Falls Risk Nursing Interventions
Falls in hospitals are a big issue, but they can be prevented. Nurses play a significant role in preventing falls by recognizing and providing interventions for patients at risk of falling.
Falls Risk Nursing Interventions
1 Conduct in-person and telephonic comprehensive care assessments.
- Conduct in-person and telephonic comprehensive care assessments.
- Include physical, cognitive, and social assessments.
- Use tools to help with assessments (e.g., checklist).
- Use a checklist to help with risk assessments (e.g., falls risk assessment tool).
2 Identify patient risk factors for falls.
Identifying patient risk factors for falls is an important part of providing safe nursing care. These include:
- Age, gender, and medical conditions. Patients with conditions such as Alzheimer’s disease or Parkinson’s disease are at an increased risk for falls because they have impaired balance and coordination. Other medical conditions that can affect balance include arthritis and diabetes mellitus. Patients with visual impairment may take longer to respond to a fall situation because they are not able to see where they are walking easily or quickly enough to avoid a fall. In addition, people who have poor hearing may be less aware of their surroundings when walking in the facility or outside of it (e.g., on the sidewalk).
- Medications and lifestyle factors that increase your risk for falling include using medications that cause drowsiness; consuming alcohol; having vision or hearing problems; having mental health conditions like depression; lacking sleep; being physically inactive, e g , not participating in regular exercise programs; having poor diet habits such as eating too much salt/sugar/fatty foods without enough fiber intake from fresh fruits & vegetables
3 Develop a comprehensive care plan based on identified risk factors.
The purpose of a comprehensive care plan is to help the patient understand their potential for falling and to identify interventions that will help them maintain their safety. A comprehensive care plan should be developed for each individual patient based on identified risk factors, such as medication side effects or mobility issues. The following are some steps you can take:
- Identify risk factors for falls in your patients. These include cognitive impairment, vision loss, gait instability, weakness/fatigue, pain and poor balance.
- Develop a detailed fall prevention care plan based on identified risks with specific interventions and follow-up instructions listed in order of priority. The patient and caregiver should both receive copies of this document so they know what is expected at home.
- Include plans for follow-up visits when appropriate (i.e., after discharge from hospital) or if further assessment is needed (i.e., before discharge). If needed continue with discharge planning until all goals are met.
4 Assess the environmental risks of each patient room, including items that may need to be removed or altered.
A patient who has fallen may have a high risk of falling again. To prevent further falls, the nurse should assess the environmental risks of each patient room, including items that may need to be removed or altered. The principal causes of falls in nursing homes are related to mobility and vision problems, which are often related to medications prescribed for patients. For example, patients taking anticholinergic drugs (e.g., atropine) or antihistamines (e.g., diphenhydramine) can experience dry mouth and blurred vision as side effects; this can lead them to lose their balance and fall. Another common cause of falls is weakness due to immobility or malnutrition; these conditions often result from serious illnesses such as cancer or heart disease rather than old age itself
5 Observe the patient ambulating throughout the hospital stay and document the observations in the medical record.
Observe the patient ambulating throughout the hospital stay, and document these observations in the medical record. Ensure that the patient is safe to ambulate and at no risk of falling. Additionally, ensure that the patient is able to ambulate safely throughout his or her hospitalization (i.e., does not require assistance with ambulation).
6 Educate patients on fall prevention, including why they are at risk and what they can do to prevent falls.
Education is necessary for patients with falls risk. Fall prevention education should be tailored to the patient’s needs and include information about why they are at risk of falls, what they can do to prevent falls, and how family members can help. Some examples of educational interventions include teaching patients how to use a cane or walker safely; instructing them on how to get out of bed; teaching them how to turn safely in bed; providing balance exercises that strengthen muscles used when walking; explaining how medications may affect mobility; discussing safety precautions around water (such as not drinking too much alcohol while bathing); advising patients who have cognitive impairment that it’s important not only for them but also others around them (like caregivers) to know where emergency numbers are located in case there’s an emergency situation like a fall.”
7 Determine if the patient meets criteria for an order of fall precautions (bed alarm, assistive device, etc.).
In order to determine whether or not the patient meets criteria for an order of fall precautions, consider the following:
- Has the patient fallen in the last 30 days?
- Is there a history of falling or losing balance?
- Is the patient’s mental status altered (e.g., confused)?
If yes to any of these, then yes to fall precautions. If no, then no.
8 Proper falls intervention and assessment can help prevent falls from happening
Fall prevention is a priority for the health industry and a team effort. It can be achieved by removing environmental risks, educating patients and their families on how to prevent falls, and creating a comprehensive care plan that includes fall precautions.
For many seniors, the fear of falling often leads them to stay at home rather than venture out into their community or attend social events like church services or luncheons with friends. Once they have moved into assisted living facilities it’s important that they continue participating in activities outside of their apartments as well as at home so that they don’t lose their ability to live independently.
When we think about preventing falls in elderly adults there are two main ways: reducing environmental hazards such as clutter, obstacles on floors (such as loose carpeting), slippery surfaces such as wet areas due to weather conditions; another way is teaching patients who are at risk for falling how not only avoid falling but also get up safely after falling down on the floor which could lead them back again into danger if not treated properly! This means encouraging them with positive reinforcements when trying new things ea
When falls are identified as a concern for your patients, it is important to know how to intervene. The steps outlined above should help you identify risk factors and develop a plan for preventing falls. However, if you suspect that there may be an underlying condition causing a patient’s falls or if they have multiple risk factors, then further investigation is warranted before any decisions can be made about interventions such as bed alarms or assistive devices.