Patients have the opportunity to bring up things they need each hour and seek assistance with ambulation and toileting with a decreased need to use the call light. Promptly answering the call light and assisting the patient will prevent the patient from getting out of bed unassisted. Having all items within reach of the patient can reduce the number of times the patient may attempt to get out of bed and ultimately reduce the risk of falling.Įncourage Assistance When Ambulating and ToiletingĮnsuring that patients are assisted can improve safety and the prevention of falls. Personal Items and Possessions Within Reach The use of a call light can be an important factor in reducing falls, as patients can ask for items to be moved closer or for assistance with mobilization. Signs placed in the patient's room to remind patients to use the call light.Ī clean and clutter-free environment allows for safe ambulation if the patient gets up independently. Wristbands can remind patients to seek assistance when getting out of bed independently. Provides safe ambulation practices for the patient, ensuring there is little room for the patient to slip on the floor. Once specific nursing interventions are selected, they should be placed on the nursing care plan. Each intervention should be selected based on the patient's fall risk (low risk, moderate risk, or high risk) using the Morse Fall Scale. Nursing interventions and safety measures vary depending on the nursing assessment and the associated nursing diagnosis. Extra clutter and cords create trip hazards if the patient were to get up by themselves, putting them at an increased risk for falls. The environment should remain free of clutter, cords, and spills. Collaborating with providers to reduce the medication the patient takes can be beneficial. Other medication side effects causing an increased risk for falls are dizziness, blurred vision, impaired cognition, and altered gait and balance. A score is then provided, determining if the patient has a low, moderate, or high fall risk.Ī thorough review of what medications the patient takes at home and what they receive in the hospital is important as many medications can cause changes in blood pressure resulting in hypotension (6) and lowered heart rate. This fall scale considers the patient's history of falls, secondary diagnosis, ambulatory aid, IV therapy, gait, and mental status. The Morse Fall Scale is a fall risk assessment used to identify risk factors for falls in hospitalized patients (5). If the patient is hallucinating or confused, they are at an increased risk of overestimating their abilities and may be more impulsive in their actions. There is a potential for loss of muscle strength and an impaired gait making it difficult for the patient to be independent in their activities of daily living. How the patient moves to the bed, in the bed, and what kind of assistance the patient will need is important to be mindful of. Other evaluations to consider during the medical history review are the patient's use of recreational drugs and alcohol.Įnsure that the patient's skin is intact and that there are no wounds on the ankles, feet, or heels that could impact the patient's ability to ambulate. Note the chronic conditions that the patient may have that impact their ability to walk, see, or hear. Caregivers can provide information on the patient's baseline status at home to compare.Įvaluation and Assessment of Primary Medical History: Example: A hypotensive patient is at an increased risk for a fall. Medical conditions and vitals can indicate that the patient is not at baseline. An important note is that the care setting (progressive, acute care, etc.) can affect how much you can assess. It is important that a thorough assessment is completed upon admission and anytime there is a patient condition change (post fall, each shift, environmental changes, etc.). What Is the Nursing Assessment for Risk for Falls?īefore providing a nursing diagnosis, a nursing assessment for risk for falls must be completed. The patient will verbalize understanding of the risk for falls. The patient will demonstrate a clutter-free environment. The patient will demonstrate the use of call light. The patient will remain free from falls during their hospital stay. Lack of fall prevention equipment: safety harness, etc History of falls (both at home and inpatient)Ĭords: IV pumps, sequential compression device Neurological deficit: stroke (current or previous), dementia, brain tumors, delirium, confusion, etc. Use of assistive devices: cane, walker, wheelchairs, etc. Impaired gait and mobility: paralysis, weakness, etc. Many fall risk factors place a patient at a higher risk for falls. Preventing falls is fundamental in reducing incidence of falls with injury.
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