The Critical Role of Nurses in Fall Prevention
Falls are a leading cause of fatal and non-fatal injuries among older adults. In a healthcare setting, the responsibility for identifying at-risk patients and implementing preventive measures often falls squarely on the shoulders of the nursing staff. A fall can lead to devastating consequences, including fractures, traumatic brain injuries, a fear of falling, and a significant decline in independence. Therefore, a nurse's ability to accurately assess fall risk is not just a routine task; it is a critical component of ensuring patient safety and quality of care. This assessment is a dynamic, ongoing process that relies on sharp observational skills, clinical expertise, and the use of structured assessment tools.
Understanding Fall Risk Factors: Intrinsic vs. Extrinsic
A nurse's assessment begins with understanding the two broad categories of risk factors that contribute to falls. A comprehensive evaluation must consider both.
Intrinsic (Patient-Related) Factors
Intrinsic factors originate from within the patient and are related to their physiological and psychological state. Key factors include:
- History of Falls: A previous fall is one of the strongest predictors of a future fall.
- Impaired Mobility and Gait: Difficulty walking, poor balance, and muscle weakness significantly increase risk. Nurses assess gait for abnormalities like shuffling or unsteadiness.
- Medication Side Effects: Polypharmacy (using multiple medications) is a major risk. Drugs like sedatives, benzodiazepines, antiepileptics, and antihypertensives can cause dizziness, drowsiness, or orthostatic hypotension (a sudden drop in blood pressure upon standing).
- Cognitive Impairment: Patients with dementia, delirium, or general confusion may not be aware of their physical limitations or environmental hazards, leading to impulsive or unsafe behavior.
- Sensory Deficits: Poor vision, such as from cataracts or glaucoma, and hearing loss can prevent a person from identifying environmental hazards.
- Altered Elimination: Urinary or bowel urgency and incontinence can cause a patient to rush to the bathroom, increasing their fall risk, especially at night.
Extrinsic (Environmental) Factors
Extrinsic factors are external to the patient and are related to their immediate environment. These are often modifiable. Key factors include:
- Hazards in the Room: Clutter, poor lighting, spills on the floor, and unsecured rugs create tripping hazards.
- Improper Equipment Use: Assistive devices like walkers or canes that are the wrong size or used incorrectly can be unstable. Likewise, unlocked wheelchair brakes are a common cause of falls during transfers.
- IV Poles and Tubing: Intravenous lines and other medical tubing can become tangled, creating a tripping hazard.
- Footwear: Patients wearing only socks or ill-fitting, non-skid footwear are at a higher risk of slipping.
Standardized Fall Risk Assessment Tools
While clinical judgment is invaluable, standardized tools provide an objective, evidence-based method to score risk and guide interventions. Two of the most widely used tools in clinical practice are the Morse Fall Scale and the Hendrich II Fall Risk Model.
The Morse Fall Scale (MFS)
The MFS is a rapid and simple tool that assesses six key variables. Points are assigned for each, and the total score categorizes the patient's risk.
- History of falling (immediate or recent): (Yes: 25, No: 0)
- Secondary diagnosis: (Yes: 15, No: 0)
- Ambulatory aid: (Crutches/Cane/Walker: 15, Furniture: 30, None/Bed rest/Wheelchair: 0)
- IV or Heparin Lock: (Yes: 20, No: 0)
- Gait/Transferring: (Impaired: 20, Weak: 10, Normal/Bed rest: 0)
- Mental status: (Overestimates or forgets limits: 15, Knows own limits: 0)
Scoring: A total score of 0-24 is considered low risk, 25-44 is moderate risk, and ≥45 is high risk.
The Hendrich II Fall Risk Model (HIIFRM)
The HIIFRM is another validated tool that focuses on specific risk factors identified in hospitalized older adults. A score of 5 or greater is considered high risk.
- Confusion, Disorientation, Impulsivity: (4 points)
- Symptomatic Depression: (2 points)
- Altered Elimination: (1 point)
- Dizziness or Vertigo: (1 point)
- Male Gender: (1 point)
- Administered Antiepileptics: (2 points)
- Administered Benzodiazepines: (1 point)
- Get-Up-and-Go Test: Assesses the ability to rise from a chair. (Points range from 0-4 based on ability and balance).
Comparison of Common Fall Risk Assessment Tools
| Feature | Morse Fall Scale (MFS) | Hendrich II Fall Risk Model (HIIFRM) |
|---|---|---|
| Primary Setting | Acute care, hospitals, long-term care | Primarily acute care, with a focus on elderly patients |
| Number of Factors | 6 variables (e.g., fall history, IV access) | 8 variables (e.g., specific meds, depression) |
| Key Focus | A broad mix of physiological, functional, and cognitive states. | Strong focus on specific clinical diagnoses and high-risk medication classes. |
| Scoring | 0-24 (Low), 25-44 (Medium), ≥45 (High) | A single threshold score of 5 or greater indicates high risk. |
From Assessment to Action: Universal Fall Precautions
Identifying risk is only the first step. The assessment findings must translate directly into a personalized care plan and universal precautions for all patients, especially those identified as high risk. Effective nursing interventions include:
- Purposeful Rounding: Checking on the patient hourly to address needs like toileting, positioning, and pain management.
- Safe Environment: Keeping the bed in the lowest position, locking wheels on beds and wheelchairs, and ensuring the call bell and personal items are within easy reach.
- Patient Education: Teaching the patient and their family about the risks and the importance of calling for assistance before getting up.
- Visual Cues: Using signage, colored armbands, or socks to alert all staff members that a patient is a high fall risk.
- Mobility Assistance: Ensuring the patient has and correctly uses appropriate assistive devices.
For a comprehensive set of tools and resources, healthcare providers can refer to the CDC's STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative.
Conclusion: A Proactive Stance on Patient Safety
Determining if a patient is at risk for falls is a fundamental nursing responsibility that blends art and science. It requires astute clinical observation, empathetic patient communication, and the disciplined use of validated assessment tools. By systematically evaluating intrinsic and extrinsic factors, nurses can move beyond simply reacting to falls and instead proactively implement strategies that protect their patients, preserve independence, and ultimately save lives.
