Keeping Residents Safe during
Outdoor Activities

Now that spring is coming to the northern part of the United States,
our thoughts turn to outdoor activities for the residents. This is a good
time to review some ways to keep the residents healthy and happy while enjoying some
fun in the sun.

Last year was one of the hottest summers on record. Having to stay indoors to keep
cool was difficult for the residents with heart conditions or respiratory problems. Even
residents without these problems were advised to stay indoors and out of the baking
heat and oppressive humidity. This can be hard when summer is usually filled with
outdoor activities and outings to the residents' favorite places.

Now is the time to plan outdoor games, picnics, barbecues, trips to see the residents’
favorite baseball teams play and other out trips, walks around the grounds of the facility,
sitting outside talking to visitors or the staff, etc. Now that the residents are able to
spend more time outdoors, the activity staff needs to build in some precautions when
planning outdoor activities. Exposure to the sun, insect bites, heat exhaustion, storage
and preparation of food, and dehydration can put the residents and facility at risk.

Before planning outings, work with the director of nursing to develop a protocol for the
different kinds of trips you would like to take. Agree on a maximum safe
temperature/humidity index. Determine chaperone ratios and when a CNA or nurse
should accompany the residents and activity staff. Develop a list of "necessities" that
must go with the staff on each outing – these may include a first aid kit and manual,
bottled water, insect repellent, sunscreen, latex gloves, incontinence products, hand
sanitizer, disposable wipes, etc. Purchase several backpacks to hold these items.
Backpacks are much easier to manage when pushing wheelchairs and escorting the
residents from place to place.

Many of the residents are on medications or have medical treatments that make them
very susceptible to the burning rays of the sun. Just a few minutes in the hot sun can
cause very serious burns. Remember that even on a cloudy day or when sitting in a
shaded area, you can get sunburned.

Before taking any resident on a summer outing or outdoors, check with the nurse to
determine if he or she is "sun sensitive." As a precaution, sun block should be applied
to all residents before going outside or on an outing where they will be outdoors for
even a short period of time. Sun block should be reapplied as directed on the bottle or
according to the facility's protocol. Sweating may cause the sun block to be affected;
therefore, reapply it more frequently on days when the residents sweat more.

Wearing a hat that shades the face and covers the head is advised. A baseball cap for
the gentlemen and a hat with a wide brim for the ladies works best. A sun visor may
shade the face, but it does not protect the scalp from burning.

A lightweight, long-sleeved shirt or blouse can help keep the sun's rays off of the
resident's arms. Residents who are sensitive to the sun should also cover their legs
and refrain from wearing shorts. Encourage these residents to substitute lightweight
slacks instead of wearing shorts, dresses, or skirts when spending time outdoors.
Encourage the residents to wear sunglasses while outdoors. Some diseases of the
eye cause the pupils of the eye to take longer to adjust from light to dark. This is also
true as we age. When helping a resident to go indoors, remind the resident to remove
his or her sunglasses before entering the building. It is also a good idea to pause for
several moments once inside the door, so the residents’ eyes will have time to adjust
to the diminished light. This is very important for ambulatory residents and for those
using canes and walkers. Talk to your administrator and ask to have benches near the
entrances to the building for the residents to sit in while their eyes adjust to the indoor
lighting.

Ask the residents' families to purchase sunscreen, sunglasses, and a hat for their
loved ones. Remind the families to mark the items with the resident's name so they
won't get "lost" during an outing. It’s also a good idea to have the nurse keep the
sunscreen in the medication cart for those residents with dementia and make sure the
sunscreen is applied before the resident goes outdoors with the staff, family, or
volunteers.

Some residents like to go outside the facility by themselves and enjoy the fresh air.
Remind them to let their nurse know they are going outdoors. All staff should be
reminded to make sure residents sitting outdoors are okay, especially when they notice
someone has been out for a long time. The staff should make sure the resident is not
dehydrated or becoming sunburned. Encourage the resident to come inside for a little
while to cool off. Tell the resident’s nurse, if the resident refuses to come indoors and
bring the resident a bottle of cold water to drink.

It is important for staff members to recognize the signs and symptoms of dehydration in
order to promptly assure correction and prevention of complications. Without timely
correction, dehydration can lead to decreased functional ability, predisposition to falls
due to orthostatic hypotension, constipation, predisposition to infection, and death.
According to the chapter on "Dehydration: Prevention and Recognition" published by
Long Term Care Educator, staff members should be alert to the following symptoms:
•        Confusion;
•        Poor skin turgor (elasticity) – skin will feel warm and moist;
•        Dry mouth and dry furrowed tongue;
•        Decrease in blood pressure and increase in pulse; and
•        Decrease in voiding, scanty output and concentrated urine.
If any of the above symptoms are noted, steps should be taken as soon as possible to
have a nurse further assess the resident for dehydration and take corrective action as
necessary.

Many people are allergic to insect bites, especially bee stings. The activity staff should
know who these residents are and what procedures should be followed if the resident
gets stung by a bee. When a nurse will be one of the chaperones, be sure he or she
takes a bee sting kit on the outing. During late summer and early fall when bees are
more of a problem, it would be wise to encourage the residents with severe reactions to
bee stings to remain inside the facility. It is also unwise to remain outside after dusk as
mosquitoes and other insects are more prevalent at this time.

It is very important to keep the residents hydrated while outdoors or on an outing. The
best form of hydration is water. Stay away from drinks with caffeine and alcoholic
beverages because these dehydrate the body. Be aware that residents often refuse
something to drink because they fear they'll have to use the restroom more frequently
and don't want to be a burden to the staff.

As we age, our sense of thirst decreases and by the time the resident feels thirsty, he or
she is already dehydrated. Giving the resident a salty snack, e.g., hot dog, soft pretzel,
peanuts, dill pickle, pizza, etc., will encourage the resident to accept a drink.
Involve the residents and family members in establishing and meeting hydration goals.
Make sure the residents, families, staff, and volunteers at your facility know the
importance of hydration, not only for the residents, but also for themselves.

Teach the interdisciplinary staff to use a direct, positive approach when administering
fluids. Avoid asking, "Do you want something to drink?" Instead say, "Here is some
cool, refreshing water for you Mrs. Jones." Older people may not feel thirsty and may not
recognize their need for fluids.

Consider giving residents water bottles (such as those used by athletes) to carry with
them while outdoors. On a regular basis, be sure to refill the residents' water bottles
with water or their favorite cool non-caffeinated beverages. If the resident enjoys iced
tea, consider making the tea with decaffeinated tea bags.

Leaving the facility's grounds and going to a forest preserve or park for a picnic can be a
lot of fun. Enjoying a meal outdoors is something the residents look forward to. Before
planning a picnic, meet with the dietary supervisor and review safe food handling
practices. Develop a protocol for outings that involve serving food. Make sure the
coolers you're using can maintain the proper temperature for the length of time needed.
A good rule is NEVER take any salad, sandwich, or dish containing mayonnaise.
Always dispose of leftover food that has been out of the cooler for more than a few
minutes.

Barbecues are another favorite activity during the summer. When grilling chicken,
hamburgers, and other raw meat, make sure you do not serve food with the same
utensils used to cook the raw meat. ALL meat must be served well done, including
hamburgers. Facilities are being cited for serving the residents grilled hamburgers that
are partially cooked.

According to the surveyors, "serving half-cooked hamburgers results in a citation with a
scope and severity of D." According to the 1993 FDA Food Code, the internal
temperature of ground meat, e.g., pork or ground beef, should be 155° Fahrenheit. In
today's era of e. coli, "mad cow" disease, and other threats, the staff must be very
careful not to serve food that may prove hazardous to the residents' health and well-
being.

To prevent heat exhaustion, keep the residents out of the direct sun whenever possible.
Have them wear light-colored, lightweight clothing, and encourage them to dress in
layers. Ask the residents to remove their sweaters and lap robes as the temperature
begins to rise or you notice the resident perspiring. Have the residents stop physical
activity and encourage them to drink a glass of water and rest for a while. Move any
resident to a cooler location if you expect heat exhaustion, but be careful that the area is
not too cold, as this will shock the resident's body and cause more problems.

As we age, our bodies have a more difficult time adjusting to temperature changes;
therefore, temperatures in the common areas should not be too cool. This can also
shock the system when coming in from the outdoors where it is very hot – 85+°
Fahrenheit – into the facility where it is 72° Fahrenheit.

If you are using buses to transport the residents on outings, make sure the buses are
air-conditioned. If this is not possible, make sure the windows open and there is
adequate ventilation while in the bus. Carry ice water and disposable cups on the bus.
It is also a good idea to take disposable washcloths along.

If the bus breaks down, try to get the vehicle into the shade and open the windows for
ventilation. If this is not possible, try to move the residents off the bus and into the
shade. Encourage each resident to drink a glass of water at frequent intervals. Wet the
washcloths for the residents to use on their face, neck, and arms – the evaporation will
help cool them. Another trick is to wet the washcloths and place the washcloth on the
residents' heads. The evaporation will help the cooling process.

Educate the residents, family members, staff and volunteers about outdoor safety
issues through the facility newsletter and/or in-service training. Volunteer to speak to
the family council, or be part of a CNA in-service training, and share this information.
Many of the tips contained in this article apply to everyone and are important
considerations for those living and working with seniors in all types of settings.
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