Falls are the most commonly reported safety incidents in hospitals, with a significant percentage leading to injuries. While not all falls are preventable, implementing robust safety measures is crucial to minimize risks. Studies show that falls can be reduced by 20-30% when risk factors are accurately identified and addressed with targeted interventions.
Nurses play a vital role in patient safety by diligently assessing fall risk factors, implementing preventive strategies, and educating patients about precautions. This proactive approach significantly contributes to better patient outcomes.
Risk Factors Associated with Falls
Identifying risk factors is the first step in preventing falls. These factors can be broadly categorized:
Adult Risk Factors
- History of Falls: Previous falls are a strong predictor of future falls.
- Assistive Device Use: Dependence on walkers, canes, or crutches can paradoxically increase fall risk if used improperly or if the environment is not adapted.
- Age 65 and Over: Age-related physiological changes increase vulnerability to falls.
- Lower Limb Prosthesis: Prosthetic limbs can affect balance and gait, increasing fall risk.
Physiological Risk Factors
- Low Visual Acuity: Impaired vision reduces environmental awareness and increases the likelihood of trips and falls.
- Hearing Impairment: Difficulties in hearing can limit awareness of auditory cues and environmental hazards.
- Orthostatic Hypotension: Sudden drops in blood pressure upon standing can cause dizziness and fainting.
- Incontinence: Urgency and frequency can lead to rushed movements and falls, especially at night.
- Impaired Mobility and Strength: Muscle weakness, balance issues, and gait abnormalities significantly increase fall risk.
- Poor Balance: Balance deficits make it difficult to maintain stability, especially during movement.
- Confusion: Altered mental status can impair judgment and awareness of hazards.
- Delirium: Acute confusional states are associated with increased agitation and risk-taking behaviors.
Medication-Related Risk Factors
- Antihypertensive Medications: Can contribute to orthostatic hypotension.
- Sedatives: Cause drowsiness, impaired coordination, and reduced reaction time.
- Narcotics: Similar to sedatives, they can impair cognitive and motor functions.
- Alcohol Use: Impairs balance, coordination, and judgment.
Environmental Risk Factors
- Restraints: While intended for safety, restraints can sometimes lead to falls if patients attempt to escape them.
- Cluttered Environments: Obstacles in the patient’s path increase the risk of tripping.
- Inadequate Footwear: Slippery or ill-fitting footwear can contribute to falls.
Note: A “risk for” nursing diagnosis indicates a potential problem that has not yet occurred. Interventions are focused on prevention.
Expected Outcomes for Fall Prevention
Effective nursing care planning aims to achieve the following outcomes:
- The patient will remain free from falls during their care.
- The patient will be in a safe environment, minimizing potential hazards.
- The patient will understand their individual risk factors for falls and the rationale behind preventive measures.
Nursing Assessment for Fall Risk
A comprehensive nursing assessment is crucial to identify patients at risk for falls and to tailor interventions appropriately. This assessment includes both subjective and objective data collection.
1. Evaluate General Health Status: Assess for acute and chronic conditions that might impact safety, such as sensory impairments (vision or hearing aids), polypharmacy, or cognitive deficits like confusion.
2. Assess Musculoskeletal Function and Assistive Device Use: Evaluate muscle strength, coordination, gait, and balance. Note any recent surgeries or injuries that could affect mobility. Observe the patient’s use of assistive devices and identify any improper techniques.
3. Utilize the Morse Fall Scale: This validated tool provides a rapid and standardized assessment of fall risk in hospitalized patients. It assigns scores based on various risk factors, categorizing patients into no risk (0), low to moderate risk (25-44), and high risk (≥45).
4. Evaluate Mental Status: Assess for confusion, sedation, or hallucinations. Patients with altered mental status may overestimate their abilities or forget limitations.
5. Assess Assistive Devices and Patient Understanding: Verify that patients have necessary assistive devices (walkers, bedside commodes, etc.) and can use them correctly and safely.
Nursing Interventions for Fall Prevention
Nursing interventions are essential to mitigate fall risks and ensure patient safety. These interventions should be individualized based on the patient’s specific risk factors and condition.
1. Implement Tailored Safety Measures: Choose fall prevention interventions based on the patient’s risk level and needs. A young, alert adult might only need a walker, while an elderly, confused patient may require a bed alarm. For severely confused patients who cannot follow instructions, restraints or 1:1 supervision may be necessary as a last resort. Restraints should only be used when all other measures have failed and with appropriate justification and monitoring.
2. Ensure Appropriate Footwear: Encourage all hospitalized patients to wear non-slip footwear. Many hospitals use color-coded socks to identify patients at high risk for falls, such as yellow socks.
3. Utilize Fall Risk Identification Systems: Employ visual cues to alert staff to patients at high risk. This includes patient wristbands, chart stickers, and signs placed in the patient’s room.
4. Maintain a Clutter-Free Environment: Remove unnecessary furniture and ensure cords and IV lines are not on the floor. A tidy environment reduces tripping hazards.
5. Keep Call Button and Personal Items Within Reach: Before leaving the room, always ensure the call button and essential items like water are within easy reach. This prevents patients from attempting to get out of bed unassisted.
6. Encourage Assistance with Ambulation: Instruct patients to use the call button and request help when getting out of bed or going to the bathroom.
7. Keep Bed in the Lowest Position: Except when performing procedures that require raising the bed, keep the bed in the lowest position to minimize injury from falls out of bed.
8. Educate Patients About Fall Risks: Have open and direct conversations with patients about their specific fall risk factors and the safety measures being implemented. Patient education enhances adherence to preventive strategies.
9. Collaborate with Therapy Services: Consult with physiotherapy and occupational therapy to help patients improve strength, balance, and learn to use assistive equipment like crutches correctly.
Nursing Care Plans Examples for Risk for Falls
Nursing care plans provide a structured approach to prioritize assessments and interventions for both short-term and long-term patient care goals. Here are two examples of nursing care plans for patients at risk for falls:
Care Plan #1: Improper Walker Use and Orthostatic Hypotension
Diagnostic Statement:
Risk for falls related to improper use of walker and orthostatic hypotension.
Expected Outcomes:
- Patient will remain free from fall-related injuries.
- Patient will demonstrate the correct and safe use of a walker.
Assessment:
1. Assess Walker Usage Technique: Observe the patient using their walker to identify specific errors in technique. This assessment informs targeted health teaching.
2. Medication Review: Review the patient’s current medication list, noting the number and types of medications, particularly those that could contribute to orthostatic hypotension.
3. Medical History Review: Obtain a comprehensive medical history to identify pre-existing conditions (stroke, brain injury, musculoskeletal disorders) that may increase fall risk.
Interventions:
1. Assist with Assistive Device Use and Maintenance: Provide ongoing support and education on the proper use and maintenance of the walker. Ensure the walker is correctly sized and adjusted for the patient.
2. Encourage Regular Exercise: Collaborate with the patient to develop a safe exercise plan to improve gait, balance, and lower extremity strength, as appropriate for their condition.
3. Optimize Room Lighting: Ensure adequate lighting, especially during nighttime hours, to reduce environmental hazards and improve visibility for patients with mobility and visual impairments.
4. Implement Fall Risk Identification: Apply a fall risk identification wristband to alert all healthcare staff to the patient’s increased risk.
5. Physical Therapy Consultation: Collaborate with a physical therapist for specialized exercises to improve balance, strength, and mobility. The therapist can also recommend appropriate assistive devices and home safety modifications.
Care Plan #2: Vertigo and Prolonged Bed Rest
Diagnostic Statement:
Risk for falls related to vertigo and prolonged bed rest.
Expected Outcomes:
- Patient will remain free from falls.
- Patient will experience a reduction in dizziness, visual disturbances, and orthostatic hypotension.
Assessment:
1. Muscle Strength Assessment: Assess muscle strength, recognizing that prolonged bed rest leads to muscle weakness and reduced mobility.
2. Vertigo History: Obtain a detailed history of vertigo, noting frequency, triggers, and associated symptoms like dizziness and visual disturbances.
3. Environmental Hazard Assessment: Assess the patient’s environment for clutter, slippery floors, loose rugs, and other potential hazards.
Interventions:
1. Address Environmental Risks: Lower the bed to the lowest setting, consider using a raised edge mattress or padding the floor. Half-side rails can assist with mobility while minimizing restraint risks.
2. Provide Assistance with Transfers: Assist the patient when getting out of bed, acknowledging the potential for weakness and orthostatic hypotension after prolonged bed rest.
3. Implement Gradual Position Changes: Instruct the patient to change positions slowly, dangle legs at the bedside, and stand momentarily before walking to minimize orthostatic hypotension.
4. Medication Administration: Administer prescribed medications for vertigo, such as antihistamines, benzodiazepines, or antiemetics, as ordered.
5. Referral to Physical Therapy: Refer the patient to physical therapy for programs focused on improving strength, balance, flexibility, and endurance to reduce fall risk.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Dittmer, D. K., & Teasell, R. (1993). Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Canadian family physician Medecin de famille canadien, 39, 1428–1437.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Morris, R. (2017). Prevention of falls in hospital. Royal College of Physicians, 17(4), 360-362. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297656/
- Preventing Falls in Hospitals. (2013, January). Agency for Healthcare Research and Quality. Retrieved October 13th, 2021, from https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html
- Stanton, M.& Freeman, A.M. (2023). Vertigo. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482356/
