Wendy dribbles and Peter falls: managing incontinence and falls across the continuum

Transcription

1 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

2 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!

3 Agenda Urinary incontinence Overview Assessment Management inpatient and community Falls Overview Assessment Intervention and strategies inpatient and community

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5 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

6 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.

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9 Types of Urinary incontinence Transient (acute) vs Established (chronic) Established Stress Urge Mixed Overflow Functional

10 Assessment of UI Determine type Factors associated Anatomical, Cultural, Physiological, Environmental, Functional, Psychological Medication review Testing Catheters

11 Medication Review Drug Class Adverse Effects Diuretics Anticholinergics Psychotropics Alpha adrenergic agonists Alpha adrenergic blockers Polyuria, frequency, urgency Mental status changes Urinary retention, stool impaction Anticholinergic effects Immobility, sedation, delirium Urinary retention Urethral relaxation Calcium channel blockers Urinary retention 11

12 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

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14 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

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16 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

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18 Falls

19 Falls Prevention

20 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

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22 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!

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24 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

25 Medications contributing to falls Drug How it can increase falls Drugs that treat mental illness Drugs that treat anxiety Drugs that treat depression Blurred vision, confusion, dizziness, inability to sleep, low blood pressure from standing Difficulty moving, confusion, low blood pressure from standing, dizziness, fainting Blurred vision, dizziness, drowsiness Powerful pain medications Sleep medication Seizure medication Blood pressure medication Low blood pressure, dizziness, drowsiness, lack of coordination Dizziness, blurred vision, drowsiness Confusion, dizziness, drowsiness, blurred vision Syncope (described as fainting), dizziness, drowsiness, muscle weakness, low blood pressure

26 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

27 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

28 Assessment for Falls History Previous falls Injury as a result of fall History of long lie Intrinsic vs extrinsic factors Morse fall risk

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31 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 % 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. FALL : An event that results in a person coming to rest inadvertently on the ground or floor or other lower level Methods (RNAO, 2011) 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 Defying Gravity Fall Risk Assessment and Prevention Strategies on 10 North 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 Involve interprofessional team & volunteers 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 (RNAO, 2011) Nursing Interventions Non-slip socks Fall alarm mats Call bell access (RNAO, 2011) and (Morse, 2009) Morse Fall Risk Scale Use of mobility aids 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. 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. Implications Results 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. Cognitive Impairment Physical Barriers Previous stroke Proximity to Bathroom The Move from 17S to 10N While Previous the ACE falls team has worked hard to assess Insufficient risk and Lighting 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 Confusion/Delirium Need to Toilet 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 Acute and increased Illness number of railings in bathrooms/ Availability of shower Call Bell room. Auditory/Visual Deficits Availability of Assistive Aids (RNAO, 2011) 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 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): Retrieved from Canadian Institute for Health Information (CIHI). (2010). Analysis in brief: falls among seniors: atlantic canada. Retrieved from Morse, J. M. (2009). Preventing patient falls: establishing a fall intervention program (2 nd 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 Note: Data is based on Safety Reports World Health Organization. (2008). Global report on falls prevention in older age. Retrieved from

32 Morse Falls Risk Assessment

33 Preventative measures

34 Home Strategies Home safety assessment De-clutter Furniture placement Lighting Railings and renovations Equipment

35 Assistive devices/home adaptations

36 Home Adaptations

37 Outpatient management Referrals to programs Falls Prevention Clinic Day programs Exercise programs Medications Calcium Vitamin D

38 Day Programs

39 Questions? Thank you