Pt falls on geriatric psych inpt unit

snowfreeze, BSN, RN · Apr 9, 2005

I work in a restraint free facility and we also have a BICC unit (dementia behavior unit). A lot of medication evaluation along with lots of physical therapy and occupational therapy help to reduce falls. Strengthening, gait training, walker utilization, proper chair pads and properly fitted wheelchairs is also helpful and is an active part of the therapy departments. A patient with frequent falls is reviewed and we try to figure out if this patient simply needs to be toileted at 4:30 or 5:00am prior to falling trying to get to the bathroom or something else simple. Do they sundown and need a dose of medication at noon, or 2pm to help with this agitation? Another fine tuning is the antihypertensives and antiarrythmia meds, is 9am really the best time to give these or is 6am better so they are not out of bed falling when the medication first kicks in. Many of our patients stay up till 1 or 2am then sleep in the morning, have breakfast in bed and get up around 10 or 11am. We do use temporary gerichairs for agitation until the ativan takes effect. 1:1 during this time is usually utilized, half hour or so is all this takes. A good activities department can assist with the afternoon boredom and looking to go home and looking for a family member that happens with so many of these residents. Something to occupy their minds and make them think of happy times. We use sing alongs, bingo, a snack period with questions about events that happened during their lifetime along with many more things to keep them busy and not bored. Smaller units and more structure helps a lot also.

I hope this helped you.

gerilou · Apr 10, 2005

I work in a restraint free facility and we also have a BICC unit (dementia behavior unit). A lot of medication evaluation along with lots of physical therapy and occupational therapy help to reduce falls. Strengthening, gait training, walker utilization, proper chair pads and properly fitted wheelchairs is also helpful and is an active part of the therapy departments. A patient with frequent falls is reviewed and we try to figure out if this patient simply needs to be toileted at 4:30 or 5:00am prior to falling trying to get to the bathroom or something else simple. Do they sundown and need a dose of medication at noon, or 2pm to help with this agitation? Another fine tuning is the antihypertensives and antiarrythmia meds, is 9am really the best time to give these or is 6am better so they are not out of bed falling when the medication first kicks in. Many of our patients stay up till 1 or 2am then sleep in the morning, have breakfast in bed and get up around 10 or 11am. We do use temporary gerichairs for agitation until the ativan takes effect. 1:1 during this time is usually utilized, half hour or so is all this takes. A good activities department can assist with the afternoon boredom and looking to go home and looking for a family member that happens with so many of these residents. Something to occupy their minds and make them think of happy times. We use sing alongs, bingo, a snack period with questions about events that happened during their lifetime along with many more things to keep them busy and not bored. Smaller units and more structure helps a lot also.
I hope this helped you.

Thanks Snow. You have some great points and ideas and I will definitely give them a try. Thanks also for your e-mail address. Because I work in a state Psych facility, patients rights is a HUGE issue for us. Believe it or not, the patients have the right to have TV's and cell phones and CD players in their room...all get taken out if they are suicidal, but yet we don't have the right to put a frail medically compromised 68 year old woman in a geri chair after falling 9 times in 7 weeks. I see the geri chair as her right to be kept free from falls and fractures, but the state, as well as other states, sees it as a restraint. We do not have any geri chairs in our facility whatsoever. Unfortunately, Ativan seems to make the two patients I am most concerned about more psychotic and disinhibitted.....You have some great ideas though and it would be a pleasure to correspond with you.

Thanksand have a great weekend.

snowfreeze, BSN, RN · Apr 10, 2005

As far as the ativan goes, depending on what the patients diagnosis is...prn klonopin or seroquel can be very sedating plus may help to straighten out their thoughts. I find that if we truly diagnosis these patients then treat the mental health issues and realize that many of these people have some type of dementia also we have happier residents and less incident reports. Vascular, alzheimers, lewy body, alcohol abuse related, stroke related and Huntingtons all need different approaches or you will end up with 14 meds and still have an out of control patient that is unpredictable. For example, schizophrenia in a non-agressive elderly patient can mimic depression in their behaviors. I guess I am trying to point out that we overmedicate instead of actually trying to figure out what is really going on in their minds chemically and how they process their environment.

All of our patients can have personal items like TVs, radios, musical instruments etc. We had an episode one weekend with a golf club that was used for an activity with in-door putting equipment. That was interesting getting that golf club away from the resident who was not being rational.

And welcome to geriatrics, there is going to be a lot of need for geriatric specialty nurses in the near future.

Da Monk · Apr 10, 2005

I worked at a psych hospital who proudly touted their no-restraint geropsych unit. Unfortunately, there were numerous falls, and one that was fatal. There were numerous 1:1's ordered, but other patients suffered from lack of staff and the cost of the 1:1's eventually led the unit into the financial red. But, even after the death and a fractured budget, the administration clung to the belief that a restraint free environment was the only way to go, no matter what. The state regulatory agency, in reality works against the acute hospital setting, saying that any device is a restaint. This included the medications that helped the patients and enabled them to return to a nursing home setting. As soon as the patient returned to the nursing home, the agency started pushing the staff to decrease the medication down to a level that was nontherapeutic. The meds were considered a chemical restraint. You can guess what happened. The patient soon returned to the acute setting with the same symptoms or worse. I found these policies detrimental to patient well-being. I would rather see a relative of mine bouncing around in a Merry-Walker rather than lying in a bed with a hip fracture or in an ICU with a subdural. Even a simple lap belt is considered a a restraint. Common sense seems to have no place in these situations. It seems that regulatory agencies must find something to monitor simply to justify their existance. And I would rather see that demented relative in a calm state of mind rather that in an agitated state perpetuated by regulations that promote the belief that the elderly are better off without psychtropic medication, no matter what. Let's get real. I know that studies show decreased death and fall numbers when there are no restraints, but I wonder about the staffing ratios where these studies were done. In a few years when I'm in a nursing home and unsteady on my feet, I hope that someone cares enough to put a little more thought into my safe care.

leslie :-D · Apr 10, 2005

yet ironically these 'chemical restraints' actually increase the risk of falls.

i've seen chair and bed alarms implemented, as well as psyche re-evaluating their meds and/or their timing.

we've had a&o pts sign a waiver form stating that all possible interventions have been executed and should they fall, the facility is absolved of any liability.

we've also done the same w/the health care proxies for the demented.

very, very seldom have we used the 1:1 as administration said it was economically unfeasible.

yet in the extreme cases you can always get an md order for restraints x 24 hrs only and then care planning has to be revised.

then there's always the 'buddy cushions' that are not considered a restraint so if the pt is demented, often they don't know how to release themselves. sometimes it works, sometimes it doesn't.

but yes, the state definitely frowns upon restraints and if you do restrain a pt, physically or chemically, just make sure you document every little detail on what justified using a restraint on a pt.

leslie

gerilou · Apr 12, 2005

I worked at a psych hospital who proudly touted their no-restraint geropsych unit. Unfortunately, there were numerous falls, and one that was fatal. There were numerous 1:1's ordered, but other patients suffered from lack of staff and the cost of the 1:1's eventually led the unit into the financial red. But, even after the death and a fractured budget, the administration clung to the belief that a restraint free environment was the only way to go, no matter what. The state regulatory agency, in reality works against the acute hospital setting, saying that any device is a restaint. This included the medications that helped the patients and enabled them to return to a nursing home setting. As soon as the patient returned to the nursing home, the agency started pushing the staff to decrease the medication down to a level that was nontherapeutic. The meds were considered a chemical restraint. You can guess what happened. The patient soon returned to the acute setting with the same symptoms or worse. I found these policies detrimental to patient well-being. I would rather see a relative of mine bouncing around in a Merry-Walker rather than lying in a bed with a hip fracture or in an ICU with a subdural. Even a simple lap belt is considered a a restraint. Common sense seems to have no place in these situations. It seems that regulatory agencies must find something to monitor simply to justify their existance. And I would rather see that demented relative in a calm state of mind rather that in an agitated state perpetuated by regulations that promote the belief that the elderly are better off without psychtropic medication, no matter what. Let's get real. I know that studies show decreased death and fall numbers when there are no restraints, but I wonder about the staffing ratios where these studies were done. In a few years when I'm in a nursing home and unsteady on my feet, I hope that someone cares enough to put a little more thought into my safe care.

Hi Da Monk,

Thanks...I agree with you wholeheartedly. :yelclap: So is there an answer to keeping the patients safe and free from bone-fracturing falls while also keeping them out of restraints and ensuring their rights are not being compromised?

Gerilou

gerilou · Apr 12, 2005

As far as the ativan goes, depending on what the patients diagnosis is...prn klonopin or seroquel can be very sedating plus may help to straighten out their thoughts. I find that if we truly diagnosis these patients then treat the mental health issues and realize that many of these people have some type of dementia also we have happier residents and less incident reports. Vascular, alzheimers, lewy body, alcohol abuse related, stroke related and Huntingtons all need different approaches or you will end up with 14 meds and still have an out of control patient that is unpredictable. For example, schizophrenia in a non-agressive elderly patient can mimic depression in their behaviors. I guess I am trying to point out that we overmedicate instead of actually trying to figure out what is really going on in their minds chemically and how they process their environment.
All of our patients can have personal items like TVs, radios, musical instruments etc. We had an episode one weekend with a golf club that was used for an activity with in-door putting equipment. That was interesting getting that golf club away from the resident who was not being rational.
And welcome to geriatrics, there is going to be a lot of need for geriatric specialty nurses in the near future.

Hi again Snow

Can you recommend any good reference books or journal articles for someone new to this field? Also, if you know of any conferences coming up or where I could find out more about them, I would be mighty glad to hear about them. I am eager to learn more....

Thanks again

Gerilou

studious · Apr 12, 2005

Hi
I am new to the forum so forgive me if this is not the appropriate place for my thread. I recently got promoted to the nurse manager of our state psych hospital's geripsych unit. Now that geri chairs are considered torture devices that are considered a form of restraint, several of our pts have been having some frequent falls. We now have these pts on 1:1 staffing, much to administrations dismay. Are there any geriatric nurses out there who can share some insight and wisdom with me? The meds alone cause hypotension
and the unit is basically a dementia unit of 18 patients.
Been an RN for 20 years (I'm 42) and still wet behind the ears. Thanks in advance for your help...
Thanks,
Gerilou

Hi there,

I'm new to this site, so forgive me if this reply goes a bit awry. I work in a restarint free unit for dementia patients. Our drugs are reviewed regularly as well, but unfortunately there is always going to be the odd fall here and there. We have implemented the use of safe hips ( I know, more than hips get broken). However, considering the mortality of elderly patients with fractures it may help you somewhere along the line???????

studious · Apr 12, 2005

Hi
I am new to the forum so forgive me if this is not the appropriate place for my thread. I recently got promoted to the nurse manager of our state psych hospital's geripsych unit. Now that geri chairs are considered torture devices that are considered a form of restraint, several of our pts have been having some frequent falls. We now have these pts on 1:1 staffing, much to administrations dismay. Are there any geriatric nurses out there who can share some insight and wisdom with me? The meds alone cause hypotension
and the unit is basically a dementia unit of 18 patients.
Been an RN for 20 years (I'm 42) and still wet behind the ears. Thanks in advance for your help...
Thanks,
Gerilou

Hi there,

I'm new to this site, so forgive me if this reply goes a bit awry. I work in a restraint free unit for dementia patients. Our drugs are reviewed regularly as well, but unfortunately there is always going to be the odd fall here and there. We have implemented the use of safe hips ( I know, more than hips get broken). However, considering the mortality of elderly patients with fractures it may help you somewhere along the line???????

jetsetter · Apr 12, 2005

Educate me please, safe hips?

gerilou · Apr 12, 2005

Thanks Studious...

I am new to this site too but have quickly found myself glued to it. The folks who have responded to me have been very helpful...I am also new to the feild of geriatric nursing...what are 'safe hips' ?I have never heard of them...

Gerilou