falls in hospitalized patients with current or recent chemotherapy treatment: a teaching session for...
TRANSCRIPT
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Falls in
Hospitalized
Patients with
Current or Recent
Chemotherapy
Treatment:
a teaching
session for
Oncology NursesJennifer Wolfe
Final Teaching ProjectUniversity of Central Florida
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Overview of Problem
• Fall Prevention is a nursing responsibility to all patients (Capone, 2012).
• Over 700,000 hospitalized patients fall each year (Sonnad et al., 2014).
• Most falls can be prevented by nursing staff and patient collaboration (Sonnad et al., 2014).
• MOST patients who fall did not consider themselves at risk to fall (Sonnad et al., 2014).
• Over 50% of cancer patients will experience a fall during their disease process (Stone et al., 2012).
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This session’s focus is fall prevention in patients with current or recent
chemotherapy treatment.
Upon completion, you will be able to:
• Identify at least 3 chemotherapy-specific factors that increases a patient’s fall risk
• Discuss 3 nursing interventions for fall prevention
• Recognize 2 non-chemotherapy medications commonly given in the hospital that can contribute to falls
• Evaluate 3 safety barriers that can be modified to prevent falls
• Resolve 1 personal knowledge deficit that was identified when completing the self-assessment prior to class
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Current Needs in caring for
patients with current or recent
chemotherapy:• Need for increased nurse involvement in fall
prevention
• Need for nurses to obtain a baseline functional assessment
• Need for nurses to have the ability to identify unique fall risk factors associated with chemotherapy treatment
• Need for nurses to know and utilize appropriate interventions to prevent falls
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Significance to YOU
SCU had 10 patient falls in 2013: 8 of them were patients with current or recent chemotherapy treatment!
2013 Patient Fall Scenario:
• 66 year old male with metastatic CRC. He received chemotherapy treatment that ended 2 days ago. His baseline is a/ox3 and ambulatory. Overnight he had c/o of frequent loose stools.
• A few hours into the shift, the patient was found on the bathroom floor during a visit by the nurse. He was awake and a/ox1 only. He was c/o pain in his legs. All post-fall policies and procedures were followed correctly.
• The question is…could his fall have been prevented? And How?
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What was known..
• Hb 6.8- planned to transfuse 1 unit of PRBCs
• NA 109- had placed a call to the Oncologist
• Drowsy
• Frequent loose stools overnight
• Recent medications: PO Lasix 20mg and PO Metoprolol 25mg
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Chemotherapy-specific fall risk
factors:These factors are all side effects of
chemotherapeutic agents
• Fatigue: Most common side effect of chemotherapy and is most felt a couple days after treatment.
• Postural Hypotension: Causes a drop in blood pressure when changing positions. This can lead to dizziness.
• Anemia: Low blood counts cause tiredness and weakness.
• Electrolyte Imbalances: Can cause weakening in the heart muscles as well as neurological changes.
• Peripheral neuropathies: Causes a decrease in sensation that can contribute to falls.
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Chemotherapy-specific fall risk factors
continued: • Changes in coordination: Related to
neurological changes can cause sporadic and unintentional movements as well as unsteadiness when walking.
• Polypharmacy: Different medications taken by chemo patients affect the nervous system.
• Nutritional Deficiencies: Related to appetite changes, nausea, vomiting, diarrhea. Poor nutrition causes weakness and muscle break down that can contribute to falls.
• Delirium/Confusion: Causes difficulty concentrating, remembering things and can alter our judgment.
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The Morse Fall Risk Assessment:
• This assessment is utilized for all adult patients.
• It classifies a patient as a high, medium or low fall risk.
• Interventions for nurses are recommended based on the patient’s score.
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Nursing Interventions for all patients at risk for falls:
• Bed locked and in the low position
• Water and call bell in reach
• Non-skid footwear
• Offer assistance with toileting
• Assess cognitive status
• Provide a clear path to the bathroom
• Involve family members in patient safety
• Utilize side rails when needed
• Utilize safety devices like mittens, lap belts, sitters
• Remove unnecessary clutter from the room
• Utilize bed alarms and sitter select devices
• Use bedside commodes as needed
• Offer bedpans and urinals as needed
• Hourly Rounding
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Nursing Interventions for patients with Chemotherapy-specific fall risk
factors:
• Advise patient to sit for a minute or so prior to getting out of bed to avoid dizziness due to postural hypotension.
• Obtain Daily Lab Values to monitor for hydration status and any electrolyte imbalances.
• Monitor nutrition status via assessing appetite, amount eaten, occurrence of nausea and/or vomiting, and lab values.
• Promote exercise daily and make recommendations to PT as needed. Nurses can utilize sit to stand and marching in place to assess basic physical mobility.
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Nursing Interventions for patients with Chemotherapy-specific fall risk
factors continued:
• Daily Functional Assessment of ADLs to assess for any changes or declines. This is essential to complete prior to administering chemotherapy.
• Communicate any and all concerns about patient safety to the nurse leader and the patient and/or family.
• Use safety devices, like bed alarms or lap belts for extremely fatigued patients.
• Be aware of the extent of the patient’s disease: patients with advanced cancer may have bone metastases and can experience pathologic fractures.
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ACTIVITY#1
• Forming Groups: Case Study
• 75 year-old female presenting with dehydration related to uncontrolled nausea and vomiting secondary to chemotherapy.
• PMH includes: former 65 pack-year smoker, atrial fibrillation and advanced non-squamous NSCLC with metastases to the breast and bone.
• MEDS: Advair 2 puffs BID, Albuterol rescue inhaler @4 PRN, Amiodorone PO 200mg Daily
• She finished a round of Pemetrexed (Alimta), IV chemotherapy, less than a week ago. She is requiring 4L nasal cannula to maintain >93% O2.
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ACTIVITY#1 CONTINUED
Alimta: Chemotherapeutic agent used alone, or in combination for NSCLC.
• 7 days before administration, patient receives folic acid and vitamin B12 daily until treatment ends
• Chemotherapy administration requires pre-medication for nausea and rash with IV zofran and PO dexamethasone
• Common Side effects: fatigue ,nausea and vomiting, thrombocytopenia, anemia, leukopenia, fever, loss of appetite, constipation and/or diarrhea, stomatitis, alopecia, and peripheral neuropathies
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ACTIVITY#1 CONTINUED
• What are the patient’s fall risk factors (both general and those related to chemotherapy)??
• Assign a recorder and a reporter
• Discuss within your group and record your answers
• The reporter will share your answers with the class
• GOOD LUCK!
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Non-Chemotherapy medications commonly given to cancer patients
that can increase falls :• Analgesics: This medication class can cause deterioration in mobility, concentration,
balance, and postural hypotension (Askari, Eslami, Scheffer, Medlock, Rooij, van der Velde & Abu-Hanna, 2013) • Opiods: Hydromorphone, Oxycodone, Fentanyl, Morphine Sulfate, Hydrocodone
(WebMd.com, 2014)
• Antidepressants: This medication class can increase the risk of falls by causing changing in bone density that can lead to fractures as well as cause blurry vision (Boyle, Naganathan & Cummung, 2010). • Tricyclic Antidepressants: amitriptyline, doxepin, nortriptlyine• SSRIs: citalopram, escitalopram, fluoxetune, sertraline
(WebMd.com, 2014)
• Hypnotics: This medication class is intended to induced relaxation and sleep which can increase the risk of falls.• Sleep Aids: midazolam, zolpidem & triazolam• Anti-Anxiety Medications: alprazolam, diazepam & lorazepam
(WebMd.com, 2014)
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Non-Chemotherapy medications commonly given to cancer patients that can increase falls continued:
• Corticosteroids: This medication class can cause dizziness, vision changes, as well as unsafe rises in blood sugar.
• Glucocorticoid: dexamethasone, prednisone
• Mineralocorticoid: Fludrocortisone
(WebMd.com, 2014)
• Diuretics: This medication class can cause dizziness as well as contribute to bone loss and increased incidence of fractures (Boyle et al., 2010).
• Thiazide diuretics: chlorthalidone, hydrochlorothiazide
• Loop Diuretics: furosemide, bumetanide, torsemide
(WebMd.com, 2014)
• Antihypertensives: This medication class is intended to decrease blood pressure which can cause postural hypotension and dizziness.
• Calcium Channel Blockers: amlodipine, diltiazem, verapamil
• Beta Blockers: atenolol, metoprolol, propanolol, caredilol
• ACE-inhibitors: catopril, enalapril, ramipril, benazepril, lisinopril
• Angiotensin Receptor Blockers: losartan, valsartan
(WebMd.com, 2014)
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Polypharmacy and Falls in patients with current or recent
chemotherapy treatment
• They often have very complex medication regimens that include chemotherapy and medications to treat any existing comorbidities and any conditions caused by cancer treatments
• As seen on previous slide, many medications produce side effects that can increase the risk for patient falls
• They are often seen by many physicians that can each (unknowingly) prescribe medications used to treat the same symptoms
(Prithviraj, Koroukian, Margevicius, Berger, Bagai & Owusu, 2012).
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ACTIVITY #2
• Four Corners
• Look at the four post-it posters in each corner of the room.
• On each poster is different medication class
• Choose one medication class and write down one example, indication, and known side effect(s) that can increase a patient’s fall risk
• When instructed, go to your corner and discuss your analysis with the group
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ACTIVITY#2 CONTINUED
Medication class choices:
1. Analgesics
2. Hypnotics
3. Diuretics
4. Antihypertensives
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Safety Barriers that Contribute to Patient
FallsIntrinsic Factors:• Cognitive and neurological conditions• Polypharmacy• Balance and gait dysfunction• Weakness• Vision problems• Postural hypotension (Stone et al., 2011)
Extrinsic Factors:• Includes environmental factors• Call bell out of reach• Low toilets• Broken furniture• Poor lighting• Wet floors• Ill-fitting footwear• Lack of handrails(Holley, 2002)
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Nursing Interventions to Modify Safety
Barriers:• Report and remove any broken furniture and/or equipment
• Instruct patient to seek assistance prior to getting out of bed
• Instruct patient to sit for a minute or two prior to standing up
• Ensure the bed is locked and low
• Assess the patient's gait and utilize sit to stand and marching in place
• Keep the room lit appropriately
• Use safety devices as needed
• Question medication combinations that you are uncomfortable with
• Assist the patient to the bathroom frequently
• Ensure the environment is quiet and calm
• Assess the patient's pain frequently
• Assess neurological and cognitive functions frequently
• Ensure the call bell is in reach
• Remove clutter from the room
• Provide the patient with the proper sized footwear
• Educate patients on their safety and possible fall risks
• Post a sign that identifies the patient as a fall risk
• Communicate with the patient and the healthcare team about your concerns
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ACTIVITY#3
• GAME TIME!
• I will show you picture of a hospital room that has safety barriers that can be modified with nursing interventions.
• The students who raise their hands and answer correctly will win some yummy candy!
• GOOD LUCK
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ROOM#1 We start with an easy one!
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ROOM#1
Modifiable Safety Barriers:
• Left side rail is up and blocking a straight path to the bathroom: can be modified by putting down the side rail
• There are cords dragging on the floor on the right side of the bed and the telephone cord is underneath the table: can be modified by untangling the cords and clipping it in place on the bed
• Use a fall risk indicator to identify this patient as a fall risk
• Utilize Hourly Rounding
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ROOM#2
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ROOM#2
Modifiable Safety Barriers:
• Foley and chest tube are across the patient and can get tangled across and/or trip the patient: can be modified by straightening the drains out and repositioning the patient
• Bed is up high which can cause a fall if the patient is exiting the bed: modified by lowering the bed and locking it
• Call bell and tray are not within the patient’s reach which can cause the patient to fall while reaching for them: modified by ensuring the tray and call bell are within reach
• Patient is hanging out of bed: modified by repositioning the patient
• Add a fall risk indicator to notify other staff members of this patient’s fall risk
• Utilize safety devices if needed to aid in fall prevention
• Utilize Hourly Rounding
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ROOM#3
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ROOM#3
Modifiable Safety Risks
• Excessive clutter in the room that can be knocked over and cause a patient to fall: modified by straightening up the room
• Baby is in the bassinet that is leaning on a bedside commode. If this tips over the baby can be seriously injured: modified by ensuring the baby’s safety and educating the parent on proper handling!
• Utilize Hourly Rounding
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ROOM#4
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ROOM#4
Modifiable Safety Barriers:
• Bed is not level and seems to be broken which can cause the patient to fall when returning to or getting out of the bed: modified by removing the broken equipment and providing the patient with a new bed
• Water and trash is sitting on the floor that can cause the patient to slip and fall: modified by cleaning it up and ensuring that the environment is always safe and clear of debris
• Instruct the patient to call for assistance
• Utilize Hourly Rounding
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References:• Askari, M., Eslami, S., Scheffer, A., Medlock, S., Rooij, S., Velde, N., & Abu-Hanna, A.
(2013). Different Risk-Increasing Drugs in Recurrent versus Single Fallers: Are Recurrent Fallers a Distinct Population?. Drugs & Aging, 30(10), 845-851. doi:10.1007/s40266-013-0110-z
• Boyle, N., Naganathan, V., & Cumming, R. (2010). Medication and falls: risk and optimization. Clinics In Geriatric Medicine, 26(4), 583-605. doi:10.1016/j.cger.2010.06.007
• Capone, L. J., Albert, N. M., Bena, J. F., & Tang, A. S. (2012). Predictors of a Fall Event in Hospitalized Patients With Cancer. Oncology Nursing Forum, 39(5), E407-E415.
• Holley, S. (2002). A look at the problem of falls among people with cancer. Clinical Journal Of Oncology Nursing, 6(4), 193. doi:10.1188/02.CJON.193-197
• Prithviraj, G. K., Koroukian, S., Margevicius, S., Berger, N. A., Bagai, R., & Owusu, C. (2012). Patient Characteristics Associated with Polypharmacy and Inappropriate Prescribing of Medications among Older Adults with Cancer. Journal of Geriatric Oncology, 3(3), 228–237. doi:10.1016/j.jgo.2012.02.005
• Sonnad, S. S., Mascioli, S., Cunningham, J., & Goldsack, J. (2014). Do patients accurately perceive their fall risk?. Nursing, 44(11), 58-62.
• Stone, C., Lawlor, P., Savva, G., Bennett, K., & Kenny, R. (2012). Prospective study of falls and risk factors for falls in adults with advanced cancer. Journal Of Clinical Oncology, 30(17), 2128-2133.