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Preventing functional decline of patients should be a priority of every hospital. However, too often, promotion of physical function and independence gets lost among the many tasks nurses must perform. Consequently functional decline is the most common complication of hospitalization for older adults.
There are many reasons for functional decline during a hospital stay, according to Barbara Resnick, PhD, CRNP, FAAN, FAANP, professor, University of Maryland School of Nursing, Baltimore, but the overwhelming culprit, she says, is the amount of time patients spend in bed.
Healthcare providers may write stay-in-bed orders when a diagnosis is unclear or for fear the patient might fall. The hospital environment may not promote physical activity with pleasant places to walk or chairs for sitting in the patient's room. Moreover, nurses may feel it's simply quicker to perform functional tasks for patients instead of allowing them the opportunity to transfer and ambulate and range their joints during routine care activities.
Inactivity Has Its Price
"Staying in bed leads to de-conditioning, pressure sores, infection, pneumonia, urinary tract infections and delirium," said Resnick. "One of the best things nurses can do to avoid these outcomes is to go to other team members for help."
Nurses, she said, can talk to rehab therapy to find ways, other than bed rest, to reduce falls.
Optimizing patient transfers is one way, while making sure beds and chairs are the optimal height for safe transfers, having patients strengthen muscles and improve balance through exercise and engaging occupational therapy, social work or volunteers so that patients at risk for falling are not left alone in a room, are all other ways to prevent falls.
"Getting patients their medications might take priority over getting them out of bed. But if people lose muscle tone in the hospital, they're actually more likely to fall because they're dizzy and weak," Resnick explained.
"Nurses should not think of themselves as merely providing care, but as optimizing patients' ability to care for themselves," she continued. "In other words, they should not necessarily use a lift just because a patient is heavy or bathe a patient because they can do it more efficiently."
Function-Focus vs. Task-Focus
One of the principal tenets of NICHE (Nurses Improving Care for Healthsystem Elders), a national program of the Hartford Institute for Geriatric Nursing at New York University College of Nursing, New York City, is function-focused, rather than task-focused nursing care.
Resnick discussed the growing awareness collaboration and mutual understanding among disciplines play to prevent decline at the13th annual NICHE conference, April 22, in Baltimore. (click here for more information)
"Whether it's working with discharge planning, rehab therapy, pharmacy or nutrition, nurses need to work with all to make the best plan of care," she said. "No older adult can be cared for optimally by a single practitioner."
Keeping Them Moving
Cynthia Brown MD, MSPH, agrees and argues that, only as a team, can healthcare staff decide which patients need to be in bed and which moving. Associate professor of medicine at the University of Alabama at Birmingham, Brown has conducted research showing patients with the least activity in hospital are most likely to have functional decline and to go to a long-term care facility.
As a PT-turned-geriatrician, Brown has a unique vantage point. She notes there are few diagnoses for which bed rest is a necessary order; nurses, as part of a team with the physician, may question this order. Once bed rest is revoked, nurses can encourage patients to get out of bed, sit up for meals and have a purpose.
'Never Events'
The Centers for Medicaid and Medicare Services declaring fall-related injuries "never events" for which hospitals may not be reimbursed may have made hospitals even more conservative.
"There's a culture of keeping people in bed," Brown pointed out. "In the typical hospital room, the TV is over the bed, and devices such as IVs and urinary catheters impede mobility. Working with physicians, nurses can prompt removal of a catheter or IV that may have been inserted days earlier in the ER."
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