Individualized Care

 

Individualized interventions to prevent bed-related falls and reduce siderail use

Capezuti, Talerico, Cochran, Becker, Strumpf, Evans (1999)

This article describes interventions to promote the safety of residents while in bed or when exiting the bed. The interventions are categorized to be specifically aimed at residents with a particular health problem. In what follows, we will discuss some suggested interventions for residents with bad memory, impaired mobility, injury risk, nocturia/incontinence, and sleep disturbance.

Individualized interventions for elders in nursing homes with:

 Cognitive/ Memory Problems

Many residents with impaired memory view side rails as barriers rather than as reminders not to get out of bed on their own. Thus, caregivers should never consider using side rails for residents automatically. Instead, they should try to promote procedural memory in the resident by encouraging him or her to consistently use an assistive device rather than just during therapy sessions. This will help encourage carry over and to enhance safety because it will help strengthen weak muscles. As well, signs and other memory trigger devices can be used to remind these residents to get up slowly and carefully (AMDA, 1998). Other useful interventions for those with cognitive/memory problems include:

• bed and chair alarms to alert staff when resident attempts to transfer on their own
• placing bed along the wall so the resident will exit on their stronger side
• hip protectors will prevent hip fractures
• do frequent checks on the resident (Morse, 1997)

Impaired Mobility

For those with impaired mobility, have them assessed by an occupational therapist, who will then implement his recommendations (NRCSA, 2004). Depending on the resident’s range of motion, different interventions can be used to prevent them from falling. For example, if the resident has full shoulder mobility and adequate upper extremity strength, then they can use a trapeze, a transfer enabler, or half or quarter side rails to help with their mobility in bed. Facilities can also offer these residents recreational therapies such as dancing and tai chi to promote balance and coordination (Wolf et al, 1996). For those with limited joint mobility, involve them in stretching exercises.

For those residents who have trouble transferring themselves into or out of bed, instruct them to use bed grab bars, bed handles, or a transfer pole. Make sure these devices are placed in the residents’ stronger side. A firm mattress can also facilitate standing since it is hard to rise from a soft, compressible mattress. Another intervention is to adjust the height of the bed and toilet to be about 100% to 120% of the patient’s lower leg length. Placing rubber mats at the resident’s bedside and bathroom and using anti-skid floor wax are also good ideas.

Other interventions to promote residents’ mobility include having them wear low-heeled shoes with good traction and non-skid socks in bed. Since low lighting contributes to fall risk, leave nightlights or bathroom lights on throughout the night for residents who can sleep through them. For those who can’t, make sure they have easy access to lights such as using motion-sensitive lights. For those who have difficulty finding their way from their bed to the bathroom, try rearranging the furniture, outlining a path to the bathroom using fluorescent tape, moving the bed closer to the bathroom, or providing a rest stop between the bed and the bathroom.

 Impaired vision

Use of night lights, bedside tables, and quad canes or walkers may help those with peripheral neuropathies and visual impairments to orient themselves in space and support themselves while getting out of bed (AMDA, 1998).

 Injury Risk

For those who are at risk for fall-related injuries, use bed boundary markers such as mattress bumpers, concave mattresses, rolled blankets, or swimming noodles placed under the bed sheets to mark the edges of bed. As well, use hip pads, floor mats around the bed, and maintain a very a low bed height to reduce the severity of injuries. Increase staff awareness by using bed alarms and implementing programs such as the “spot the dot” program, which are colour-coded dots placed on the doors of high risk residents to remind staff to check up on these residents whenever they pass their room. If side-rails are in use, use side-rail pads or bed bumpers to minimize the risk of skin tears from the metal rails.

Nocturia/Incontinence

The primary intervention in preventing falls from incontinence is to seek incontinence evaluation and perform individualized toileting rounds. The resident should also use bedpans, extra absorbent pads and other incontinence products to keep the bed dry. Clearly identify the bathroom using pictures instead of words. For those with nocturia, caregivers should consider medication for reducing urgency (NRCSA, 2004).

Sleep Disturbance

Because falls occur when residents are awake and when they are not fully rested, insomnia can be a serious risk for falls. For residents with insomnia, seek medical evaluation and review their medication. Try to promote comfort and relaxation by using music, body pillows, and scheduled analgesics. As well, maintain a regular sleep/wake cycle (i.e. avoid excessive daytime napping).

Fear of Falling

Because a fear of falling is usually the result of balance or mobility issues or a previous fall, residents who have a fear of falling should have a balance/strength assessment done by a physical or occupational therapist. As well, it is a good idea to use hip protectors - especially if the resident is at high risk of fracture, and to lower the bed to a very low position to reduce the distance the resident would fall while getting out of bed (NRCSA, 2004).

Dizziness

For residents with dizziness, it is important to monitor and treat orthostatic hypotension. T hey should also be evaluated to determine the underlying cause of dizziness. As well, these residents should be taught to rise slowly from the bed to prevent fainting (NRCSA, 2004).

Other Considerations:

For decisions regarding bed rail use, it is recommended that they be made within the framework of an individual patient assessment. These include:

• medical diagnosis, conditions, symptoms, and/or behavioural symptoms
• sleep habits
• medications
• acute medical or surgical interventions
• underlying medical conditions
• existence of delirium
• ability to toilet self safely
• cognition
• communication
• mobility (in and out of bed)
• risk of falling
• patient’s bed environment