What actions can a nurse take to eliminate minimise falls risk?

Falls are the most frequently reported incidents in critical care hospitals, accounting for 14-53% of incidents. A nurse can take several evidence-based actions to eliminate or minimise falls risk, including conducting thorough risk assessments, modifying the environment, and engaging both the patient and their family in the prevention plan. By implementing proactive, personalized strategies, nurses can significantly reduce the incidence of patient falls and related injuries.

Quick Summary

Nurses can minimize falls by conducting personalized risk assessments, modifying the environment, reviewing medications, and engaging patients and families in the safety plan. Intentional hourly rounds and targeted education are key interventions to address individual patient needs and environmental hazards.

Key Points

• Thorough Risk Assessment: Consistently use validated tools like the Morse Fall Scale to assess and document a patient's intrinsic and extrinsic fall risk factors, especially upon admission and after condition changes.

• Hourly Rounding: Implement and perform intentional hourly rounding to proactively address common patient needs like pain, positioning, and toileting, reducing the need for unassisted movement.

• Environmental Safety: Ensure the patient's environment is free of hazards by keeping beds low, floors clear and dry, and personal items within easy reach.

• Medication Review: Collaborate with a pharmacist to review a patient's medication list for drugs that increase fall risk, and consider adjusting or discontinuing them where appropriate.

• Patient and Family Engagement: Educate patients and their families about identified fall risks and the personalized prevention plan to encourage their active participation in safety measures.

• Assistive Device Management: Ensure patients have and correctly use appropriate, well-fitted assistive devices like walkers or canes and provide regular supervision.

• Team Collaboration: Use clear communication tools, like high-risk signage, and conduct post-fall huddles to ensure all healthcare team members are aware of fall risks and to learn from any incidents.

Comprehensive Fall Risk Assessment

Effective fall prevention begins with a thorough and ongoing assessment of each patient's risk factors. Nurses should use validated screening tools, such as the Morse Fall Scale, to systematically evaluate a patient's likelihood of falling. This process should be initiated upon admission and repeated regularly throughout the patient's stay, especially after any significant change in their condition.

Assessing Intrinsic and Extrinsic Factors

A comprehensive assessment goes beyond a simple score to consider both intrinsic (patient-related) and extrinsic (environmental) risk factors. Intrinsic factors include: a history of previous falls, gait and balance deficits, muscle weakness, visual and hearing impairments, cognitive issues like delirium or dementia, and certain medical conditions such as vertigo, diabetes, or depression. Extrinsic factors include: environmental hazards like clutter, poor lighting, slippery floors, and unstable equipment.

Patient and Family Education

Education is a cornerstone of fall prevention. Nurses should involve the patient and their family in the fall prevention plan from the beginning. This includes explaining identified risk factors, detailing the personalized prevention strategies being used, and demonstrating how to use the call light properly. Empowering patients with this knowledge increases their participation and adherence to safety protocols.

Implementing Universal and Targeted Interventions

Based on the risk assessment, nurses can implement a combination of universal and targeted interventions. Universal interventions are applied to all patients to create a safe environment, while targeted interventions address specific, identified risks.

Universal Interventions for All Patients

• Maintain a safe environment: Keep the patient's room free of clutter and ensure floors are clean and dry. Lock the wheels on beds and wheelchairs when stationary to prevent them from moving during transfers.
• Proper positioning and placement: Keep the patient's bed in the lowest position when they are resting. Place the call light, personal belongings, and bedside tables within safe and easy reach to prevent patients from reaching or overextending.
• Encourage proper footwear: Ensure the patient wears non-slip, well-fitting footwear when ambulating.
• Hourly rounding: Conduct intentional, frequent rounds to proactively address patient needs, such as toileting, pain, and positioning. This helps prevent patients from attempting to get up unassisted.

Targeted Interventions for High-Risk Patients

• Enhanced supervision: For patients with cognitive impairment or a high fall risk score, place them in a room with better visual access to the nursing station or assign a companion (sitter) for one-on-one observation.
• Medication management: Review the patient's medications, consulting with a pharmacist and physician, to identify and potentially reduce or discontinue drugs that increase fall risk, such as sedatives, diuretics, and certain antidepressants.
• Mobility assistance: Collaborate with physical and occupational therapists to develop individualized exercise plans to improve the patient's strength, gait, and balance. Use gait belts during transfers and ambulation as per protocol.
• Toileting schedule: Establish and adhere to a scheduled toileting program for patients with frequent or urgent toileting needs to prevent unassisted trips to the bathroom.

Environmental and Assistive Device Management

Nurses must be vigilant about managing both the physical environment and the proper use of assistive devices. These extrinsic factors are often modifiable and can have a significant impact on fall risk.

Comparison of Environmental Modifications vs. Assistive Devices

Feature	Environmental Modifications	Assistive Device Management
Purpose	To remove hazards and improve visibility and accessibility within the patient's space.	To enhance a patient's mobility, stability, and functional independence.
Examples	Ensuring clear pathways, adjusting lighting, using grab bars in bathrooms, and removing throw rugs.	Proper use and fitting of canes, walkers, or wheelchairs; providing non-slip footwear.
Implementation	Setting up the room and ensuring consistent maintenance by all staff.	Training the patient and staff on correct usage, and regularly inspecting devices for safety.
Primary Role	Creates a safe, predictable, and accessible living or hospital space.	Compensates for a patient's physical limitations and gait deficits.
Limitations	May not be sufficient if intrinsic risk factors are severe. Can be a challenge in a changing, busy environment.	Ineffective if the patient does not use it correctly, or if the device is not properly fitted or maintained.

Communication and Collaboration

Effective communication among the healthcare team is vital for a successful fall prevention program. Nurses should use clear protocols to document and communicate a patient's fall risk to all staff, including during handovers and transfers to different departments. Many hospitals use visual aids like red armbands or specific signage to alert all team members to a patient's high fall risk status. Post-fall huddles are also important to review the circumstances of any fall and identify areas for improvement.

Conclusion

Minimizing falls risk is a multifaceted effort that relies on the nurse's dedication to patient safety. The proactive steps of comprehensive assessment, individualized care planning, environmental management, and collaborative communication are critical. By implementing evidence-based strategies, nurses play an indispensable role in protecting patients from harm, preserving their health, and fostering a culture of safety throughout the healthcare setting. By empowering patients and collaborating with the wider care team, nurses ensure that every action taken moves toward a safer patient environment.

Frequently Asked Questions

What is the role of medication management in minimizing fall risk?

Medication management involves regularly reviewing a patient's medications with a pharmacist or physician to identify and address any drugs that increase fall risk. Sedatives, diuretics, and certain antidepressants are commonly implicated and may require dose adjustment or discontinuation to reduce the risk of dizziness and sedation.

How do hourly rounds help reduce falls?

Intentional hourly rounding is a proactive strategy where nurses or assistants check on patients frequently to address common needs such as toileting, pain, and repositioning. By anticipating these needs, nurses prevent patients from attempting to get up on their own, which significantly reduces the risk of falls.

What environmental modifications can a nurse make in a patient's room?

Nurses can make several environmental modifications to minimize fall risk. This includes keeping the bed in the lowest position, ensuring the call light and personal items are within reach, maintaining clear pathways free of clutter, and ensuring adequate lighting, especially at night.

Why is patient and family education important for fall prevention?

Patient and family education is crucial because it empowers them to be active participants in the safety plan. By understanding the risks and the specific prevention strategies, patients are more likely to adhere to safety protocols, and family members can reinforce these measures.

What is the Morse Fall Scale?

The Morse Fall Scale is a widely used and validated tool that helps nurses quickly and systematically assess a hospitalized patient's risk of falling. The scale evaluates several factors, and the resulting score helps determine the level of intervention required.

How can nurses assist patients with mobility challenges?

For patients with mobility issues, nurses can collaborate with physical therapists to implement exercise programs that improve strength and balance. They should also use proper techniques and assistive devices, such as gait belts, when assisting with transfers and ambulation.

What should happen after a patient falls?

After a patient falls, a nurse should immediately assess the patient for injuries and ensure their safety. The incident should be documented, and a post-fall huddle should be conducted by the healthcare team to analyze the circumstances of the fall. This allows the team to identify why the fall occurred and adjust the patient's care plan to prevent future incidents.