Teaching and Learning to Care: Training for Caregivers in Long Term Care. TLC for LTC

Transcription

1 Teaching and Learning to Care: Training for Caregivers in Long Term Care When People Fall: Prevention for Those at Risk by Marie Boltz, MSN, CRNP, NHA Gerontological Nursing Consultant for Supported by a grant from the Health Resources and Services Administration Bureau of Health Professions United States Department of Health and Human Service

2 Delaware Valley Geriatric Center 3615 Chestnut Street Philadelphia, PA Permission is granted to copy participant materials under Tab 3.

3 Acknowledgements Appearing in Video: Name Appearing as Joani M. Butera...Companion assisting resident Lucy E. Colman...Resident in transferring PT scene Barbara Hicks...Resident in exercise group Rita M. Keddie...Activities personnel Edith Martin...Resident in exercise group Christine Moyes...Resident in dining scene Barbara L. Robinson...Activities personnel Renee Rotman...Resident in exercise group Holly Shank...Caregiver Charles Stewart...Resident in drug scene Mildred Stromberg...Resident in exercise group Kenneth R. Van Demark...Physical Therapist Special thanks to: Lorrie Goss, RNC, Director of Nurses, Pennswood Village, for coordination of the video shoot. Pennswood Village for permitting video production.

4 Table of Contents Tab 1. Presentation Materials for the Instructor! Forms for administration at start of module! Instructional materials! Forms for administration at end of module Tab 2. Handout Materials for the Participants to Use and Keep! Introduction to Module and Objectives! Handouts! Optional Additional materials

5 References Cali, C.M., & Kiel, D.P.(1995). An epidemiological study of fall-related fractures among institutionalized older people. Journal of the American Geriatrics Society, 43, Capezuti, E. (2000). Preventing falls and injuries while reducing siderail use. Annals of Long-Term Care, 6, Capezuti, E.A., Talerico, K.A., Wagner, L., et al. (1999). The effect of a low-height bed intervention on night falls among frail nursing home residents. Gerontologist, Department of Health and Human Services, Food and Drug Administration. (1995). FDA safety alert: Entrapment hazards with hospital bed siderails. August 23. Donius, M. (1995). Fall prevention and management. In J. Rader (Ed.), Individualized dementia care.(45-167). New York: Springer. Hoskin, A.F. (1998). Fatal falls: Trends and characteristics. Statistical Bulletin, Apr.-June, Maki, B.E. (1997). Gait changes in older adults: Predictors of falls or indicators of fear? Journal of the American Geriatrics Society, 45, Rawsky, E. (1998). Review of the literature on falls among the elderly. Image, 30(1), Shaw, C.G. & Taylor, S.J. (1992). A survey of wheelchair seating problems of the institutionalized elderly. Assistive Technology, 3(1), Tideisakar, R. (1997). Falls in old age: Its prevention and management. New York: Springer.

6 Appendix A. Individualized Interventions to Prevent Falls and Fall-Related Injuries Fear of falling Explore past fall experiences with the person, associated symptoms (dizziness, syncope, etc.) and perceived areas of vulnerability. Explore degree of acceptable risk. Diligently identify risks and collaborate with the older person to develop a focused plan to address risk(s). Collaborate with the older adult to develop a plan to maximize mobility and independence and acknowledge and track progress. Gait problems and loss of mobility Consult physical therapy and occupational therapy to develop a restorative plan that includes range of motion, strengthening exercise, orthotics, and a walking program. Follow-through on restorative plan: - Encourage self-care during dressing, grooming and recreational activities. - Assist with ambulation to meals and activities. - Assist with transfers to alternate seating. Provide equipment and/or environment that promotes mobility: - If wheelchair used, assess seating for comfort, height, ease of transfer, and posture. Assess arm and foot rests for support. Provide adaptation as needed. - Adjust bed and toilet height to the person s leg length. - Install grab-bars in the bathroom. - Facilitate safe transfer and ambulation from bed by providing a half or quarter rail, trapeze, or transfer enabler on strong side. Those at risk should wear treaded slippers and easily removable nightwear to bed. Use non-skid rugs or mats and create a clear pathway to the bathroom. Use nightlight at bedtime. Assess the person s ability to turn on light safely. - Provide pillows and bolsters to promote comfort and positioning. - Discuss use of hip pads with the older person. - If a person has difficulty identifying bed borders, use concave mattress, rolled blankets, or swimming noodles under sheets to mark edges of bed. Provide call-bell or other mechanism to call for help. Pain and Insomnia Perform evaluation and pharmacological review, and maintain scheduled analgesia. Assess positioning and utilize position-relieving devices as needed. If insomnia is present, seek medical evaluation and pharmacological review. Use white noise to promote relaxation.

7 Impaired Cognition Provide a structured, consistent schedule that includes personal care, meals, and lifestyle programs and recreation. Encourage follow-through on restorative mobility plan by providing purposeful activity that promotes range of motion, strengthening, transfers, and ambulation, based on the person s potential. Develop a plan for 24- hour oversight for those with similar functional level and safety needs. Provide equipment and address environmental needs: - Remove barriers, including full-length siderails. - If a person is mobile in bed but not ambulatory, use a very low bed (7-13 inches off the floor). Place mattress on the floor if unable to acquire low bed. - If siderails are used, assess and modify to avoid the following safety hazards: wide offset between mattress and rail, wide space between bars on the rails, wide offset between the mattress and the head of the bed (note that half and quarter rails can also present these safety hazards). Utilize a system to identify those at risk for falls-injuries and remind staff of need for frequent oversight. Assess effectiveness of motion sensor lights and position change alarms. Monitor response to psychoactive medications and clarify desired effect of medication to assess risk (including fall-injury risk) versus benefit, on an ongoing basis. Urinary Incontinence and Nocturia Seek incontinence evaluation. Implement planned toileting program and document response. Perform individualized elimination rounds at night. Assist the person to the bathroom at bedtime and at planned intervals, based on needs. Incontinence care on a pre-planned basis. Provide illustration of toilet on bathroom door. Hearing and Vision Loss Provide glasses, clean and in good repair, as needed. Make sure glasses are easily accessible from bed at night. Create a clear pathway to the bathroom to compensate for certain visual problems (e.g., central visual field cut). Outline path to the bathroom with fluorescent tape in contrasting color on the floor or wall. Assess that hearing aids with working batteries are worn. Change batteries every two weeks and as needed.

8 Dizziness and Postural Hypotension Acquire medical evaluation, including assessment of medications. Teach how to rise slowly from lying and sitting positions. Teach correct way of sitting on toilet: do not sit until legs are felt against the place hands on siderails, then sit down. Teach prevention of Valsalva maneuver related to excessive straining when defecating or urinating. toilet, Leaning or Sliding in Chair Approaches to seating: - Consider wheelchair for transport only. - Transfer to a comfortable reclining chair. - Evaluate possibility of an extended backrest. - Adjust the wheelchair back and seat to create a slight tilt back and wedge. - Experiment with specialized cushions, solid seat inserts, and formed foam pads. Movement and activities: - Exercise, including standing exercise, range of motion exercise. - Provide diversion or meaningful activities in front of the person. - Assess daily routine and need for rest time. Oversight and supportive care: - Assist the person to a place in view of assigned, consistent staff, who are engaged with that person and possibly other people (as opposed to sitting at the nurse s station). - Toileting or continence care. - Pain assessment and treatment.

9 Appendix B. Education for Various Disciplines on Falls Direct care staff need to be educated on their distinct roles in preventing falls, including: - the use of restorative care - safe use of equipment - assistive devices, beds, alarms - warning symptoms to report - use of the care plan, the process to review and revise the plan of care - immediate response to a fall Nurses need to be educated on: - use of the fall risk assessment - care plan interventions to prevent falls/injuries - immediate response to falls - the post-fall assessment and care plan revision - their involvement in quality assurance/improvement activity - older adult education - managing orthostasis, medication side effects Rehabilitation staff should be educated regarding: - clinical assessment and interventions to prevent falls - process of post-fall assessment - environmental modifications to prevent falls/injuries - older adult education - exercise benefits and implementation, use of equipment, pacing activity, etc. Medical staff education should include: - pharmacologic approaches to minimize fall risk - assessment and treatment of orthostatic hypotension - assessment and treatment of delirium - fall risk identification Environmental support staff requires education on: - equipment maintenance, including quality control activity - schedules and routines that promote safety and do not interfere with the person s activity - security system and their respective roles in implementing and/or maintaining this system

10 Activity staff should receive education on: - interventions to improve strength, balance, function, and mood - methods to provide support and supervision during activities Administrative staff requires education on: - quality improvement techniques surrounding fall/injury prevention and management

11 Tab 1. Materials for the Instructor Introduction Why this Module? According to the Centers for Disease Control and Prevention, one of every three adults, age 65 and older, in the United States falls each year. Falls are the leading cause of injury-related deaths among people 65 years and older. The U.S. Public Health Service estimates that two-thirds of the deaths associated with a fall are preventable. This program is designed to assist facilities in their efforts to reduce the number of falls and injuries due to falls. What is the Content? Key content for you to teach in this module includes: 1. The risk factors and common causes that are associated with falls including agerelated risk factors, cognitive loss, health problems and environmental conditions. 2. What an assessment after a fall should include. 3. Strategies to compensate for physical impairment, cognitive loss and incontinence. 4. Components of a prevention and management program, including education. Learning Objectives: At the end of this module, direct care staff will be able to: 1. Identify risk factors and common causes for falls. 2. Discuss proper assessment after a fall. 3. Discuss intervention and prevention strategies. 4. Describe a falls education program.

12 What Key Concepts Should be Covered? Many nursing home residents fall; about half of them fall annually. A fall is often a warning sign of illness or other problem. Risk factors may be due to physical changes, increased sensitivity to medicines and decreased ability to deal with stress and environmental conditions. The environment should be designed and maintained to prevent falls. The risk of nighttime falls is increased by siderails, sleep disorders, pain, restlessness and incontinence. A preventive program will help by maintaining mobility and function. How to Use this Module: The component elements are described in the order in which they appear in the body of the module. Attendance Form can be duplicated for your use. Pretest: A brief test of True/False and multiple choice items. You should have sufficient copies for presenter and participants. An instructor version with correct answers is supplied and test-scoring instructions appear with the test. Have participants put an identifier (such as their mother s maiden name) which only they will recognize. You can use this identifier to match pre- and post- tests. Your presentation materials include: A paper copy of the overheads with notes about the content for your use when teaching from the overheads. Overhead transparencies for projection can be made from slides A videotape is available via the DVGEC website. The videotape segment for this module should be shown after Overhead 15, Prevention and Management: Fitness and Activity Programs. The video illustrates the components of a facility-based program for the prevention of falls. Note: If there is more content than you can teach in the time available, consult with your staff development educator to select ahead of time what will be covered. All objectives and test item materials should be covered.

13 Participant Post-test which is identical to the Pre-test but with the items in different order with a Post-test heading. Have participants use the same identifier as on the participant Pre-test so that you can match pre- and post-test scores. Program Evaluation form for completion by participants. Program Evaluation form for completion by instructor. Before Your Presentation: Because face-to-face contact time with staff is so limited, prior preparation is essential! Review all materials, paying special attention to the objectives, key concepts and test items. PRACTICE presenting the content using the overhead transparencies and the Instructor Notes. We suggest that you practice the presentation two ways: a) straight through to make sure your presentation is consistent with the available time, and b) pausing to practice when you feel dissatisfied with your delivery of content. Make sure you have sufficient copies of tests and handouts. Suggestion: Put transparencies in a small binder for presentation -- keeps them in order and allows instructor to flip through them. Like wise put the instructor notes in a binder to facilitate presentation. At the Time of Your Presentation: After introductions, distribute the Participant Pre-test. Have participants put an identification code (like their mother s maiden name) on the test so that you can match pre-and post test scores; then collect completed tests. Put the facility name and the date on the Attendance Sheet and have participants sign it. Make presentation using transparencies and the Instructor version with notes. Follow instructions with the last two slides for showing and discussion of video. Have participants complete post-test using the same identification code. Have participants complete the Participant Evaluation form. After Your Presentation: Please complete the Instructor Evaluation form and return to the Staff Development Educator. Score pre- and post-tests using form provided. Return scored tests, completed evaluation forms and instructional materials to your staff development educator.

14 References Cali, C.M., & Kiel, D.P.(1995). An epidemiological study of fall-related fractures among institutionalized older people. Journal of the American Geriatrics Society, 43, Capezuti, E. (2000). Preventing falls and injuries while reducing siderail use. Annals of Long-Term Care, 6, Capezuti, E.A., Talerico, K.A., Wagner, L., et al. (1999). The effect of a low-height bed intervention on night falls among frail nursing home residents. Gerontologist, Department of Health and Human Services, Food and Drug Administration. (1995). FDA safety alert: Entrapment hazards with hospital bed siderails. August 23. Donius, M. (1995). Fall prevention and management. In J. Rader (Ed.), Individualized dementia care.(45-167). New York: Springer. Hoskin, A.F. (1998). Fatal falls: Trends and characteristics. Statistical Bulletin, Apr.-June, Maki, B.E. (1997). Gait changes in older adults: Predictors of falls or indicators of fear? Journal of the American Geriatrics Society, 45, Rawsky, E. (1998). Review of the literature on falls among the elderly. Image, 30(1), Shaw, C.G. & Taylor, S.J. (1992). A survey of wheelchair seating problems of the institutionalized elderly. Assistive Technology, 3(1), Tideisakar, R. (1997). Falls in old age: Its prevention and management. New York: Springer.

15 Attendance Form Facility Name: Date: Name Position Degree

16 Your ID Today s Date / / Example: Which of these is NOT a season: a. Winter b. Autumn c. Summer d. Easter e. Spring Participant Pre-Test 1. Which of the following are considered fall risk factors? a. The use of a diuretic. b. Previous history of falls. c. Fear of falling. d. All of the above. 2. One of the most effective actions nurses can take to prevent falls is to: a. Consult PT to assess a person who is sliding out of a wheelchair. b. Use siderails as an effective barrier for the confused older person who may get out of bed unsupervised. c. Provide low dose Risperdol for the individual who wanders at night. 3. For the person with dementia who walks to the point of exhaustion, the following should be implemented: a. Assess and respond to need for hydration. b. Develop a structured program of activities, personal care, and exercise. c. Intermittent use of a physical restraint to promote rest. d. a and b.

17 4. Which of the following health problems increase the risk for falls? a. Upper respiratory infection. b. Dehydration (that is, decreased fluid volume). c. Hypoglycemia (that is, low blood sugar). e. a and b. f. b and c. 5. General strategies to prevent falls include: a. Assessment. b. Balance and fitness programs. c. Family and staff education. d. All of the above. e. a and b. 6. The following are effective interventions to reduce the risk for falls associated with urinary incontinence: a. A consistent toileting program. b. Decrease fluid intake. c. Medical evaluation to treat reversible causes of incontinence. d. a and c. e. all of the above. Circle T if the statement is True, F if the statement is false. Example: This is a test. T F 7. In order to promote safe transfers from and to bed, bed height should be 25% of lower leg length. T F 8. Falling, along with changes in function and mental status, can be a symptom of disease in the older adult. T F

18 Your ID Today s Date / / Example: Which of these is NOT a season: a. Winter b. Autumn c. Summer f. Easter g. Spring Participant Pre-Test: Instructor s Key 1. Which of the following are considered fall risk factors? a. The use of a diuretic. b. Previous history of falls. c. Fear of falling. d. All of the above. 2. One of the most effective actions nurses can take to prevent falls is to: a. Consult PT to assess a person who is sliding out of a wheelchair. b. Use siderails as an effective barrier for the confused older person who may get out of bed unsupervised. c. Provide low dose Risperdol for the individual who wanders at night. 3. For the person with dementia who walks to the point of exhaustion, the following should be implemented: a. Assess and respond to need for hydration. b. Develop a structured program of activities, personal care, and exercise. c. Intermittent use of a physical restraint to promote rest. d. a and b.

19 4. Which of the following health problems increase the risk for falls? a. Upper respiratory infection. b. Dehydration (that is, decreased fluid volume). c. Hypoglycemia (that is, low blood sugar). d. a and b. e. b and c. 5. General strategies to prevent falls include: a. Assessment. b. Balance and fitness programs. c. Family and staff education. d. All of the above. e. a and b. 6. The following are effective interventions to reduce the risk for falls associated with urinary incontinence: a. A consistent toileting program. b. Decrease fluid intake. c. Medical evaluation to treat reversible causes of incontinence. d. a and c. e. all of the above. Circle T if the statement is True, F if the statement is false. Example: This is a test. T F 7. In order to promote safe transfers from and to bed, bed height should be 25% of lower leg length. T F 8. Falling, along with changes in function and mental status, can be a symptom of disease in the older adult. T F

20 Your ID Today s Date / / Participant Post-Test Circle the letter of the best answer. Example: Which of these is NOT a season: a. Winter b. Autumn c. Summer d. Easter e. Spring 1. For the person with dementia who walks to the point of exhaustion, the following should be implemented: a. Assess and respond to need for hydration. b. Develop a structured program of activities, personal care, and exercise. c. Intermittent use of a physical restraint to promote rest. d. a and b. 2. Which of the following are considered fall risk factors? a. The use of a diuretic. b. Previous history of falls. c. Fear of falling. d. All of the above. e. All but c. 3. Which of the following health problems increase the risk for falls? a. Upper respiratory infection. b. Dehydration (that is, decreased fluid volume). c. Hypoglycemia (that it, low blood sugar). d. a and b. e. b and c.

21 4. One of the most effective actions nurses can take to prevent falls is to: a. Consult PT to assess a person who is sliding out of a wheelchair. b. Use siderails as an effective barrier for the confused older adult who may get out of bed unsupervised. c. Provide low dose Risperdol for the person who wanders at night. 5. General strategies to prevent falls include: a. Assessment. b. Balance and fitness programs. c. Family and staff education. d. All of the above. e. a and b. 6. The following are effective interventions to reduce the risk for falls associated with urinary incontinence: a. A consistent toileting program. b. Decrease fluid intake. c. Medical evaluation to treat reversible causes of incontinence. d. a and c. e. all of the above. Circle T if the statement is True, F if the statement is false. Example: This is a test. T F 7. Falling, along with changes in function and mental status, can be a symptom of disease in the older adult. T F 8. In order to promote safe transfers from and to bed, bed height should be 25% of lower leg length. T F

22 Your ID Today s Date / / Participant Post-Test: Instructor s Key Circle the letter of the best answer. Example: Which of these is NOT a season: a. Winter b. Autumn c. Summer d. Easter e. Spring 1. For the person with dementia who walks to the point of exhaustion, the following should be implemented: a. Assess and respond to need for hydration. b. Develop a structured program of activities, personal care, and exercise. c. Intermittent use of a physical restraint to promote rest. d. a and b. 2. Which of the following are considered fall risk factors? a. The use of a diuretic. b. Previous history of falls. c. Fear of falling. d. All of the above. e. All but c. 3. Which of the following health problems increase the risk for falls? a. Upper respiratory infection. b. Dehydration (that is, decreased fluid volume). c. Hypoglycemia (that it, low blood sugar). d. a and b. e. b and c.

23 4. One of the most effective actions nurses can take to prevent falls is to: a. Consult PT to assess a person who is sliding out of a wheelchair. b. Use siderails as an effective barrier for the confused older adult who may get out of bed unsupervised. c. Provide low dose Risperdol for the person who wanders at night. 5. General strategies to prevent falls include: a. Assessment. b. Balance and fitness programs. c. Family and staff education. d. All of the above. e. a and b. 6. The following are effective interventions to reduce the risk for falls associated with urinary incontinence: a. A consistent toileting program. b. Decrease fluid intake. c. Medical evaluation to treat reversible causes of incontinence. d. a and c. e. all of the above. Circle T if the statement is True, F if the statement is false. Example: This is a test. T F 7. Falling, along with changes in function and mental status, can be a symptom of disease in the older adult. T F 8. In order to promote safe transfers from and to bed, bed height should be 25% of lower leg length. T F

24 Participant Evaluation Form Date: / / Facility: Please circle the best response. Example: Strongly Disagree Disagree Agree Strongly Agree 1. I can describe risk factors and causes of falls in the frail elderly. Strongly Disagree Disagree Agree Strongly Agree 2. I can describe how to assess a person after a fall. Strongly Disagree Disagree Agree Strongly Agree 3. I can tell you about strategies to compensate for sensory or cognitive losses. Strongly Disagree Disagree Agree Strongly Agree 4. This program will help me in my care of older adults. Strongly Disagree Disagree Agree Strongly Agree 5. This program will help me work better with other staff. Strongly Disagree Disagree Agree Strongly Agree 6. Overall I rate this program: Poor Fair Good Excellent 7. Overall I rate this instructor: Poor Fair Good Excellent 8. This program would be better if:

25 Instructor Evaluation Form Date: / / Facility: 1. Learning objectives for this module were appropriate. Strongly Disagree Disagree Agree Strongly Agree 2. This module was well-designed to meet its objectives. Strongly Disagree Disagree Agree Strongly Agree 3. Instructor materials for this module were easy to use. Strongly Disagree Disagree Agree Strongly Agree 4. The content of this module was at the right level for participants. Strongly Disagree Disagree Agree Strongly Agree 5. The videotape for this module helps to meet the objectives. Strongly Disagree Disagree Agree Strongly Agree 6. As an instructor, I rate this module overall as: Poor Fair Good Excellent 7. This module would be better if: Instructor information: My most advanced degree is: in. Masters in, Bachelors in, Associate Degree I have been teaching in long-term care for years, months. My current title is:

26 Tab 2. Materials for Participants Handout: Why this module? People who are older than 65 fall often. Each year, half of all people in nursing homes fall. Those falls are a major cause of injuries and deaths. It is important to understand why people fall and how to avoid falls whenever possible. What should you learn in this module? At the end of this module you should know how to: Describe what usually causes falls in vulnerable elderly persons. Discuss what to do when a fall has occured. Describe strategies to compensate for physical limitations, reduced mental ability and incontinence. Describe things a home or facility can do to prevent falls: - There is an individual plan to provide each individual with a safe and enabling environment, - There are fitness and activity programs, - Residents, staff and residents families all know about falls and prevention - The nursing home is always working on reducing falls using quality improvement projects. Falls: What do you need to know? Many elderly people fall: each year, about half of nursing home residents fall. Falls often warn us that a resident has an illness or other problem. Residents are more likely to fall - when their bodies and health change, - when they become more sensitive to medicines, - and when they have more problems dealing with stress. Nursing homes can fix their environment to prevent falls. Residents fall more at nighttime when there are siderails on beds, when they have trouble sleeping, pain, restlessness and incontinence. A preventive program will help maintain mobility and function.

27 Handout: Physical Changes that Increase the Risk of Falls 1. A shift in the center of gravity 2. Decreased muscle strength 3. Decreased range of motion in the hips and the knees 4. Decreased ability to right oneself, i.e., regain sense of balance 5. Slower reaction time 6. Decreased position sense 7. Gait changes (older adults tend not to pick up their feet as high, increasing their tendency to trip; older women often walk with a narrow-based, waddling gait; older men tend to use wide-based, short-stepped gaits) 8. Sensitive receptors that make the person more likely to faint when straining at stool or coughing 9. Sensory changes, especially hearing and vision loss

28 Handout: Assessment Immediately After a Fall After a person falls, the nurse and medical practitioner must assess the person for injury, and secure treatment as necessary. The next crucial step is the interdisciplinary team s assessment to determine the probable cause of the fall(s) and develop a plan to prevent future falls/injuries. Immediately after the fall, staff should: Assess for injuries. Obtain and record sitting and standing blood pressure and other vital signs. Note if the heart rate is irregular, a sign of arrhythmia. Assess for change in range of motion. Notify the physician and older adult s responsible party. Continue to monitor the person according to the facility s policy. Complete the incident report. Do not document fault. Conduct a post-fall assessment, assessing extrinsic (environmental, lack of assistive devices, etc.) vs. intrinsic factors (orthostasis, sedation, signs of illness etc.). Note any relationship of the fall to activity (e.g., eating, getting out of bed, defecating). Notify all team members (including nursing administration) of fall. Discuss technology options with supervisor (Low bed, alarms, etc). Notify family member-mention events surrounding fall, presence or absence of injuries, and current state of older adult.

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30 A Guide to Bed Safety Bed Rails In Hospitals, Nursing Homes and Home Health Care: The Facts # Bed Rail Entrapment Statistics Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and 1999, 371 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 228 people died, 87 had a nonfatal injury, and 56 were not injured because staff intervened. Most patients were frail, elderly or confused. # Patient Safety Patients who have problem with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient s health care team will help to determine how best to keep the patient safe. Historically, physical restraints (such as vests, ankle or wrist restraints) were used to try to keep patients safe in health care facilities. In recent years, the health care community has recognized that physically restraining patients can be dangerous. Although not indicated for this use, bed rails are sometimes used as restraints. Regulatory agencies, health care organizations, product manufacturers and advocacy groups encourage hospitals, nursing homes and home care providers provide safe care without restraints. * In this brochure, the term patient refers to a resident of a nursing home, any individual receiving services in a home care setting, or patients in hospitals. # The Benefits and Risks of Bed Rails Potential benefits of bed rails include: * Aiding in turning and repositioning within the bed. * Providing a hand-hold for getting into or out of bed. * Providing a feeling of comfort and security. * Reducing the risk of patients falling out of bed when being transported. * Providing easy access to bed controls and personal care items. Potential risks of bed rails m ay include: * Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. * More serious injuries from falls when patients climb over rails. * Skin bruising, cuts, and scrapes. * Inducing agitated behavior when bed rails are used as a restraint. * Feeling isolated or unnecessarily restricted. * Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.

31 Participant Forms: Instructions We ask for your cooperation in completing the attached forms that allow us to meet the reporting requirements of the federal government and are helpful in evaluating this module for future use. Included are: 1. Participant Profile form: answer the best you can even if some items seem confusing. This forms asks for identifying information, but will be kept separate from others. 2. Participant Pre-test: before you begin to participate in the training, answer this brief set of questions. When you complete the post-test at the end, you ll see how much you ve learned. At the top, write in a word or number that only you will recognize as identification, then use it again on the post test. 3. Participant Post-test: After the presentation is complete, answer the questions again. Be careful; they are in a different order. 4. Participant Evaluation form: Results from this form will be sent back to us at the. Please help us evaluate the program. Note to Instructors: 1. These forms, which you saw first in Tab 2, are included again here to make it easier for you to make copies. 2. Participants are given instructions above, so that latecomers can complete the paperwork without interrupting the program. 3. Please have participants complete the pre-test BEFORE you give them their handout. Thank you for your cooperation in seeing that these forms are completed. Please return them to the Staff Development Coordinator who will return them to the DVGEC.

32 DVGEC CONTINUING EDUCATION PARTICIPANT PROFILE FORM Date: Name: (First) (Last) Gender: Male Female Age Bracket: " Less than 20 years " " " " " 60 or older JobTitle: Organization Name: Preferred mailing address: _ Home Work (street) (city, state, zip code) Work Telephone: ( ) Fax Number: ( ) Race (check all that apply) Ethnicity: "African American or Black "American Indian or Alaska Native "Asian, Specify: "Native Hawaiian/Other Pacific Islander "Caucasian or White "Other, specify Ethnicity "Hispanic/Latino "Other, specify Your Education (Check All the degrees you hold): Less than High School High School Associate s, Specify Bachelor s, Specify Masters, Specify Doctorate, Specify: Do you consider yourself to have ever been from an economically or educationally disadvantaged background? Yes No

33 What activities do you perform in your work? (Check ALL that apply) " Direct Care/Practitioner " Technical Duties " Counseling " Administration " Academic Teaching " Curriculum Development " Clinical Teaching " In-Service Coordination " Research " Continuing Ed Coordination " Publications " Health Education " Grant Writing for Research " Community Work " Grant writing for Training & Education " Board or Committee Membership " Other: What is your background & training? Your Discipline (Check ALL that apply) Primary Care " Nursing "LPN "Nurse PhD " Pharmacy "RN/and or BSN "Other Nursing " Physician Assistant "NP "CNS Allied Health " Clinical Laboratory Sciences " Home Health Aide/Medical Asst " Nutrition " Rehabilitation Therapies " Technician/Technologists " EMT " Other Allied Health, Specify: Related Professions "Clinical/Counseling Psychology "Other Counseling "Health Education "Health Administration "Nursing Home Administration "Public Health "Dental Public Health "Social/Behavioral Sciences "Social Work Other Field(s) "Specify: What license(s) and certificates(s) do you hold?

34 Your ID Today s Date / / Circle the letter of the best answer. Example: Which of these is NOT a season: a. Winter b. Autumn c. Summer d. Easter e. Spring Participant Pre-Test 1. Which of the following are considered fall risk factors? a. The use of a diuretic. b. Previous history of falls. c. Fear of falling. d. All of the above. 2. One of the most effective actions nurses can take to prevent falls is to: a. Consult PT to assess a person who is sliding out of a wheelchair. b. Use siderails as an effective barrier for the confused older person who may get out of bed unsupervised. c. Provide low dose Risperdol for the individual who wanders at night. 3. For the person with dementia who walks to the point of exhaustion, the following should be implemented: a. Assess and respond to need for hydration. b. Develop a structured program of activities, personal care, and exercise. c. Intermittent use of a physical restraint to promote rest. d. a and b.

35 4. Which of the following health problems increase the risk for falls? a. Upper respiratory infection. b. Dehydration (that is, decreased fluid volume). c. Hypoglycemia (that is, low blood sugar). d. a and b. e. b and c. 5. General strategies to prevent falls include: a. Assessment. b. Balance and fitness programs. c. Family and staff education. d. All of the above. e. a and b. 6. The following are effective interventions to reduce the risk for falls associated with urinary incontinence: a. A consistent toileting program. b. Decrease fluid intake. c. Medical evaluation to treat reversible causes of incontinence. d. a and c. e. all of the above. Circle T if the statement is True, F if the statement is false. Example: This is a test. T F 7. In order to promote safe transfers from and to bed, bed height should be 25% of lower leg length. T F 8. Falling, along with changes in function and mental status, can be a symptom of disease in the older adult. T F

36 Your ID Today s Date / / Circle the letter of the best answer. Example: Which of these is NOT a season: a. Winter b. Autumn c. Summer d. Easter e. Spring Participant Post-Test 1. For the person with dementia who walks to the point of exhaustion, the following should be implemented: a. Assess and respond to need for hydration. b. Develop a structured program of activities, personal care, and exercise. c. Intermittent use of a physical restraint to promote rest. d. a and b. 2. Which of the following are considered fall risk factors? a. The use of a diuretic. b. Previous history of falls. c. Fear of falling. d. All of the above. e. All but c. 3. Which of the following health problems increase the risk for falls? a. Upper respiratory infection. b. Dehydration (that is, decreased fluid volume). c. Hypoglycemia (that it, low blood sugar). d. a and b. e. b and c.

37 4. One of the most effective actions nurses can take to prevent falls is to: a. Consult PT to assess a person who is sliding out of a wheelchair. b. Use siderails as an effective barrier for the confused older adult who may get out of bed unsupervised. c. Provide low dose Risperdol for the person who wanders at night. 5. General strategies to prevent falls include: a. Assessment. b. Balance and fitness programs. c. Family and staff education. d. All of the above. e. a and b. 6. The following are effective interventions to reduce the risk for falls associated with urinary incontinence: a. A consistent toileting program. b. Decrease fluid intake. c. Medical evaluation to treat reversible causes of incontinence. d. a and c. e. all of the above. Circle T if the statement is True, F if the statement is false. Example: This is a test. T F 7. Falling, along with changes in function and mental status, can be a symptom of disease in the older adult. T F 8. In order to promote safe transfers from and to bed, bed height should be 25% of lower leg length. T F

38 Participant Evaluation Form Date: / / Facility: Please circle the best response. Example: Strongly Disagree Disagree Agree Strongly Agree 1. I can describe risk factors and causes of falls in the frail elderly. Strongly Disagree Disagree Agree Strongly Agree 2. I can describe how to assess a person after a fall. Strongly Disagree Disagree Agree Strongly Agree 3. I can tell you about strategies to compensate for sensory or cognitive losses. Strongly Disagree Disagree Agree Strongly Agree 4. This program will help me in my care of older adults. Strongly Disagree Disagree Agree Strongly Agree 5. This program will help me work better with other staff. Strongly Disagree Disagree Agree Strongly Agree 6. Overall I rate this program: Poor Fair Good Excellent 7. Overall I rate this instructor: Poor Fair Good Excellent 8. This program would be better if:

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