Safety of the Older Adult

BSN217 GERONTOLOGY NURSING – THEORY

Semester Three 2021/2022
Learning Outcomes

1. Identify the nurse’s role in the promotion of safety for

older adults.
2. Describe normal age-related changes contributing to
falling.
3. Differentiate between intrinsic and extrinsic causes of
falling in older adults.
4. Identify fall risk reduction interventions.
5. Recognize fall consequences on older adults.
 Learning Outcomes
6. Implement nursing interventions to reduce serious injuries
among at risk older adults.
7. Discuss different types of environmental hazards in the home
of older adults such as: burn and non-burn injuries, seasonal
safety, medication safety, automobile safety, abuse and neglect.
8. Implement interventions to treat hypo-hypothermia
9. Provide care to an older adult exposed to abuse or neglect
10. Educate clients on strategies to promote automobile safety
 Safety of The Older Adult
Safety is a broad concept that refers to security and
prevention of accidents or injuries.

Older adult patients are at particular risk for injuries

associated with hospitalization.

Thornlow (2009) revealed that hospitalized patients age 65

and older experience higher rate of patient safety incidents
than younger adults.
I. Nurse’s Role
Gerontologic nurses must provide a standard of
care that promotes safety and prevent injuries,
while respecting individual’s autonomy to make
decision.

Nurses must
• Identify patients at risk and
• Apply evidence-based nurse’s integrated cognitive,
functional, nutritional and social support (Thornlow, 2009).
II. Falls
Fall has been defined as unintentionally
coming to rest on a lower surface such as
ground or floor.

It is a major health problem for those older

than 65 and

It is a leading cause of morbidity and

mortality in this population group.

Older individuals who fall are more likely to

be hospitalized as a result of falling or
concomitant injuries than other age-groups.

clipartguide.com
 Fall Statistics

One third of people older than 65 years fall at least one time each year,
and about half of those falls repeatedly.

Up to 20% of hospitalized patients and 45% of those in long term

facility will fall.

Of those who fall and require hospitalization, 50% will die within 1
year.

Of those who fall, 20% to 30% suffer moderate to severe injuries

• Such as hip fractures or head traumas
• That reduce mobility and increase the risk of premature death.

Direct care cost related to falls are $20 billion and projected to rise to
over $35 billion by 2020.
UAE Statistics
Age-related Changes Contributing to Falling
Vision

1-Presbyopia:
• Structural changes in eye shape cause reduction in the eye’s
accommodation. 
• Difficulty encountered with ascending or descending steps.

Nursing Interventions
• Instruction must be given to watch door edges & landing steps.

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 Age-related Changes Contributing to Falling
Vision

2- Eye Glare:
• Due to tendency of the lens to become cloudy & form cataract.

Nursing Interventions
• Instruct the patient to wear wide-brimmed hats or sunglasses
and to shade indoor windows.
 Age-related Changes Contributing to Falling
Hearing

1.Presbycusis: atrophy of the ossicles in the inner ear which causes

changes in sound conduction including loss of high-tone frequency.

2. Amplification of background noise and decrease in directional

changes.

Nursing Interventions

• Introduce visual or vibratory cues to compensate for hearing loss, and

• Instruct patients to observe foot placement on floor by watching their step
• (the vestibular system is an integral part of maintaining balance).
The inner ear
 Age-related Changes Contributing to Falling
Cardiovascular

Loss of tissue elasticity  which affects the arteries

decrease tissue recoil, resulting in changes in blood
pressure (postural hypotension).

Nursing Interventions
• Educate patient to change position slowly and to dangle the legs a
few minutes when arising from supine position.
• Encourage older adults to wait between position changes and to
hold onto the side of the bed.
 Age-related Changes Contributing to Falling
Musculoskeletal

Osteoarthritis: occurs in weight bearing joints, causing pain,

eroding joint stability and loss of supportive cartilage.

Nursing Interventions
• Identify the problem, encourage and assist in ambulation, and joint range
of motion.
• Encourage patients to use assistive device to aid mobility and avoid
further joint damage.
• Use of ice and hot packs.
• Use of anti-inflammatory agent and
• Pain killer as prescribed.

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 Age-related Changes Contributing to Falling
Neurologic

Functional Impairment due to :

• Slowing in reaction time,
• loss of postural stability
•  (Impaired righting reflexes i.e. maintaining balance) and gait disorders
 lead to falls.

Nursing Interventions
• Monitoring mobility,
• Offering assistance
• Promote autonomy.
• In some cases older adults require to use walking aids (straight cane,
stationary walker).
• Shoes should be inspected for low, sturdy heels and leather soles
• (which provide extra ankle and foot support).
 Fall Risk
Can be categorized according to intrinsic and extrinsic factors

Normal age related

changes
Intrinsic Factors
Disease &
Risk Factors for Medication effects
Falls

Environmental
Extrinsic Factors
hazards
 Intrinsic risk factors

1.Diseases
• Cognitive impairment (dementia, confusion, delirium).
• Cardiovascular disease (arrhythmias, MI, bradycardia)
• Neurologic disorders ( Parkinsonism, CVA, seizures).
• Respiratory disease (COPD).
• Metabolic disturbances (dehydration , electrolyte
imbalance).
• Hematologic disorders (profound anemia, vitamin B12
deficiency).
• Endocrine disease (hypoglycaemia).
• Transient ischemic attack (TIA).
 Intrinsic risk factors

2.Medications Effects
• Diuretics.
• Antihypertensive medications
• Benzodiazepines and other hypnotics.
• Antipsychotic and Antidepressant.
• Anticholinergics (diphenhydramine).
 Extrinsic risk factors
Environment
• Steps especially last step in the staircase.
• Floor surfaces that are slippery, wet, extra-shiny or uneven.
• Frayed or torn carpet may catch the heel.
• Throw rugs can lead to tripping or sliding.
• Edging and curbs that lacks contrasting color.
• Misplaced grab rails, bars which older adults can’t reach.
• Shower or tubs without non-skid mats.
• Poor lighting or extra-glaring bright light.
• Inappropriate footwear.
• Physical restraints.
 Extrinsic risk factors

Restraint
• Any action, word or deed used for purpose or intent of:
• restricting the free movement or decision making
abilities of a person.
• Capezuti and colleagues (2002) cite physical restraint as
a contributor to risk for falling, therefore it should
never be employed for “safety precaution.”
• Researchers found that there are no significant
differences in the number of falls, but a decrease in
severity of fall-related injuries after discontinuing the
restraints (Miller, 2009).
 Restraint (cont’d)

Since 1990, agencies

such as ANA, U.S FDA
and joint commission
have challenged the
use of restraints in
hospital and long-
term care facilities.
 Restraint (cont’d)
Indication :
• Maintaining the safety of the person.
• Managing agitation & aggression.
• Preventing wandering.
• Facilitate treatment.

Concern:
• Punishment.
• Enable work schedules to be completed.
• Stop tampering with medical devices.
• Stop removal of dressings, catheters.
 Restraint (cont’d)

What to consider before deciding to restrain?

Physical examination – identify potential underlying causes of
behavior:
• Metabolic disturbances,
• Drug effects.

Assess environment – identify irritants that may escalate

behavior
• Loud overhead paging,
• Room temp.

Identify patient specific problems – (forgetfulness) to determine

• If needs are being met and appropriate treatment/rehabilitation or alternatives
to restraint are explored.
Restraint (cont’d)
Nursing Implication

• Collaborative decision making – nurse,

doctors , relative, & patient if able.
• Never restrain in place of using
observation
Restraint (cont’d)
Nursing care for restrained patient :

Assessment
• For potential pressure areas secondary to
limitation of movement.
• Capillary return,
• Swelling or deformity around the area of restraint.
• Document any new abnormal findings.
Risks for Serious Injury
Older individual who fall are at the greatest risk for serious
physical injury.

Falls are the leading cause of

• Hip fracture ,
• Mortality rate with hip fractures and
• High treatment cost.

Conditions associated with greatest risk for serious injury are

• Mental status changes ,
• Osteoporosis,
• Gait or balance instability,
• Restraint use.
Video on fall risk assessment
https://www.youtube.com/watch?v=rlpQn2O_PFs
Home work / Class activity
Scenario
Ms. Amal is now 82 years old and has been admitted to the hospital for heart failure
management. Additional medical problems include arthritis, osteoporosis, recurrent
depression, early stage dementia, and history of fractured hip. Current medication
include furosemide 40 mg twice daily, enalapril 10 mg twice daily, & digoxin 0.125
mg daily; she is also on IV therapy (N/S 0.45 500cc every 24hrs).
You are the nurse on the acute care floor assigned to her care on the day of
admission.
During your initial nursing assessment, Ms. Amal is quiet and withdrawn. When you
ask about her living situation, she says she moved to the assisted-living facility 2
years ago, after she was hospitalized for treatment of fracture hip. She had fallen in
the bathroom at night. During the past year, she reports that she has fallen twice in
her room, but she has not had any serious injury.
A mental status assessment indicates that she is alert and oriented but her short
term memory is impaired and she had difficulty with abstract idea.
Ms Amal complained to the nurse that the call bell in the room is not working and
the light in the toilet is dim.
Home Work / Class activity
Question

Tabulate and describe intrinsic and extrinsic factors that can contribute
to falls in the case of Ms. Amal.
Fall & Injury prevention
The goal of fall risk reduction intervention program is
to:
• Eliminate or reduce risk factors.

The most successful approaches to fall risk reduction

are:
• Multifactorial assessment
• Followed by interventions directed at identify risk factors.
Fall & Injury prevention

Gerontologic nurse should

• 1. Identify the individuals who are at risk for serious injury,
• 2.Educate them about the importance of
• Behavioral modification.
• Physical modification
• Environmental safety

Behavioral modification requires older clients to recognize the

problems & make conscious attempts to change their behaviors

Diseases and conditions associated with risk of injury require

appropriate treatment.
 Fall & Injury Prevention
Strategies
1. Environmental modification
• Sturdy handrails should be present on both sides and uneven steps should
be repaired.
• Floor surfaces should have low-pile carpeting, in good repair, and clutter
free.
• Curbs landing surfaces should be painted with contrasting color.
• Lightning should be adequate in high-traffic and dimly lit areas.
• Tubs and showers should have adhesive mats, and be free of bar soap(that
can lead to accidental fall).
• Wear low heel, nonskid shoes.
• Scan environment before waking to look for possible hazards
• (Box 12-9, pp 218 in your textbook ).
 Fall & Injury Prevention
Strategies
2. Physical modifications
• Cushion the landing surface
• Use a mattress on the floor
• Use specialized tile that absorb the impact of falls
• Lower the distance to the floor surface
• Use low rise beds
• Cushion bony prominences
.
• Sit in a shower chair instead of standing on a tub
 Fall & Injury Prevention Strategies
3. Behavioral modification
• Muscle strengthening & gait training exercises
• Medication should be reviewed and limited to those
absolutely essential (vit D & calcium )
• Well balanced, nutrition meals rich in calcium
Life style
• Avoid alcohol & smoking
• Change position slowly & carefully
• Stabilize position before moving
Mobility
• Use assistive devices as prescribed
• Assume a seated position during high risk activities – bathing
& dressing
• Avoid risky behavior – climbing on ladders if unsteady
 Fall & Injury prevention Strategies

Assistive devices
• It is important to provide instruction and supervision in
correct use of assistive device, consult specialist.
 Fall & Injury Prevention Strategies

Principles for use of assistive devices

• Every assistive device should be adjusted to individual height.
Walker
• When using walker, step down with weak then strong leg,
• Don’t climb stairs with walker.
cane
• Place your cane firmly in the ground before taking a step,
• Do not place it too far ahead from you,
• Put all of your weight on unaffected leg then move the cane
and affected leg.
• When using cane on the stairs, step up with the stronger leg and
down with the weaker leg
• Replace cane tips frequently and choose one with flat bottom.
 Fall Consequences

Physical injury:
• In 2001 more than 11.500 people over age 65 died because of
falls.
• Trivial trauma (skin tears and sprains).
• Serious injury (hip fracture, subdural hematoma or internal
bleeding.
Psychological trauma:
• Fear of falling (fallophobia) may restrict an individual’s life
space.
• Loss of confidence that leads to reduce physical activity,
increase dependency and social withdrawal.
Video on fall prevention
https://www.youtube.com/watch?v=SW7w5EkkEMM
 III. Safety and Home Environment:
A. Burn Injuries in the Home

Risk factors
• The major cause of scald burn is the temperature of hot
water coming from the faucets.
• Unattended stove with water boiling in a pan or kettle.
• A space heater can be overturned by accident, causing a
fire.
• Smoking in bed or in a chair or falling asleep while
smoking.

At temperature of 140 F,(600C) only 3 sec of exposure are

needed to produce 3rd degree burns.
 Prevention of Burn Injuries
Nurses must instruct older adults to:
• Use thermometer and container with safety handle to check
the hot water temperature.
• Adjust the hot water tank accordingly , temp should not be
above 1200 F (480C).
• When space heaters are used , an emergency shutoff must be
operable.& keep it at 3 m from flammable items.
• The electrical cords must be intact and appropriate for the
electrical outlet.
• Have fire extinguisher available for use, and make sure smoke
detectors are working
 Prevention of burn Injuries
(cont’d)

Nurses must instruct older adults to:

• Never leave cooking unattended
• Wear short or tight fitting sleeves when cooking
Precautions
Cooking

• Keep towel , pot holders & curtains away from

flams
• Double check kitchen before sleeping

• Never smoke in bed

• Develop & practice fire escape plan
B. Non-Burn Injuries in the Home:
Carbon Monoxide toxicity from use of
heating oil or natural gas.

Skin exposure or ingestion of household

chemicals , herbicides, pesticides.

Fan injuries when air conditioner is

unavailable.

Use of knives in the kitchen

Food borne disease.

Non-Burn Injuries in the Home
Nurses must instruct older adults to:

When using knives, cut away from the body using proper
cutting surface.
• If a knife should fall, do not try to catch it.
• When wiping blades, point the cutting edges away from the hand.

Use carbon monoxide detector in the home.

All hazardous household cleaning substance should be

kept in a locked cabinet.
 Non-Burn Injuries in the Home
(cont’d.)

Label the corrosive or caustic substance (disinfectant, drain cleaners)

• Use gloves and eye protection .

Clean while fans are unplugged

Washing fruits, vegetables and hands.

Food Clean all surfaces to prevent the spread of fungus and bacteria (use
safety bleach diluted with tap water).

Meat and poultry should be kept cold,

• Danger zone between 40-140 F bacteria can multiply rapidly.
IV. Seasonal Safety Issues
Older adults are at risk of environmental
temperature-induced illnesses.

Older person vulnerable to heat or cold

related symptoms ranging from
weakness, dizziness, and fatigue to
exhaustion.

Nurses should prepare seasonal

information materials that deal with the
dangers of hyperthermia or
hypothermia for all older adults.
V. Hyperthermia:
Heat stroke is a life threatening problem that must be
treated immediately.
 Thyrotoxicosis
Med
Conditions
 CVA
 Dehydration
Risk factors
 Extensive use of occlusive Environment
clothing
 Heat syncope & heat exhaustion
 Malignant hyperthermia
 Alcohol abuse
Substances
 Delirium tremor
 Salicylic acid intoxication
V. Hyperthermia:
Management
• Fast and effective cooling is the corner stone of treatment for
heat stroke.
• Heat-related deaths and illness can be prevented by drinking plenty
of fluids.
• Placing a fan near the client
• Decrease the room temperature
• Placing ice packs on the groin & axilla together with cooling
blankets
• Antipyretics
• Bed rest to reduce heat production
• Nurses should identify older adults who are living without air
conditioning to keep their homes cooled to a safe temperature
zone.
VI. Hypothermia:

Household temperature below 65o F (18.33o C)

are associated with hypothermia in older adults.

Causes:
• Older adults fail to sense the cold when air temperature
remains below optimum levels for even short periods.
• Thermoregulatory impairment will lead to failure of the
body to perform adequate constriction and shivering in
response to cold.
Hypothermia:
Risk factors
 Accidental immersion in water Environment
 Exposure to cold temperature

 Alcohol, substance abuse, Drugs

(Opioids, benzodiazipines, barbituarate…
substances
 Excessive heat loss and impaired
production
 Surgery & trauma
 Nutritional deficiency Med/surg
 Sepsis Conditions
 Stroke & Spinal cord injury
 Anoxia &Uremia
 Hypoglycemia & hypothyroidism
 Adrenal insufficiency
Hypothermia:

Clinical Manifestation
• Fatigue &Apathy
• confusion & lethargy
• Shivering &Numbness
• Slurred speech
• Impaired coordination
• Coma
 Hypothermia
Interventions
Moderate without
Mild Moderate to severe
cardiac symptoms
• Passive external • Warming blankets • Active core
rewarming with • Covering of the head rewarming
insulated covering • Heating lamps • Warm IV fluids
• Warm Water • Warm humidified
• Moving client to immersion O2
warm environment • Warm gastric &
bladder irrigation
• Peritoneal dialysis
& pleural lavage in
cases of cardiac
instability
VI. Automobile Safety
Driving is a complex skill that involves rapid cognitive and psychomotor
coordination.

Many older adults

• Have Age –related changes
• Have Chronic illness and
• Are on medications

slow down their response to road.

A decline in an older adults ability to drive safely may be a result of:

• Presbyopia,
• Decrease dark adaptation,
• Decrease depth perception,
• Susceptibility to glare,
• General slowing reflexes.
Automobile Safety

Person over age 70 have been associated with

greater than 23% fatalities per 100,000 driver.

Nurse must
• Assess the older adults ability for safe driving and
• Discuss the possibility of driving cessation
• Provide guidelines for safe travel:
 Automobile Safety

Guidelines for safe travel

• Avoid night driving.
• Avoid driving in poor weather condition (ice, snow, fog).
• Avoid driving while you are under the influence of certain drugs.
• Continue to wear appropriate hearing aids and glasses during driving
• keep automobile’s maintenance records up to date.
• Maintain space between oneself and the vehicle in front.

The issues of quality of life, personal autonomy and safety dictate that older
adults need to be supported in their desire to continue to drive automobiles
Sample MCQ
An example of an intrinsic factor for falls in the older adult is:

A. Having a cat as a pet

B. Weakened muscles in the lower extremity.
C. Glaring lights in the hallway
D. The use of cane
Sample MCQ
Which nursing intervention best demonstrates the understanding that
older adults are at increased risk for falls because of normal age-related
changes?

A. Speaking in a loud voice when warning the client about safety hazards
B. Turning on lights so the client can see objects such as furniture in the
immediate area.
C. Encouraging the client to use a walker while climbing the stairs
D. Advising the client to avoid exercising painful joints
 Judgment of today

Not only
hospital
safety is our
priority
Judgment of today

But also
home
safety
Class activity
Scenario
Ms. Amal is now 82 years old and has been admitted to the hospital for heart failure
management. Additional medical problems include arthritis, osteoporosis, recurrent
depression, early stage dementia, and history of fractured hip. Current medication
include furosemide 40 mg twice daily, enalapril 10 mg twice daily, & digoxin 0.125
mg daily; she is also on IV therapy (N/S 0.45 500cc every 24hrs).
You are the nurse on the acute care floor assigned to her care on the day of
admission.
During your initial nursing assessment, Ms. Amal is quiet and withdrawn. When you
ask about her living situation, she says she moved to the assisted-living facility 2
years ago, after she was hospitalized for treatment of fracture hip. She had fallen in
the bathroom at night. During the past year, she reports that she has fallen twice in
her room, but she has not had any serious injury.
A mental status assessment indicates that she is alert and oriented but her short
term memory is impaired and she had difficulty with abstract idea.
Ms Amal complained to the nurse that the call bell in the room is not working and
the light in the toilet is dim.
Class activity
Question

Tabulate and describe intrinsic and

extrinsic factors that can contribute to
falls in the case of Ms Amal.
 References

Meiner, S. &Luecknotte, A.(2015). Gerontologic Nursing.

(3rd edition.). Mosby: St Louis.
http://
gulfnews.com/news/gulf/uae/abu-dhabi-half-of-all-road-
accidents-caused-by-those-aged-18-30-from-2009-2012-
1.1261472
http://www.dha.gov.ae/AR/Media/News/pages/
dubaihealthauthorityholdsinjurypreventionworkshop.asp
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