Foundations of Nursing - Aspiration, Restraints, and Falls

What is aspiration?

The entry of food, fluid, or foreign materials into the trachea and lungs.

What are common causes of aspiration?

Oropharyngeal secretions, food, drink, medications, gastric contents, or emesis.

What is dysphagia?

Difficulty swallowing or the inability to swallow.

What are some risk factors for dysphagia?

Poor dental health, cancer, neurologic diseases (e.g., CVA, Parkinson's, dementia).

What can happen when protective reflexes are impaired?

Aspiration can occur, leading to potential respiratory complications.

What serious condition can result from aspiration?

Aspiration pneumonia, which has high mortality and morbidity rates. Increases LOS and ICU admission.

What is aspiration pneumonitis?

Inflammation of the lungs caused by the entry of foreign materials.

What is the major risk involved with aspiration?

Oxygenation and diffusion impairment

What is the primary goal in caring for patients at risk for aspiration?

Prevention of aspiration.

What should be assessed to identify patients at risk for aspiration?

Level of consciousness, speech, and health history risk factors.

What position should patients be in during feeding to prevent aspiration?

Head of bed (HOB) elevated.

What are signs of aspiration to monitor for?

Dyspnea, cough, cyanosis, wheezing, fever, and altered voice quality - coughing, choking, throat clearing, gurgling, or "wet" voice during or after swallowing

What interventions can help prevent aspiration during feeding?

Supervise oral intake, provide appropriate food consistency, position patients properly, place whole or crushed pills in soft foods, and never give oral fluids to a comatose patient.

How should patients be positions after eating?

HOB should be raised for at least 30min after feeding. Patients with decreased level of consciousness on their side.

What are some risk factors for aspiration in older adults?

Age-related changes in airway protective mechanisms and swallowing process, underlying pulmonary disease, and musculoskeletal disorders.

What are some risk factors for aspiration following a CVA?

Age > 65, hx pneumonia, severe dysarthria, more than 2 chronic diseases, bilateral brain injury or lesion location in brainstem

What history might indicate a patient is at risk for aspiration?

History of choking, cough, immediate or delayed cough, drooling, altered voice quality, throat clearing, absent swallow, or decreased oxygen saturation.

Who else is at risk for aspiration?

Patients with altered mental status, history of dysphagia, aspiration, aspiration pneumonia, residual food in mouth after swallowing, neurological disorders, presence of gastrointestinal tubes, presence of endotracheal or tracheostomy tubes, poor dentition, presence of a cervical collar.

What are bedside swallow screen tools used for?

To assess a patient's swallowing ability at the bedside for those at risk for aspiration. Used for pts determined at risk for aspiration. Many tools - facility dependent, validity and reliability of these tool varies. No one specific tool is "superior" to others.

What is the best practice for evaluating swallowing ability?

Consulting a Speech-Language Pathologist (SLP) for a swallowing evaluation.

How is aspiration diagnosed and treated?

-Speech Therapy Consult

-Registered DieticianConsult

-CXR (ordered by physician)

-Swallowing Studies

-May need Bronch? Possible Antibiotics (C&S)?

-Aspiration precautions

What precautions should be taken for patients at risk of aspiration?

Positioning, NPO status until cleared by SLP, supervised feeding, avoiding straws, using thickened liquids, monitoring, oral care, and educating patients.

What role does oral care play in preventing aspiration?

It reduces oral bacteria that can be aspirated.

What should patients be educated about to prevent aspiration?

Swallowing techniques, taking small bites, and proper positioning.

What is a restraint?

Physical devices or chemical means to limit a pt's freedom and movement that cannot be easily removed by the pt.

How do federal guidelines impact restraints>?

Reinforce pt rights; restraints can only be used to protect the pt, staff, and others.

What are restraint order requirements?

Requires an order from a licensed healthcare provider (HCP) and face-to-face assessments.

What are some reasons that a patient may be ordered restraints?

Risk of harm to staff or themselves, flight risk, manage wandering, prevent tampering with medical devices.

What are common examples of restraints in the hospital?

Side rails (4 side rails up), Geri chairs with attached tray, Ankle, Wrist, Waist restraints, Mitts, Leathers, chemical, barricading a doorway, physical holding.

Chemical restraints

Medications used to limit a patient's movement.

Negative effects of physical restraints

Skin breakdown, Contractures, Incontinence, Depression/anxiety, Delirium, Aspiration, Death.

How does a restraint get ordered?

Need an order from MD (PA or CRNP) within one hour unless serious risk to you or pt (emergent!). There are no PRN restraint orders.

How does a restraint get renewed?

They need renewed every 24 hours (non-leathers).

What are the restraint type limitations?

Only one type of restraint at a time; physical or chemical.

What details need to be included in a restraint order?

The type of restraint, justification for the restraint, and criteria for removal.

What is a leathers restraint?

A particular type of restraint that should rarely be used and requires specific orders and assessments.

What are behavioral restraints?

Restraint used for behavioral issues, but not a restraint in the physical sense; such as medications.

What is not a restraint?

Certain measures used to prevent tampering with interventions, but not physically inhibiting the patient in anyway. EX: wrapping an IV to distract a patient from picking at it.

How should a patient assessment go before restraint measures are taken?

Determine whether behavior pattern exists, assess for pain, rule out causes for agitation, and assess respiratory status, vital signs, blood glucose level, fluid and electrolyte issues, and medications.

How can family involvement help?

Involve the family in patient's care. Use what they know to help calm the patient.

What are some alternatives to restraints?

Ask family members or significant other to stay with the patient. Reduce stimulation, noise, and light. Distract and redirect, using a calming voice. Use simple, clear explanations and directions. Check environment for hazards. Use night light. Bed alarms. Allowing movement when appropriate (walking). Low-height beds. Floor mats. Allow use of hearing aids and glasses. Music and vidoes. Diversional activities. Conceal tubing. Relocate patient closer to nurses station.

What are falls?

Leading cause of fatal and nonfatal injuries in persons 65 years and older. In the hospital, older adults are 50% more likely to have a fall than younger patients.

What happens to patients after a fall?

Higher risk for increased hospital length of stay, decreased mobility, increased mortality, increased likelihood for discharge to a long-term care facility.

Should fall risks be handled with restraints?

Never use restraints simply to prevent a patient from falling. Physical restraints can increase the possibility of serious injury due to a fall—they do not prevent falls.

How can falls be prevented?

Room near nurses' station. Call bell at side. Personal items within reach. Hourly rounding. Reminders to call for assistance OOB. Bed/chair alarms. Non-skid footwear/slippers. Alert staff to fall risk.

When restraints are the last resort for a fall risk...

The least restrictive restraint should be the first option. Restraints must never be applied for the convenience of the staff. Notify family members or contact person.

What are the negative outcomes associated with restraint use?

Skin breakdown, Contractures, Incontinence, Depression, Delirium, Anxiety, Aspiration and respiratory difficulties, Death.

How do you care for a patient in restraints?

Routine toileting, circulation check q 2 or more, two finger check for tightness, remove and do ROM q 2, food and water, proper documentation, attach to frame not side rail.

What are the current restraint guidelines?

The current standard for long-term care facilities is to provide safe care without the use of physical or chemical restraints. Federal and state mandates, as well as The Joint Commission, recommend that acute-care facilities use restraints only as a last resort.

How do restraint guidelines ensure patient autonomy?

Federal guidelines reinforce that in all settings, the primary responsibility is to protect and promote patient's rights, and that restraints may only be used to protect the patient, staff, or others. Any health care facility that accepts Medicare and Medicaid reimbursement must abide by the federal guidelines for the use of restraints.