 1. Pull back foreskin for perineal care 2. Return it to normal position after cleaning, rinsing, and drying the tip of the penis **Cleaning the penis** 3. Clean the tip with a circular motion starting at the meatus 4. Clean the shaft with downward strokes **Circumcised** -- fold of skin covering the glans of the penis was surgically removed **Uncircumcised** -- foreskin covers the head of penis **Alopeci**a -- hair loss **Hirsutism** -- excessive body hair **Dandruff** -- excessive amounts of dry, white flakes from the scalp **Pediculosis (Lice)** - infestation with wingless insects that feed on blood **Scabies** -- a skin disorder cause by female mite **Pediculosis capitis (Head lice)** -- infestation of the scalp with lice **Pubis corporis (Body) --** infestation of the pubic hair with lice **Scabies- mite -- spiderlike organism, transmitted to others by close contact/special cream to kill mites** **Brushing and combing hair** -- frequency and timing of brushing and combing hair are personal. May be part of early morning care, morning care, or afternoon care. Some people brush their hair before meals, before visitors arrive, and at bedtime. Encourage patients/residents to do their own hair care. The person chooses how to brush, comb, and style hair. Assist as needed. Daily brushing and combing prevent matted and tangled hair. So does braiding. You need person's consent to braid hair. Never cut the persons hair. Special measures are needed for curly, coarse, and dry hair. The person's hair care practices and products are part of the care plan. Let the person guide hair care. **figure 23-4+figure 23-5** A page of a book Description automatically generated\ **Shampooing:** - Shampooing a person in bed -- a shampoo basin under the head protects the linens and mattress from water. The device drains into a basin on a chair by the bed. Use a water pitcher to wet and rinse hair - during shower/tub bath - use hand-held nozzle for persons in shower chairs or taking tub baths. Direct spray of water at the hair. **Shampooing- promoting safety and comfort**  **Shaving (Box 23-1, focus on older persons)** A paper with text on it Description automatically generated **Shaving- figure 23-9**  \*shaving the face in the **direction of hair growth, long stroke- larger areas of face, short stroke- chin and lips**) **Caring for mustaches and beards** -- needs daily care, daily washing and combing is needed, food and mouth and nose drainage can collect in the whiskers. (ask the pt how to groom, never shave or trim a mustache or beard) **Nail and foot care -** (Temp 105 F, fingernail soak 5-10 mins, Feet soak 15-20 mins) **Changing Garments- focus on older persons** **Removing clothing** - from the **unaffected (Strong side) first** **Putting clothing** - from the **affected (Weak side) first** Changing patient gown -(**remove the gown from the arm without IV, keep IV bag above the patient, CNA does not adjust control on IV pumps/change the rate**) figure 24-8  **Affected side** -- side of the body with weakness from illness or injury; weak side **Unaffected side** -- side of the body opposite the affected side; strong side **Under garment** -- item of clothing worm next to the skin under clothing **Garment** -- an item of clothing **Acute pain** -- sharp or severe. Felt suddenly from injury, disease, trauma, or surgery **Chronic pain** -- continues for a long time (longer than 12 weeks occurs on and off, or is persistent) **Radiating pain** -- felt at the site of tissue damage and spreads to other areas **Phantom pain** -- seems to come from a body part that is no longer there (amputated leg may still sense leg pain) **Insomnia** -- chronic condition in which the person cannot sleep or stay asleep all night **Pain** -- to ache, hurt, or be sore; discomfort **Comfort** -- a state of well-being; the person has no physical or emotional pain and is calm and at ease **Rest** -- to be calm, at ease, and relaxed with no anxiety or stress **Sleep apnea** -- pauses in breathing that occur during sleep **Sleep deprivation** -- the amount and quality of sleep are not adequate, causing reduced function and alertness **Sleepwalking** -- when the person leaves the bed and walks about while sleeping **Signs and symptoms** - (write down what the person says, use the person's exact words to report and record) The nurse needs the following information: - location - onset and duration - intensity - description - factors causing pain - factors affecting pain - vital signs - other signs and symptoms **The back massage- delegation guide** A page of a medical manual Description automatically generated **Back massage figure 33-4** -- (stroke **upward from lower back to shoulder**, down over the upper arm, back up the upper arms, across the shoulder, and down to the lower back)