The CNA Study Guide – Risks Connected to Common Injuries
Section 2 – Risks Connected to Common Injuries
As the body ages, it no longer is able to reproduce cells as quickly as it could. It also loses its elasticity, which can lead to easier tears and breakdowns in the skin tissue. This is a major reason as to why elderly patients are more likely to suffer from certain skin injuries. Additionally, the reduction in blood circulation, new mental conditions, a reduction in ability and even decreased sensation, coupled with external issues such as poor nutrition can lead to these problems. In connection with the loss of elasticity, the skin itself becomes thinner. The outer layer of the skin, also known as the epidermis, is already just 0.1 millimeters thick. This becomes even thinner over the course of time. Collagen loss in the skin lease to the elasticity problem. When the skin is unable to stretch and return to its original shape, it increases the chance of breakdown due to friction and force. The body does not sweat or produce as much oil as it once did, and dry skin breaks down faster. These kinds of sin injuries are very serious and may develop into additional risks for the patient. A nursing assistant needs to inform their next in command nurse about any kind of skin issues right away, in order to avoid these additional risks. The skin problems will be documented and treated accordingly, on top of being monitored for any kind of chance in the skin.
When a patient is in need of complete and constant care, their chance of injury increases as they rely on the nursing assistant and other members of the staff to move their body, otherwise they may develop pressure ulcers or skin tears.
Pressure ulcers and skin tears are more common in individuals who are:
- Dependent on a wheelchair
- Suffer limit mobility
- Have a spinal cord injury
- Maintain poor nutrition
- Poor circulation, often due to heart problems or diabetes
- Pressure, often excessive, on bony areas or thin skin
- Elder patients are at increased chance of developing these problems
- Weak immune system
- Dependent on others for assistance in their care.
Slipping and falling is another major cause of injury within a patient. Some of the top causes and risks connected with slipping and falling include (but are not limited to):
- Balance issues
- Weakness in the muscles
- Dizziness, which can come from low blood pressure, medication or heart problems
- A history of previous falls (these people are more prone to future falls)
- Slow reflexes
- Problems with their vision
- Memory loss or easily confused
- Unsafe shoes or foot problems
- Sight problems
- Tripping on hazards, ranging from rugs to poor lighting, slippery surfaces, stairs or sharp corners
Varying Risks For Spills
Spills can lead to injuries not only with patients but with the nursing staff as well. The chance of a spill may increase when working in an irregular surface area (both inside and outside) that has poor drainage or damaged/clogged pipes. This can lead to the presence of prolonged moisture, which may increase the chance of a spill.
If a nursing assistant needs to take a patient outside, it is important for the nursing assistant to understand the outside walking conditions, the surface for which they will walk on and any other irregularities. These irregularities can be anything from uneven pavement and slight elevation changes in the sidewalk, all the way to ice on the walkway or pooled water after a rain. It is important for the nursing assistant to remain with the patient whenever possible and to always be aware of what is going on with both the patient and the surroundings. Good judgment and common sense are critical here.
The floor on the inside of a building will vary. If the floor is damaged, becomes uneven or has not been cleaned in a while it can become a slipping potential. Nursing assistants must always be careful of indoor flooring and the hazards present. If new damage occurs to the flooring, it must be reported and proper warning signs placed to warn others.
Standing water can develop around drainage that is no longer working correctly. This can range from clogged gutters on the outside, leading to water spilling and pooling in undesired locations. Nursing assistants need to report these water problems to ensure the area is properly repaired.
From time to time, slippery material may spill, ranging from water to grease or other fluids. In locations where food is prepped, equipment is stored, around drinking fountains, entrances to a building, bathrooms or doors to the outside where it snows or rains, these areas are more prone to spills. Flooring, especially around where a patient’s room needs to be monitored the most. Due to a patient’s potential for disorientation, reduced consciousness, and other illness issues, these areas must be cleaned and corrected first.
Burns are a problem and can lead to more serious injuries. Some of the most common risks for a burn include, but are not limited to:
- Elderly individuals living on their own
- Mental conditions including dementia and Alzheimer’s
- Hearing loss (so they do not hear smoke detectors)
- Reduced sense of smell
- Suffer from Parkinson’s
- Intoxicated from drugs or alcohol
Bruising is another common injury patients may suffer from. Some of these risks include:
- Being elderly
- Vision problems
- Frail with very thin skin
- On blood thinning medication
- Room hazards, like sharp corners, throw rugs, exposed cords and so on
- Altered mental state, due to medical condition or medication the patient is on
Patient Comfort and Safety
Preventing a patient’s injury often comes with improving their level of comfort. Bony areas of the body require additional padding. Boney areas can include the head, heels, tailbone, and elbows. Padding placement may vary based on the position of the patient.
When a patient is lying down, the lower back will experience less pressure if the knees are elevated (with a pillow). The head position of the bed should be raised based on the patient’s individual comfort. Providing bedpan assistance every two hours is necessary.
When the patient is on their back, it is important to:
- Place a pillow under their head, their heels, lower arms, and knees
- Check to make sure the nurse call button, water, and other required items are within easy reach
- Insert pillows under the head for desired comfort level of the patient.
- Raise and lock side rails around the bed whenever a patient is unable to move about on their own without assistance.
When a patient is on their side, it is important to:
- Place a pillow under their head
- Slide a pillow under their back to keep the patient from rolling over
- Elevate their head, based on the patient’s comfort level
- Position a pillow between arms.
- Make sure knees are bent and place a pillow between the legs, ankles, and knees
When a patient is seated, either in a wheelchair or lounging, it is important to:
- Position a pillow or cushion under the patient’s bottom (especially when the chair is hard)
- Place a folded blanket under the patient’s forearms, especially when the chair hard
- Check to avoid added pressure to the knees. If pressure is present, a folded blanket can be useful.
When you transfer a patient from their bed into a sitting position, you need to:
- Talk with the patient and point out what you will be doing
- Unlock and lower the side rails. Also, make sure the bed itself is locked so it will not roll
- Position one of your hands behind the patient’s shoulder. The other hand should go on their knees
- Whenever necessary, have another staff member assist you (especially if the patient is heavy)
- Lift up and turn the shoulders of the patient while swiveling their knees at the same time. Do this so their knees are positioned over the edge of the bed
- Allow the patient to rest here in order to catch their breath. You may need to leave your hand on them to help stabilize
When you transfer a patient from the sitting position on the bed to a chair or wheelchair, you need to:
- Talk with the patient and point out what you will be doing
- Position the wheelchair as near to the bed as possible. Place the wheelchair against the side rail
- Check again to make sure both the bed and the wheelchair are locked down and cannot move.
- Position the footpads on the wheelchair out of the way
- Prior to moving, place the nonslip footwear onto the patient
- Stand in front of the patient with a wide leg stance for additional balance. Have the patient place their hands on your shoulders
- When present, use the gait belt. When not present, take hold of the patient’s waist and help them stand. Do so on the count of three.
- Rotate the patient into the wheelchair, allowing them to back up until the back of the chair is against their legs.
- Slowly lower the patient down into the wheelchair, then position the footpads into the necessary location.
When you transfer a patient from a bed to a stretcher, you need to:
- Talk with the patient and point out what you will be doing
- Ask for assistance from another employee. If the patient is heavier, you may need additional support
- Lower down the side rails and the head of the bed. Do the same with the stretcher
- Check to ensure both the bed and the stretcher are locked
- Cross the arms of the patient over their chest
- Roll the patient onto their side using the draw sheet. The other aid should position a sliding board under the back of the patient
- Roll the patient back onto their back
- Pull the draw sheet. The other employee should push the shoulder and hip of the patient while you pull until the patient is complete on the stretcher.
- When the patient is heavier, a third staff member may need to help transfer the feet and legs.
- Remove slider board (or sheet) and ensure the patient’s comfort.
When moving a patient up in their bed, you need to:
- Ask for help from a second assistant
- Talk to the patient to point out what will be happening
- Check to see if bed is locked.
- Lower side rails
- Lower the bed’s head so everything is level.
- Cross patient’s arms over their chest
- Each assistant should position themselves on opposite sides of the bed. From there, each takes hold of the draw sheet
- Counting to three, assists should boost up the patient to the bed’s head
- When possible, a patient should bend their knees while lifting their head and use their heels to push up
- Ensure the patient’s comfort
When maintaining a patient’s level of comfort, this also means focusing on their room. The temperature should be set at a patient’s comfort level (make sure to ask what makes them feel comfortable). Available sheets and bedding should be available, as well as blankets. Having personal items like a sweater or blanket from home can help improve comfort levels as well. Discussing the patient’s desire for lighting and the window being open/closed is recommended. Decorating a room with family photographs and other home objects will help reduce stress and improve a patient’s comfort level. Additionally, scheduling daily routines around a patient’s habits can establish normalcy.
Accident Prevention Protocols
The vast majority of accidents to the elderly take place within their homes. Falls represent the most common form of accident. However, most accident prevention is straightforward and revolves around general maintenance and cleaning. Patients should have an understanding of what their own body’s capabilities are and where they need help. To do this, keeping regular physician appointments and staying on prescribed medication helps. Knowing side effects and identifying these can help prevent certain accidents as well. On top of this caregivers, such as family members, should understand what the individual’s limitations are and medication side effects as well. This way, they can care for the individual while taking care of all safety hazards within the home as well.
If an elderly individual lives at home, certain measures need to be conducted with regards to burns, fires, poisoning, and hypothermia. Poisoning in senior citizens is most often due to gas and medication. Gases come in the form of carbon monoxide and other heating fuels like propane and natural gas. It is important to look at all fuel-based devices to ensure correct functionality. Chimneys need to be cleaned annually.
Medication complications in older adults can vary in severity. Making sure medication is taken as prescribed and properly organized will help prevent these kinds of injuries. Individual pillbox compartments can help with this.
Burns or scalding more commonly occur from water that is too hot. Whenever possible, kettles should be avoided. Instead, closed off, spout based kettles or wall mounted heaters can be used. When carrying hot objects, the shortest distance between the kitchen and where it is to be carried is desirable in order to avoid spilling and burns. When using the stove, rear burners should be used to avoid easy burns when walking past and all handles should be pushed away from the edge to avoid knocking into the handles.
Hypothermia is another possible problem with the elderly. This happens when the internal body temperature drops under 95. Ways to avoid hypothermia include properly heating the home (especially in cold weather), offering multiple blankets and clothing layers and helping assist with exercise in order to boost blood flow and body heat.
Preventing Falls In a Patient’s Home
Falls are the top injury causing issue for patients inside of their home. In order to prevent falls on the home front, preventative tactics include:
- Checking rugs and moving when easy tripped over
- Adding mats to slippery floors
- Improving poor lighting
- Know when a patient is at a higher risk of falling
- Look over the entire home for potential problems and hazards
- Have canes and walkers on hand
- Offer reachers and grabbers for picking up hard to reach items
- Install gait belts
- Installing railings in the bathroom and around hallways
- Ensure correct, non-slip footwear is worn
- Educate staff and family members on how to prevent slipping
- Work with patients on daily activities
- Check lighting and rails in stairwells
If a patient is bed-ridden, some methods for preventing falls include:
- Keep both sides of the side rails up
- Position call light and other desirable personal items within the patient’s reach
- Position bed alarms on the bed of the patient to notify staff members of an attempt to get out of bed
- Provide bathroom assistance every two hours to avoid patients getting out of bed on their own
Falling With Your Patient
There may be times where it is apparent a patient is going to fall and there is nothing you can do to avoid that from happening. When this is the case, it is necessary to assist the person down to the ground safely. If you are standing in front or behind the patient, you need to spread out your legs in order to create a wider area of support for the body. You want to also keep an arm under the patient’s shoulder (or at least under their arm) in order to help slow down the fall to the ground. It is very important for you to do what you can to protect the head first and, from there, to do what you can to direct them away from any hard surface or object, including furniture.
All healthcare centers will identify the patients who are at the greatest risk of falling down. These individuals will need special assistance and require additional precautions to be in place. There may be signs on a patient’s door that signals they are a fall risk. The patient may also wear a color-coded bracelet or another identifying mark that lets staff members know they are at a greater risk of falling down. On top of this, all staff members will receive proper education with regards to what kind and how much assistance they need. Some residents might be able to walk with help and stand with some assistance, while another patient might require at least two staff members to help them stand and to transfer them over to another location.
Helping With Ambulation
There will be times when dealing with ambulation. When this does come up, you need to execute the following steps:
- SBA (or Stand by Assistance). The patient may not require any actual assistance in order to move and can walk on his or her own. However, it is important to stand by and monitor the situation. Typically, a gait belt is not required for these patients.
- CGA (or Contact-Guard Assistance). This is when a patient does need assistance within the area in order to prevent falls. They are able to generally walk on their own but they are at a greater risk of falling down.
- MN (or Minimum Assistance). This patient is in need of small amounts of support when moving around. This is when a gate belt may prove beneficial
- MAX (Maximum Assistance). This is a patient who is not able to stand on his or her own without help. It often takes at least two staff members to help with the patient.
When a patient requires some sort of assistive device for ambulation it is important they receive instruction on how to use it. They may need reminders just to make sure they know exactly how to use it. It is very important they use it properly, so remaining with a patient who is just learning how to use such a device is a must. If a patient is learning how to walk with a walker they need to have a gait belt present.
Walking With Canes
Canes offer stabilization for weak legs. When utilizing a cane, you need to:
- Position the cane in the strong, dominant hand of the patient and step with the weak leg while moving the cane out with the strong hand.
- The weight should be placed on the cane side when stepping out with the strong leg
- Following every step (or whenever necessary), a patient can stop and rest to make sure they are balanced.
Walking with a Walker With Wheels
Walkers are provided to patients when both legs are weak and if they have trouble balancing when walking on their own. The appropriate steps for using a walker are:
- Have the patient stand inside of the walker while holding onto the sides of the walker with each hand.
- The patient must lift and push the walker in the direction they wish to move. The rear legs of the walker need to be in line with the patient’s toes.
- The weight of the patient must then be placed on their stronger let and, form there, they step with the weaker leg first while continuing to hold onto the walker. It is important to remain centered within the walker
- The patient should then step with their stronger leg and meet the other leg. Here they can rest or adjust their balance when necessary.
It is important that the surface an individual using assisstive walking devices on is flat and clear of any items that might cause them to slip. Trips often occur when there is a rug or thick carpeting and the base of the walker or the cane is not able to remain and hold firm contact. Some walkers do have wheels in order to make it easier for a patient to slide the walker when walking. Some walkers do have wheels on all four of the legs. In these instances, the patient must place his or her weight onto the walker with their hands in order to provide additional support while leaning forward.
When using a walker with wheels the walker is not picked up during the walking process. These wheeled walkers allow for a faster pace of movement. It is important to monitor the placement of the walker and to make sure it does not move too far in front of the patient.
When moving from a seated position (such as a chair or bed) to a walker, you need to:
- Position the walker directly in front of the patient.
- The patient must grab hold of the arms on the side of the chair.
- Assist the patient in standing from the chair.
- The patient should place one hand on the handgrip, followed by the other
- Before letting the patient go, it is necessary to check to see if the patient has become dizzy. It is possible to become dizzy and weak when standing from a chair too quickly.
Crutches are a short-term device used when a patient has limited mobility. This may be due to a sprained ankle, leg or another foot injury. Placing any weight on the leg may prevent the injury from healing properly and prove painful. Physical therapists will assist in fitting the appropriate crutch length. The armpit rests will fit right into the patient’s armpit without the patient lifting their shoulders or having to stoop. If the crutches are too tall, it increases the chance of a patient tripping over the crutches. Additionally, too much pressure is placed on the armpit. When crutches are too short, leaning onto the crutches will cause a back strain. Handgrips need to be altered so arms are slightly bent at the elbow and the grip is as comfortable as possible.
A crutch gait is a three-point gait that helps a patient when they are not able to place weight on one leg. To use the gait, both crutches and the weaker leg must move forward. All weight is then placed on the crutches and the stronger leg steps forward. It is very important to maintain excellent balance for this to work correctly (and to avoid injury).
The two-point crutch gait is used when booth legs are weaker and the patient doesn’t have good coordination. To use this system, a patient needs to move the left crutch and right foot together. The process is repeated with the right crutch and left foot. This gait works well and allows for faster mobility, but it is a bit more challenging to learn than the three-point crutch gait option.
The swing through crutch gait is designed to when it is not possible to place all of the patient’s body weight onto both legs. To execute this gate, the patient must move both crutches forward, followed by swinging both legs forward at the same time, ensuring the legs swing past the crutches. Of all the gaits, this is the fastest but it does require considerable arm strength as very little (if any) weight is placed on the arms. This is also a gait used by younger individuals and is not commonly utilized by senior citizens.
The swing to crutch gait is designed for patients with a weakness in both legs. To execute this gait, the patient must move both crutches forward and put their weight on both crutches while swinging their legs forward at the same time. It is important to not swing past the crutches in order to avoid balance issues. Again, this move requires excellent arm strength and might not be used by seniors.
When standing on crutches a patient must hold both crutches to their side and lead forward, off a chair with their arm. Once standing up, they can position the crutches.
In order to sit with crutches, the patient must place both crutches onto their injured side. While holding the handgrips (with one hand), they will use the other to brace the chair and sit.
When using crutches on stairs it is important for the patient to be confident with their position on level ground. If they are not, they can slide down the steps on their bottom. Using a railing can help with one hand while holding crutches with the other. The crutches should stay on the same step the patient is standing on. The good leg should take the first step. The patient then straights and brings down the crutches and the injured leg to the next step.
While going down steps, patents need to place crutches on the next step lower and move their injured foot forward. Then, they need to position the good foot down to the crutches on the lower step.
Techniques for Restraint
A restraint is any device that is attached to the body that limits a person’s mobility. When applied correctly, a restraint cannot be removed easily or even controlled by the person. Restraints are not just physical but emotional, environmental and chemical. The use of restraints in any form is controversial as there is an ethical issue here with regards to limiting a patient’s freedom. Often these are just temporary fixes to a problem and should only be executed at the last resort. These are used to limit a person’s movement in order to avoid injury and often they require a physician’s direct order.
Some kinds of restraints include:
- Physical: straps, wrist restraints or vests that prevent movement
- Environmental: side rails, locked beds, closed windows and so on
- Chemical: medical used to control a patient’s behavior
- Emotional: Verbally cueing a patient’s emotions in order to cause a patient to act in a certain way
A doctor or practitioner is in charge of ordering the utilization of these restraints. Nurses, caregivers, and nursing assistants are responsible for carrying out these restraints and making sure everything is executed safely. Once a restraint is applied following an order, the physician or practitioner will need to visit the patient within 24-hours to assess the situation.
There are alternatives to restraints. Some of these include:
- Talking with the patient to help improve cooperation
- Use distractions (such as music or a television)
- Position the patient within view of a caregiver
- Sit with the patient
- Move the patient to a quiet area of the facility
- Check to make sure all of a patient’s needs (especially bathroom needs) are met
- Position personal items within reach of the patient.
While Using Restraints
Every healthcare facility will have protocols in place when using restraints. Some of these circumstances include:
- Demonstrate aggress toward the staff or other patients
- Interfering with medical services like an IV or catheter.
- Patient is moving in ways that may cause injury
- Patient is attempting to interfere with a procedure
When Apply Restraints
- Follow facility policy
- Receive an order from the medical practitioner or physician, unless the situation is an emergency
- Receive consent from the patient or next of kin
- Talk to the patient and explain what is going on, even if the patient is not able to understand
- Monitor the patient based on the facility checking requirements. Double-check positioning of the restraint every 30 minutes and remove every two hours to ensure proper range of motion. Reposition the patient and provide toileting every two hours.
- Always explain why the restraints are being used
Applying the Physical Restraints
The vests have holes designed for the arms with an opening in the back. The straps in the back will secure to the side of the bed or a chair, depending on the location of a patient. A quick-release knot should be tied along the lower portion of the bed. It is important for two fingers to slide in between the patient’s chest and the vest to avoid cutting off circulation.
When using ankle and wrist restraints, the straps are tied to a lower area of the bed or chair that cannot move. Tie these in a quick-release knot and make sure the restraints are not too tight. You also want to make sure the patient’s legs and arms are not in an odd position. You can help aid the improvement of their position by placing pillows under arms, knees, and legs.
The Legal Ramifications of Restraints
Restraints can lead to injury and, if the restraints are not correctly used, the patient’s family can bring about legal action against the facility. When in restraints a patient feels helpless and vulnerable. They are also at greater risk of abuse (sexually, elder abuse, or psychological). Violence toward them carried out by other patients can happen as well.
Some possible injuries from restraints include, falls, bruises, broken bones, skin tears, depression or death from strangulation.
The Risk Factors For Elopement
Elopement is when a patient wanders away unsupervised. This is a major safety concern as injury or death can occur if the patient falls or walks into a busy road. It may also expose them to whether they are not accustomed to and a lack of food. Within the United States alone, 34,000 Alzheimer’s patients wander out of their homes or healthcare facilities on an annual basis.
Patient’s with memory problems is the top reason why elopement happens (such as Alzheimer’s disease, disorientation or dementia). These patients are more likely to wander because they don’t understand their current location or whereabouts. They become confused and think they need to perform a certain task, like visiting the store or feeding a pet. Patients with mental impairments are more likely to wander off, especially if they can walk independently. Patients who can walk without assistance are far more likely to wander off than those who have limited mobility or who are confined to a wheelchair.
In order to prevent elopement from occurring, you need:
- Proper training with the staff
- Understanding the habits of different residents and which ones are more likely to wander off, who have done so in the past, or who may have mental and memory disorders that can increase the chance of wandering
- Have an alarmed and locked door that is not for use by the patients
- You need to have a quick response to the sounding of an exit door alarm.