Falls are a significant concern in healthcare settings, representing the most frequently reported safety incident among hospitalized patients. Alarmingly, a substantial percentage, between 30% and 50%, of these falls result in injuries of varying severity. While it’s important to acknowledge that not all falls are preventable, implementing robust safety measures is crucial to significantly reduce the risk. In fact, studies have shown that falls can be decreased by 20% to 30% when risk factors are effectively identified and paired with appropriate interventions.
Nurses play a pivotal role in patient safety, and their diligence in assessing risk factors, integrating preventive measures, and clearly communicating the rationale behind fall precautions to patients is paramount. This proactive and informed approach leads to the best possible outcomes and ensures a safer environment for those under their care.
Risk Factors Associated with Fall Risk
Identifying risk factors is the cornerstone of fall prevention. These factors can be broadly categorized and encompass a range of patient characteristics and environmental conditions.
Adult-Specific Risk Factors
- History of Falls: A prior fall is one of the strongest predictors of future falls.
- Assistive Device Use: Reliance on devices such as walkers or canes can paradoxically increase risk if used improperly or if the environment isn’t conducive to their use.
- Age 65 Years and Older: Physiological changes associated with aging naturally increase fall risk.
- Lower Limb Prosthesis: Adjusting to and managing mobility with a prosthesis can present balance and coordination challenges.
Physiological Risk Factors
- Low Visual Acuity: Impaired vision significantly increases the risk of trips and falls due to environmental hazards.
- Hearing Impairment: Reduced auditory awareness can limit a patient’s ability to perceive environmental cues and hazards.
- Orthostatic Hypotension: Sudden drops in blood pressure upon standing can cause dizziness and fainting, leading to falls.
- Incontinence: Urgency and frequency associated with incontinence can lead to rushed movements and falls, particularly at night.
- Impaired Mobility and Strength: Weakness, limited range of motion, and balance deficits are direct contributors to fall risk.
- Poor Balance: Underlying conditions or age-related changes can compromise balance and stability.
- Confusion: Disorientation and impaired cognitive function can lead to poor judgment and increased risk-taking behaviors.
- Delirium: Acute confusional states significantly impair awareness and increase the likelihood of falls.
Medication-Related Risk Factors
- Antihypertensive Medications: These can contribute to orthostatic hypotension, particularly when initiating therapy or adjusting dosages.
- Sedatives: Medications that induce sedation can impair alertness, coordination, and reaction time.
- Narcotics: Opioid pain medications can cause drowsiness, dizziness, and confusion.
- Alcohol Use: Alcohol consumption impairs balance and judgment, increasing fall risk.
Environmental Risk Factors
- Restraints: While intended for safety, restraints can sometimes lead to falls if patients attempt to maneuver or escape them.
- Cluttered Environments: Obstacles such as furniture, equipment, and spills create tripping hazards.
- Inadequate Footwear: Slippery or ill-fitting footwear increases the risk of slips and falls.
Important Note: A “risk for” nursing diagnosis indicates a potential problem that has not yet occurred. Nursing interventions are therefore focused on proactive prevention strategies.
Expected Outcomes for Fall Risk Care Plans
Well-defined goals and expected outcomes are essential for effective fall risk management. Common nursing care planning goals include:
- Patient will remain free from falls. This is the ultimate and primary outcome.
- Patient will demonstrate a safe environment free from potential hazards. This focuses on patient and family education and environmental modifications.
- Patient will verbalize understanding of their individual risk factors for falls. Patient education and engagement are crucial for adherence to preventive measures.
Nursing Assessment for Fall Risk
A thorough nursing assessment is the first critical step in developing a personalized fall risk care plan. This involves gathering both subjective and objective data to identify individual risk factors.
1. Comprehensive Health Status Evaluation: Assess the patient’s overall health, noting both acute and chronic conditions that could impact safety. This includes inquiring about the use of aids like hearing aids or glasses, polypharmacy (multiple medications), and any cognitive impairments such as confusion.
2. Musculoskeletal and Neurological Assessment: Evaluate muscle strength, coordination, gait, and balance. Note any history of recent surgery, physical injuries, or conditions that may affect mobility and stability.
3. Utilize the Morse Fall Scale: Employ a standardized fall risk assessment tool like the Morse Fall Scale. This tool provides a rapid and validated method for identifying patients at risk of falling in a hospital setting. The Morse Fall Scale assigns scores based on various risk factors, with a score of 0 indicating no risk, scores between 25-44 indicating low to moderate risk, and scores of 45 or higher indicating high risk.
4. Mental Status Evaluation: Assess cognitive function and level of consciousness. Patients who are confused, sedated, or experiencing hallucinations may overestimate their physical capabilities or forget their limitations, increasing their fall risk.
5. Assistive Device Assessment: If the patient uses assistive devices, evaluate their appropriateness and proper usage. Ensure patients have access to necessary devices, such as walkers or bedside commodes, and that they understand how to use them safely and correctly.
Nursing Interventions for Fall Risk
Nursing interventions are the actions taken to mitigate identified fall risks and promote patient safety. These interventions should be tailored to the individual patient’s needs and risk level.
1. Implement Personalized Safety Measures: Select fall prevention interventions based on the patient’s specific condition and risk profile. For instance, a young, alert patient may only require a walker for support, while an elderly patient with confusion might need a bed alarm system. For patients with severe confusion who cannot follow directions, restraints or continuous 1:1 supervision may be necessary as a last resort to ensure safety. Restraint use must always adhere to strict institutional policies and ethical considerations.
2. Promote and Provide Appropriate Footwear: Encourage all hospitalized patients to wear non-slip footwear. Many hospitals utilize color-coded socks, often yellow, to visually identify patients at high risk for falls, alerting staff to exercise increased vigilance.
3. Utilize Fall Risk Identification Protocols: Implement clear and visible fall risk identifiers such as patient wristbands, chart stickers, and signage in the patient’s room. These visual cues serve as constant reminders to all healthcare staff to exercise heightened fall precautions when assisting the patient.
4. Maintain a Clutter-Free Environment: Ensure the patient’s room is free of clutter and potential tripping hazards. Remove unnecessary furniture, keep electrical cords and IV lines off the floor, and promptly clean up any spills.
5. Keep Essential Items Within Reach: Prior to leaving the room, always ensure the patient’s call button and personal items like water, tissues, and eyeglasses are within easy reach. This minimizes the patient’s need to reach or attempt to get out of bed unassisted, thereby reducing fall risk.
6. Encourage Assistance with Ambulation: Educate and encourage patients to use their call button to request assistance whenever they need to get out of bed, especially for toileting or ambulating. This proactive approach promotes a culture of safety and reduces independent, potentially risky movements.
7. Maintain Bed in the Lowest Position: Except when actively providing care at the bedside that necessitates raising the bed height, consistently keep the bed in the lowest position. This simple measure significantly reduces the potential injury severity should a fall from the bed occur.
8. Educate Patients and Families about Fall Risks: Engage in open and direct conversations with patients and their families about the individual risk factors that contribute to their fall risk. Clearly explain the specific safety measures being implemented and the rationale behind them. This education fosters patient and family understanding and promotes adherence to the care plan.
9. Collaborate with Therapy Services: Consult with physiotherapy and occupational therapy professionals to optimize patient mobility and safety. Therapy services can provide tailored interventions to improve strength, balance, and coordination. They are also crucial in instructing patients on the correct and safe use of new assistive equipment, such as crutches or walkers.
Nursing Care Plan Examples for Fall Risk
Nursing care plans provide a structured framework for prioritizing assessments and interventions to achieve both short-term and long-term patient care goals. Below are examples of nursing care plans addressing fall risk.
Care Plan #1
Diagnostic Statement:
Risk for falls related to improper walker use and orthostatic hypotension.
Expected Outcomes:
- Patient will remain free from injury.
- Patient will demonstrate the correct and safe use of a walker.
Assessment:
1. Walker Use Evaluation: Observe and assess how the patient uses their walker. Identifying specific errors in technique allows for targeted health teaching and skill development.
2. Medication Review: Thoroughly review the patient’s current medication regimen. Note the number and classes of medications, as polypharmacy and certain drug classes can contribute to orthostatic hypotension.
3. Comprehensive Medical History: Obtain a detailed medical history, including any pre-existing conditions such as stroke, brain injury, or musculoskeletal disorders, which may predispose the patient to falls.
Interventions:
1. Assistive Device Education and Support: Provide comprehensive education and support to the patient on the proper use and maintenance of their walker. Recognize that adjusting to assistive devices takes time, and incorrect use significantly increases fall and injury risk. Ensure the walker is appropriately sized and adjusted for the patient.
2. Encourage Therapeutic Exercise: Collaborate with the patient to establish appropriate exercise goals, if medically suitable. Regular exercise can improve gait, balance, and lower extremity strength, reducing fall risk.
3. Optimize Room Lighting: Ensure adequate room lighting, especially during nighttime hours. Proper lighting minimizes environmental hazards and reduces fall risk, particularly for patients with impaired mobility or vision.
4. Fall Risk Identification Wristband: Apply a fall risk identification wristband to the patient. This visual cue immediately alerts all healthcare team members to the patient’s heightened fall risk and the need for consistent fall precautions.
5. Physical Therapy Consultation: Collaborate with a physical therapist for specialized assessment and intervention. Physical therapists are experts in recommending exercises to improve balance, strength, and mobility. They can also assist in identifying and procuring appropriate assistive devices and advise on environmental safety modifications, including home modifications if relevant.
Care Plan #2
Diagnostic Statement:
Risk for falls related to vertigo and prolonged bed rest.
Expected Outcomes:
- Patient will remain free from falls.
- Patient will not experience dizziness, visual disturbances, or orthostatic hypotension.
Assessment:
1. Muscle Strength Assessment: Assess muscle strength, particularly in the lower extremities. Prolonged bed rest leads to muscle deconditioning and weakness, directly impacting mobility and increasing fall risk.
2. Vertigo History: Obtain a detailed history of vertigo, including frequency, duration, and triggers. Vertigo, characterized by a sensation of spinning or dizziness, significantly increases the risk of falls.
3. Environmental Hazard Assessment: Thoroughly assess the patient’s immediate environment for potential hazards such as clutter, slippery floors, and unsecured rugs. Identifying and removing these hazards is crucial for fall prevention.
Interventions:
1. Environmental Risk Factor Mitigation: Implement environmental modifications to minimize fall risk. Lower the bed to its lowest position, consider using a raised edge mattress or padding the floor beside the bed, and ensure clear pathways. Half-side rails or upright poles can be used cautiously to assist with bed mobility, but full side rails should be avoided as they can increase agitation in some patients and are not proven to prevent falls.
2. Assisted Transfers and Mobility: Provide assistance with transfers and mobility, especially when getting out of bed. Prolonged bed rest significantly impacts muscle strength, cardiac reserve, and endurance, making unassisted transfers unsafe.
3. Implement Gradual Position Changes: Instruct the patient to change positions slowly, particularly when moving from lying to standing. Encourage dangling legs at the bedside before standing to minimize orthostatic hypotension.
4. Medication Administration as Prescribed: Administer medications as prescribed to manage vertigo symptoms. These may include antihistamines, benzodiazepines, or antiemetics, depending on the underlying cause and patient presentation.
5. Physical Therapy Referral for Rehabilitation: Refer the patient to physical therapy or other appropriate exercise programs focused on strength, balance, flexibility, and endurance training. Programs incorporating at least two of these components have demonstrated effectiveness in reducing fall rates and the number of individuals experiencing falls.
References
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- 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/
