Falls in

Hospitalized

Patients with

Current or Recent

Chemotherapy

Treatment:

a teaching

session for

Oncology NursesJennifer Wolfe

Final Teaching ProjectUniversity of Central Florida

Overview of Problem

• Fall Prevention is a nursing responsibility to all patients (Capone, 2012).

• Over 700,000 hospitalized patients fall each year (Sonnad et al., 2014).

• Most falls can be prevented by nursing staff and patient collaboration (Sonnad et al., 2014).

• MOST patients who fall did not consider themselves at risk to fall (Sonnad et al., 2014).

• Over 50% of cancer patients will experience a fall during their disease process (Stone et al., 2012).

This session’s focus is fall prevention in patients with current or recent

chemotherapy treatment.

Upon completion, you will be able to:

• Identify at least 3 chemotherapy-specific factors that increases a patient’s fall risk

• Discuss 3 nursing interventions for fall prevention

• Recognize 2 non-chemotherapy medications commonly given in the hospital that can contribute to falls

• Evaluate 3 safety barriers that can be modified to prevent falls

• Resolve 1 personal knowledge deficit that was identified when completing the self-assessment prior to class

Current Needs in caring for

patients with current or recent

chemotherapy:• Need for increased nurse involvement in fall

prevention

• Need for nurses to obtain a baseline functional assessment

• Need for nurses to have the ability to identify unique fall risk factors associated with chemotherapy treatment

• Need for nurses to know and utilize appropriate interventions to prevent falls

Significance to YOU

SCU had 10 patient falls in 2013: 8 of them were patients with current or recent chemotherapy treatment!

2013 Patient Fall Scenario:

• 66 year old male with metastatic CRC. He received chemotherapy treatment that ended 2 days ago. His baseline is a/ox3 and ambulatory. Overnight he had c/o of frequent loose stools.

• A few hours into the shift, the patient was found on the bathroom floor during a visit by the nurse. He was awake and a/ox1 only. He was c/o pain in his legs. All post-fall policies and procedures were followed correctly.

• The question is…could his fall have been prevented? And How?

What was known..

• Hb 6.8- planned to transfuse 1 unit of PRBCs

• NA 109- had placed a call to the Oncologist

• Drowsy

• Frequent loose stools overnight

• Recent medications: PO Lasix 20mg and PO Metoprolol 25mg

Chemotherapy-specific fall risk

factors:These factors are all side effects of

chemotherapeutic agents

• Fatigue: Most common side effect of chemotherapy and is most felt a couple days after treatment.

• Postural Hypotension: Causes a drop in blood pressure when changing positions. This can lead to dizziness.

• Anemia: Low blood counts cause tiredness and weakness.

• Electrolyte Imbalances: Can cause weakening in the heart muscles as well as neurological changes.

• Peripheral neuropathies: Causes a decrease in sensation that can contribute to falls.

Chemotherapy-specific fall risk factors

continued: • Changes in coordination: Related to

neurological changes can cause sporadic and unintentional movements as well as unsteadiness when walking.

• Polypharmacy: Different medications taken by chemo patients affect the nervous system.

• Nutritional Deficiencies: Related to appetite changes, nausea, vomiting, diarrhea. Poor nutrition causes weakness and muscle break down that can contribute to falls.

• Delirium/Confusion: Causes difficulty concentrating, remembering things and can alter our judgment.

The Morse Fall Risk Assessment:

• This assessment is utilized for all adult patients.

• It classifies a patient as a high, medium or low fall risk.

• Interventions for nurses are recommended based on the patient’s score.

Nursing Interventions for all patients at risk for falls:

• Bed locked and in the low position

• Water and call bell in reach

• Non-skid footwear

• Offer assistance with toileting

• Assess cognitive status

• Provide a clear path to the bathroom

• Involve family members in patient safety

• Utilize side rails when needed

• Utilize safety devices like mittens, lap belts, sitters

• Remove unnecessary clutter from the room

• Utilize bed alarms and sitter select devices

• Use bedside commodes as needed

• Offer bedpans and urinals as needed

• Hourly Rounding

Nursing Interventions for patients with Chemotherapy-specific fall risk

factors:

• Advise patient to sit for a minute or so prior to getting out of bed to avoid dizziness due to postural hypotension.

• Obtain Daily Lab Values to monitor for hydration status and any electrolyte imbalances.

• Monitor nutrition status via assessing appetite, amount eaten, occurrence of nausea and/or vomiting, and lab values.

• Promote exercise daily and make recommendations to PT as needed. Nurses can utilize sit to stand and marching in place to assess basic physical mobility.

Nursing Interventions for patients with Chemotherapy-specific fall risk

factors continued:

• Daily Functional Assessment of ADLs to assess for any changes or declines. This is essential to complete prior to administering chemotherapy.

• Communicate any and all concerns about patient safety to the nurse leader and the patient and/or family.

• Use safety devices, like bed alarms or lap belts for extremely fatigued patients.

• Be aware of the extent of the patient’s disease: patients with advanced cancer may have bone metastases and can experience pathologic fractures.

ACTIVITY#1

• Forming Groups: Case Study

• 75 year-old female presenting with dehydration related to uncontrolled nausea and vomiting secondary to chemotherapy.

• PMH includes: former 65 pack-year smoker, atrial fibrillation and advanced non-squamous NSCLC with metastases to the breast and bone.

• MEDS: Advair 2 puffs BID, Albuterol rescue inhaler @4 PRN, Amiodorone PO 200mg Daily

• She finished a round of Pemetrexed (Alimta), IV chemotherapy, less than a week ago. She is requiring 4L nasal cannula to maintain >93% O2.

ACTIVITY#1 CONTINUED

Alimta: Chemotherapeutic agent used alone, or in combination for NSCLC.

• 7 days before administration, patient receives folic acid and vitamin B12 daily until treatment ends

• Chemotherapy administration requires pre-medication for nausea and rash with IV zofran and PO dexamethasone

• Common Side effects: fatigue ,nausea and vomiting, thrombocytopenia, anemia, leukopenia, fever, loss of appetite, constipation and/or diarrhea, stomatitis, alopecia, and peripheral neuropathies

ACTIVITY#1 CONTINUED

• What are the patient’s fall risk factors (both general and those related to chemotherapy)??

• Assign a recorder and a reporter

• Discuss within your group and record your answers

• The reporter will share your answers with the class

• GOOD LUCK!

Non-Chemotherapy medications commonly given to cancer patients

that can increase falls :• Analgesics: This medication class can cause deterioration in mobility, concentration,

balance, and postural hypotension (Askari, Eslami, Scheffer, Medlock, Rooij, van der Velde & Abu-Hanna, 2013) • Opiods: Hydromorphone, Oxycodone, Fentanyl, Morphine Sulfate, Hydrocodone

(WebMd.com, 2014)

• Antidepressants: This medication class can increase the risk of falls by causing changing in bone density that can lead to fractures as well as cause blurry vision (Boyle, Naganathan & Cummung, 2010). • Tricyclic Antidepressants: amitriptyline, doxepin, nortriptlyine• SSRIs: citalopram, escitalopram, fluoxetune, sertraline

(WebMd.com, 2014)

• Hypnotics: This medication class is intended to induced relaxation and sleep which can increase the risk of falls.• Sleep Aids: midazolam, zolpidem & triazolam• Anti-Anxiety Medications: alprazolam, diazepam & lorazepam

(WebMd.com, 2014)

Non-Chemotherapy medications commonly given to cancer patients that can increase falls continued:

• Corticosteroids: This medication class can cause dizziness, vision changes, as well as unsafe rises in blood sugar.

• Glucocorticoid: dexamethasone, prednisone

• Mineralocorticoid: Fludrocortisone

(WebMd.com, 2014)

• Diuretics: This medication class can cause dizziness as well as contribute to bone loss and increased incidence of fractures (Boyle et al., 2010).

• Thiazide diuretics: chlorthalidone, hydrochlorothiazide

• Loop Diuretics: furosemide, bumetanide, torsemide

(WebMd.com, 2014)

• Antihypertensives: This medication class is intended to decrease blood pressure which can cause postural hypotension and dizziness.

• Calcium Channel Blockers: amlodipine, diltiazem, verapamil

• Beta Blockers: atenolol, metoprolol, propanolol, caredilol

• ACE-inhibitors: catopril, enalapril, ramipril, benazepril, lisinopril

• Angiotensin Receptor Blockers: losartan, valsartan

(WebMd.com, 2014)

Polypharmacy and Falls in patients with current or recent

chemotherapy treatment

• They often have very complex medication regimens that include chemotherapy and medications to treat any existing comorbidities and any conditions caused by cancer treatments

• As seen on previous slide, many medications produce side effects that can increase the risk for patient falls

• They are often seen by many physicians that can each (unknowingly) prescribe medications used to treat the same symptoms

(Prithviraj, Koroukian, Margevicius, Berger, Bagai & Owusu, 2012).

ACTIVITY #2

• Four Corners

• Look at the four post-it posters in each corner of the room.

• On each poster is different medication class

• Choose one medication class and write down one example, indication, and known side effect(s) that can increase a patient’s fall risk

• When instructed, go to your corner and discuss your analysis with the group

ACTIVITY#2 CONTINUED

Medication class choices:

1. Analgesics

2. Hypnotics

3. Diuretics

4. Antihypertensives

Safety Barriers that Contribute to Patient

FallsIntrinsic Factors:• Cognitive and neurological conditions• Polypharmacy• Balance and gait dysfunction• Weakness• Vision problems• Postural hypotension (Stone et al., 2011)

Extrinsic Factors:• Includes environmental factors• Call bell out of reach• Low toilets• Broken furniture• Poor lighting• Wet floors• Ill-fitting footwear• Lack of handrails(Holley, 2002)

Nursing Interventions to Modify Safety

Barriers:• Report and remove any broken furniture and/or equipment

• Instruct patient to seek assistance prior to getting out of bed

• Instruct patient to sit for a minute or two prior to standing up

• Ensure the bed is locked and low

• Assess the patient's gait and utilize sit to stand and marching in place

• Keep the room lit appropriately

• Use safety devices as needed

• Question medication combinations that you are uncomfortable with

• Assist the patient to the bathroom frequently

• Ensure the environment is quiet and calm

• Assess the patient's pain frequently

• Assess neurological and cognitive functions frequently

• Ensure the call bell is in reach

• Remove clutter from the room

• Provide the patient with the proper sized footwear

• Educate patients on their safety and possible fall risks

• Post a sign that identifies the patient as a fall risk

• Communicate with the patient and the healthcare team about your concerns

ACTIVITY#3

• GAME TIME!

• I will show you picture of a hospital room that has safety barriers that can be modified with nursing interventions.

• The students who raise their hands and answer correctly will win some yummy candy!

• GOOD LUCK

ROOM#1 We start with an easy one!

ROOM#1

Modifiable Safety Barriers:

• Left side rail is up and blocking a straight path to the bathroom: can be modified by putting down the side rail

• There are cords dragging on the floor on the right side of the bed and the telephone cord is underneath the table: can be modified by untangling the cords and clipping it in place on the bed

• Use a fall risk indicator to identify this patient as a fall risk

• Utilize Hourly Rounding

ROOM#2

ROOM#2

Modifiable Safety Barriers:

• Foley and chest tube are across the patient and can get tangled across and/or trip the patient: can be modified by straightening the drains out and repositioning the patient

• Bed is up high which can cause a fall if the patient is exiting the bed: modified by lowering the bed and locking it

• Call bell and tray are not within the patient’s reach which can cause the patient to fall while reaching for them: modified by ensuring the tray and call bell are within reach

• Patient is hanging out of bed: modified by repositioning the patient

• Add a fall risk indicator to notify other staff members of this patient’s fall risk

• Utilize safety devices if needed to aid in fall prevention

• Utilize Hourly Rounding

ROOM#3

ROOM#3

Modifiable Safety Risks

• Excessive clutter in the room that can be knocked over and cause a patient to fall: modified by straightening up the room

• Baby is in the bassinet that is leaning on a bedside commode. If this tips over the baby can be seriously injured: modified by ensuring the baby’s safety and educating the parent on proper handling!

• Utilize Hourly Rounding

ROOM#4

ROOM#4

Modifiable Safety Barriers:

• Bed is not level and seems to be broken which can cause the patient to fall when returning to or getting out of the bed: modified by removing the broken equipment and providing the patient with a new bed

• Water and trash is sitting on the floor that can cause the patient to slip and fall: modified by cleaning it up and ensuring that the environment is always safe and clear of debris

• Instruct the patient to call for assistance

• Utilize Hourly Rounding

References:• Askari, M., Eslami, S., Scheffer, A., Medlock, S., Rooij, S., Velde, N., & Abu-Hanna, A.

(2013). Different Risk-Increasing Drugs in Recurrent versus Single Fallers: Are Recurrent Fallers a Distinct Population?. Drugs & Aging, 30(10), 845-851. doi:10.1007/s40266-013-0110-z

• Boyle, N., Naganathan, V., & Cumming, R. (2010). Medication and falls: risk and optimization. Clinics In Geriatric Medicine, 26(4), 583-605. doi:10.1016/j.cger.2010.06.007

• Capone, L. J., Albert, N. M., Bena, J. F., & Tang, A. S. (2012). Predictors of a Fall Event in Hospitalized Patients With Cancer. Oncology Nursing Forum, 39(5), E407-E415.

• Holley, S. (2002). A look at the problem of falls among people with cancer. Clinical Journal Of Oncology Nursing, 6(4), 193. doi:10.1188/02.CJON.193-197

• Prithviraj, G. K., Koroukian, S., Margevicius, S., Berger, N. A., Bagai, R., & Owusu, C. (2012). Patient Characteristics Associated with Polypharmacy and Inappropriate Prescribing of Medications among Older Adults with Cancer. Journal of Geriatric Oncology, 3(3), 228–237. doi:10.1016/j.jgo.2012.02.005 

• Sonnad, S. S., Mascioli, S., Cunningham, J., & Goldsack, J. (2014). Do patients accurately perceive their fall risk?. Nursing, 44(11), 58-62.

• Stone, C., Lawlor, P., Savva, G., Bennett, K., & Kenny, R. (2012). Prospective study of falls and risk factors for falls in adults with advanced cancer. Journal Of Clinical Oncology, 30(17), 2128-2133.