Clinical Findings
- Unexplained abrasions, Pt found on floor, or reported falling.
Possible Causes: Sedation, debilitation, unfamiliar surroundings, side rails left down, call-bell malfunction or not left within easy reach, drug reaction, improper use of restraints, dysrhythmias, altered LOC, altered proprioception, spill on floor.
Collaborative Management
- Do not move Pt if they are unconscious, complain of severe pain, or have a deformity of an extremity (obvious fracture, internal rotation of hip or knee).
- If Pt is unconscious, get help, assess ABC, immobilize c-spine.
- If Pt is conscious, have Pt lie still while you call for help.
- If Pt is alert with no obvious injuries, assist to bed or chair with help from another staff member.
- Assess LOC and orientation, VS, and pain level.
- Assess ability to move all extremities—assess alignment and symmetry, soft tissue and skin for abrasions, swelling, or deformity.
- Assess for acute underlying condition, such as infection, TIA, UTI, hypotension, or cardiac dysrhythmia.
- Assess for orthostasis, problems with gait, changes in mental status, and recent changes in functional status.
- Review records for preexisting conditions, medication use, and previous falls.
- Assess MAR for polypharmacy or medication that may have contributed to fall.
- Ask if Pt felt dizzy or light-headed before falling.
- Assess environment for potential cause of fall and safety hazards.
- Determine extent of injury and initiate fall prevention strategies—modify environment to eliminate hazards; arrange for one-on-one care if Pt is confused.
- Treat minor injuries—clean and dress abrasions; apply ice to contusions or areas of swelling.
- Monitor Pt closely for changes in condition, especially changes in mental status, which can suggest brain injury.
- Assess distal CSM of injured extremities.
- Assist with x-rays or other diagnostic tests.
- Complete an incident report.
Fall Risk Assessment and Interventions
| Risk Factor | Intervention |
|---|
Assessment Data- Age >65 yr
- History of falls
| - Monitor frequently.
- Pt should be close to nurses’ station.
- Implement fall prevention interventions.
|
Medications- Polypharmacy
- CNS depressants
- BP/HR lowering
- Diuretics
- GI motility meds
| - Review meds with physician.
- Assess for meds that may affect BP, HR, balance, or LOC.
- Educate about use of sedatives, narcotics, and vasoactive meds.
- Encourage nonopioid pain management.
|
| Mental Status | - Routinely reorient Pt to situation.
- Maintain a structured environment.
- Use pressure-sensitive bed/chair alarms.
|
| Cardiovascular | - Change positions slowly.
- Review MAR for possible changes.
|
Neurosensory- Visual impairment
- Peripheral neuropathy
- Difficulty with balance or gait
| - Provide illumination at night.
- Minimize clutter and remove unnecessary equipment from room.
- Provide protective footwear.
- Provide appropriate assistive devices and instruct on proper use.
|
GI/GU- Incontinence
- Urinary frequency
- Diarrhea
| - Ensure call light is within easy reach.
- Create toileting schedule.
- Provide bedside commode or urinal or unobstructed, well-lit path to bathroom.
|
| Musculoskeletal | - Provide range-of-motion exercises and stretching.
- Provide PT or OT consults.
- Provide appropriate assistive devices.
|
| Deconditioning | - Start PT for strengthening exercises, balance training.
|
Assistive Devices- Use of cane, walker, or WC
| - Ensure that assistive devices are not damaged and are appropriately sized.
- Instruct Pt on proper and safe use.
|
Environment- Cluttered room.
- Tubes and lines
| - Minimize clutter; remove unnecessary or infrequently used equipment.
- Ensure call light is within easy reach.
|