wendy dribbles and peter falls: managing incontinence and
TRANSCRIPT
Wendy dribbles and Peter falls:
managing incontinence and falls
across the continuum
Mary Ann Hamelin, RN, MScN, GNC(c), CNS
Leanne Verscheure, RN, MEd, GNC(c), CNS
Geriatric Institute June 26, 2014
Wendy Dribbles and Peter Falls
• Peter is down cast about his fall
• Wendy fells badly for her accident
• Young Michael says – “well look on the
bright side – at least it wasn’t Tinkerbell –
you’d need an umbrella!”
Agenda
• Urinary incontinence
– Overview
– Assessment
– Management – inpatient and community
• Falls
– Overview
– Assessment
– Intervention and strategies – inpatient and
community
Urinary incontinence- why? • Factors:
– Anatomical - Cultural
– Physiological - Environmental
– Functional
– Psychological
• Continence requires
– Intact lower urinary tract function
– Cognitive and functional ability
– Motivation to maintain continence
– Environment that enables continence
Urinary incontinence- why? • Age associated factors:
– Decreased bladder elasticity and innervation
• decreased bladder capacity and urine flow rate
• increased post void residual and involuntary bladder
contractions
• reduced voided volume
– Benign prostatic hyperplasia in men (BPH)
• urinary urgency, hesitancy, & frequency
– Menopausal loss of estrogen in women → atrophic vaginitis
Despite age associated changes, urinary
incontinence is NOT a normal part of aging.
Types of Urinary incontinence
• Transient (acute) vs Established (chronic)
• Established – Stress
– Urge
– Mixed
– Overflow
– Functional
Assessment of UI
• Determine type
• Factors associated – Anatomical, Cultural, Physiological, Environmental,
Functional, Psychological
• Medication review
• Testing
• Catheters
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2014/07/03 9:40:54 AM 0000_NICHE Program Development
Drug Class Adverse Effects
Diuretics Polyuria, frequency, urgency
Anticholinergics Mental status changes
Urinary retention, stool impaction
Psychotropics Anticholinergic effects
Immobility, sedation, delirium
Alpha adrenergic agonists Urinary retention
Alpha adrenergic blockers Urethral relaxation
Calcium channel blockers Urinary retention
Medication Review
Testing for UI • Physical exam
– Abdominal exam (suprapubic distention)
– Genital exam (discharge, atrophic vaginitis)
– Rectal exam (constipation, fecal impaction)
– Skin (fungal rashes, perineal irritation)
• Testing
– Urinalysis
– Culture and sensitivity (to treat or no to treat?)
– PVR (>100cc is abnormal)
– Bladder scanner (ultrasound)
– urodynamics
Inpatient Strategies • Treat underlying causes of transient UI
• Established UI management
– Environmental (equipment)
– Dietary
– Toileting programs (purposeful rounding,
scheduling, prompting, bladder training)
– Pelvic floor exercises
– Consults – OT/PT
• Minimize risk for complications
In/Outpatient Strategies
• Pharmacologic options
– Anticholinergics – urge incontinence and overactive
bladder
– Alpha-adrenergic blockers - frequency and urgency
– Pseudoephedrine – stress incontinence
– Topical estrogen – stress and urge incontinence in
women
• Surgical consultation
• Other techniques
Falls Prevention
Definition of a fall
• An event by which a person comes to rest
inadvertently on the ground or lower
level
– Witnessed or not
– Injury or not
– Intrinsic or extrinsic factors or both
Complications from falls is the leading
cause of death from injury in both men and
women >65 years old
Defying Gravity • Evidence that fall prevention programs are effective
when they are multifactorial in design and target individual risk factors
• Mixed results for hospital based fall prevention programs
• Need for further development and testing of approaches • Physical restraints do not reduce patient falls and are
associated with soft tissue damage, injuries, fractures, delirium, and death
• Fall prevention is challenging in older hospitalized adults
Focus on risk reduction and don’t get discouraged!
Intrinsic Factors • Intrinsic – those factors or conditions that occur
within the person
– Underlying medical illness or presence of chronic disease
– Physical status and age related changes
• Use of high risk medications – Psychotropic agents – Benzodiazepines – Sedatives and hypnotics – Antidepressants – Neuroleptics (antipsychotics) – Anti-arrhythmics – Digoxin – Diuretics
Medications contributing to falls Drug How it can increase falls Drugs that treat mental illness Blurred vision, confusion, dizziness, inability to
sleep, low blood pressure from standing
Drugs that treat anxiety Difficulty moving, confusion, low blood
pressure from standing, dizziness, fainting
Drugs that treat depression Blurred vision, dizziness, drowsiness
Powerful pain medications Low blood pressure, dizziness, drowsiness, lack
of coordination Sleep medication Dizziness, blurred vision, drowsiness
Seizure medication Confusion, dizziness, drowsiness, blurred
vision
Blood pressure medication Syncope (described as fainting), dizziness,
drowsiness, muscle weakness, low blood
pressure
Intrinsic factors
• Medical workup – Dizziness, syncope, poor balance, unsteadiness
– Mental confusion, delirium, dementia
– Generalized weakness, fatigue
– Arrhythmias
– Seizure
– Gait ataxia
– Dyspnea
– Lower extremity weakness, numbness, joint pain
– Unilateral weakness from TIA or CVA
Extrinsic Factors • Environmental considerations
– Floor surfaces – slippery, wet, glare, uneven,
cracked – Unsafe equipment - unsteady IV poles, unlocked
beds or stretchers, faulty or collapsing items – Cluttered pathways – Inadequate lighting or glare – Unsafe bathrooms – lack of support rails or bars, lack
of nonskid floor surfaces and mats – Unsafe footwear - loose fitting, no tread, barefoot,
higher heels – Physical restraints
Assessment for Falls
• History
• Previous falls
• Injury as a result of fall
• History of long lie
• Intrinsic vs extrinsic factors
• Morse fall risk
Defying Gravity Fall Risk Assessment and Prevention Strategies on 10 North
Implications Fall incidence can be limited through careful
assessment and evidence-based prevention
strategies. Fall prevention aligns with the
organizational aim for excellence in patient care
and safety, ultimately seeking to improve patient
outcomes and promote a positive overall
experience in hospital. Fall incidence is a nursing
sensitive indicator and one which will be closely
monitored on our journey to Magnet accreditation.
NEXT STEPS: Moving forward, the ACE Unit’s goal is
zero falls. The unit also welcomes information
sharing on its fall prevention approach with GIM and
other in-patient units.
Acknowledgements
We would like to thank Barb Allen, NUA, ACE Unit and all ACE
Unit staff for their support and continued commitment to
patient safety.
Thank you also to our ward clerks, volunteers, and
interprofessional team.
References
Adams, J. & Kaplow, R. (2013). A sitter-reduction program in an acute health care system. Nursing
Economics, 31(2):83-89. Retrieved from
http://www.medscape.com/viewarticle/806798
Canadian Institute for Health Information (CIHI). (2010). Analysis in brief: falls among seniors: atlantic
canada. Retrieved from
https://secure.cihi.ca/estore/productbrowse.htm?locale=en#F
Morse, J. M. (2009). Preventing patient falls: establishing a fall intervention program (2nd Ed.). New York,
NY: Springer Publishing Company, LLC.
Registered Nurses’ Associated of Ontario. (2011). Nursing best practice guideline: prevention of falls and
fall injury in the older adult. Retrieved from
http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult
World Health Organization. (2008). Global report on falls prevention in older age. Retrieved from
http://www.who.int/ageing/publications/Falls_prevention7March.pdf
Introduction
Falls are the number one cause (54.4%) of admissions to hospital in Canada for injuries (RNAO, 2011). Specifically, in seniors, falls were the cause of 84.8% of all injury admissions (RNAO, 2011). Falls, however, do not just happen in the community. 30-50% of individuals who are moved to unfamiliar environments like hospitals, nursing homes or long term care facilities experience a fall (WHO, 2008). Furthermore, 7% of seniors hospitalized due to a fall, who incurred a hip fracture, died (RNAO, 2011). Fall prevention for inpatients at Mount Sinai Hospital is imperative not only to promote safety and prevent injury, but also to decrease the amount of time an individual needs to be in hospital. The 10 North Acute Care for Elders (ACE) Unit cares for patients over 65 years of age, a population shown to be at a high risk of falls.
Purpose
The 10 North staff sought to increase patient safety on the unit through fall prevention.
Goal The ACE staff sought to reduce the number of falls that occur
while patients are on the unit.
Methods
ACE nursing staff applied evidence-based assessment protocols, collaborated with interprofessional resources, and implemented
thoughtful and evidence-based fall prevention interventions.
Risk Factors for Falls
The Move from 17S to 10N While the ACE team has worked hard to assess risk and prevent falls, the unit also moved from 17 South to 10 North and this move
has positively influenced fall prevention. The open concept layout of the unit is such that patients, in general, are at closer proximity to the nursing station. Nurses have better sight lines to patient rooms and shorter distances to travel the farthest rooms on the unit. The new unit has 24-hour floor lights to guide patients to bathroom at
night and increased number of railings in bathrooms/ shower room.
Nursing Interventions
Sitters as the Last Resort
The use of sitters or security is not a routine part of the Ace Unit’s fall prevention strategies. In fact, the literature has shown that use of sitters neither reduce the number of fall incidents nor the severity of an injury from a fall (Adams & Kaplow, 2013). On the ACE unit there has been a reduction in the incidents of falls concurrently with a decrease in the
overall use of sitters and security as constant observers. While a PSW or Security are utilized at times, the use of such personnel is considered only a part of a broader fall
prevention strategy when there is a need to gain additional information to further inform the fall prevention plan. It is recognized that the use of a sitter or security cannot be the
only strategy to prevent falls, but their use on a limited basis, as a part of a broader fall prevention strategy, may
assist in fine tuning that plan.
Most importantly = constant care providers do not guarantee fall prevention
Authored by Alexia Cumal, RN, BScN, Carli Grieve, RN, BScN, and Mary Ann Hamelin, RN, MScN, GNC(c), CNS 10 North Unit Council
With Contributions From the ACE/10N Team
Having patient sit in front of nursing station
Advocate for discontinuing lines and drains
Witnessed and unwitnessed Fall Care Plans
Review meds that may contribute to falls
Pocket talkers for the hearing impaired
Move patient closer to nursing station
Prompt voiding every 2hrs
Q 1 hour monitoring
Fall alarm beds
Mobility
Involve interprofessional
team & volunteers Non-slip socks Fall alarm mats Call bell access
Use of mobility aids
It Takes a Village
The introduction of fall
beds on the unit require a
nurse to respond quickly
when the patient gets up
and the alarm sounds.
Current unit culture on 10N
is such that each fall bed
alarm is everyone’s
responsibility.
The ‘High Risk for Falls’
signs indicate that a patient
requires more frequent
checks. This too is
approached and maintained
through teamwork.
Results
Note: Data is based on Safety Reports Cognitive Impairment
Previous stroke
Previous falls
Confusion/Delirium
Acute Illness
Auditory/Visual Deficits
FALL :
An event that results in a
person coming to rest
inadvertently on the
ground or floor or other
lower level (RNAO, 2011)
Morse Fall
Risk Scale
(RNAO, 2011)
(RNAO, 2011)
(RNAO, 2011) and (Morse, 2009)
Fall Care Plan
Developed by the ACE unit
staff, the fall prevention care
plan is added to the Kardex as
a communication tool on the
measures taken to prevent
falls for individual patients.
Physical Barriers
Proximity to Bathroom
Insufficient Lighting
Need to Toilet
Availability of Call Bell
Availability of Assistive Aids
Morse Falls Risk Assessment
Preventative measures
Home Strategies
• Home safety assessment
– De-clutter
– Furniture placement
– Lighting
– Railings and renovations
– Equipment
Assistive devices/Home
adaptations
Home Adaptations
Outpatient management
• Referrals to programs
– Falls Prevention Clinic
– Day programs
– Exercise programs
• Medications
– Calcium
– Vitamin D
Day Programs
Thank you
• Questions?