Which actions should the nurse take to prevent falls? A Comprehensive Guide

Over one-third of falls in hospitalized patients are considered preventable. It is therefore paramount for nurses to be proactive in implementing a multi-faceted approach to fall prevention. This guide details exactly which actions should the nurse take to prevent falls, ensuring patient safety and well-being.

Quick Summary

To prevent falls, nurses must conduct comprehensive patient risk assessments, implement environmental safety measures, manage fall-inducing medications, utilize assistive devices, and provide essential patient and family education.

Key Points

• Assess Thoroughly: Use standardized tools like the Morse Fall Scale to accurately identify patients at high risk for falls.

• Secure the Environment: Keep bed low, call light accessible, and clear pathways of clutter to prevent environmental hazards.

• Review Medications: Monitor and manage medications that increase fall risk, collaborating with pharmacists as needed.

• Educate Patients and Families: Teach safe movement techniques and reinforce the importance of calling for assistance.

• Utilize Assistive Devices: Ensure proper use of mobility aids like walkers and canes, and consider bed alarms for high-risk individuals.

• Document and Communicate: Document all risk assessments and interventions, communicating changes in patient status to the entire care team.

The Importance of Proactive Fall Prevention

Falls are a serious concern in healthcare, with consequences ranging from minor injuries to severe, life-threatening complications. Beyond the immediate physical harm, falls can also lead to a loss of patient confidence, decreased mobility, and longer hospital stays. The nurse's role is not simply reactive but must be centered on a proactive, evidence-based approach to minimize risk for all patients, especially the elderly and those with compromised mobility or cognitive function.

Comprehensive Patient Risk Assessment

The foundation of any fall prevention strategy is an accurate and timely risk assessment. This process should not be a one-time event but an ongoing part of patient care, adapted to changes in the patient's condition.

Identifying High-Risk Individuals

• Use Standardized Tools: Tools like the Morse Fall Scale or the Hendrich II Fall Risk Model are widely used to quantify a patient's risk based on specific criteria.
• Assess Medical History: Reviewing a patient's history for previous falls, osteoporosis, or other conditions affecting bone density is crucial.
• Monitor Medications: A thorough medication reconciliation is necessary, focusing on drugs known to increase fall risk, such as sedatives, diuretics, and certain blood pressure medications.
• Evaluate Gait and Balance: Observe the patient's mobility, balance, and gait. A nurse should note any unsteadiness or difficulty walking.
• Check Sensory Deficits: Poor vision and hearing can significantly impact a patient's awareness and stability. Ensure patients have their glasses and hearing aids.
• Assess Cognitive Status: Confusion, disorientation, and dementia increase the likelihood of a fall, particularly when a patient attempts to get up unassisted.

Implementing Environmental Safety Modifications

Nurses play a key role in ensuring the patient's immediate environment is as safe as possible. Simple changes can have a profound impact on reducing fall incidents.

Maintaining a Hazard-Free Zone

1. Keep the Call Light Within Reach: Ensure the patient knows how to use the call light and that it is always easily accessible. Respond to all calls promptly.
2. Optimize Bed Position: Keep the bed in the lowest possible position. Use bed alarms for high-risk patients to alert staff when they attempt to get out of bed.
3. Clear Pathways: Remove all clutter, including medical equipment, cords, and personal items, from walkways and floors.
4. Provide Adequate Lighting: Ensure the room is well-lit, especially at night. A nightlight can help prevent disorientation.
5. Secure Assistive Devices: Ensure walkers, canes, and wheelchairs are correctly used and positioned within the patient's reach.
6. Apply Non-Skid Footwear: Provide and ensure the patient wears non-skid socks or shoes to prevent slipping on hard surfaces.

Medication Management and Review

Many medications can have side effects that directly contribute to fall risk. The nurse is the front line in monitoring for these adverse effects and communicating with the healthcare team.

Nursing Actions for Medication Safety

• Educate the Patient: Inform the patient about the potential side effects of new medications, particularly dizziness or drowsiness.
• Collaborate with Pharmacy: Work with the pharmacy team to identify and recommend alternatives to high-risk medications where possible.
• Administer Medications Mindfully: If a patient receives a new sedative, closely monitor their mobility and cognitive state for a few hours after administration.

Fall Prevention Strategies: A Comparative Look

Intervention Type	Nursing Action	Impact on Fall Risk
Proactive	Conduct regular fall risk assessments; implement preventative measures before an incident occurs.	High Impact: Directly identifies and mitigates risks before they lead to a fall.
Reactive	Respond to a call bell after a fall has occurred; document the incident.	Low Impact: Addresses the outcome of a fall rather than preventing it.
Environmental	Ensure bed is low, call light is accessible, and paths are clear.	High Impact: Creates a safer physical space, reducing trip and slip hazards.
Patient-Specific	Provide individualized care plans, including mobility aids and patient education.	High Impact: Tailors interventions to the patient's unique needs and risks.
Pharmacological	Monitor and manage medications that increase fall risk.	Medium to High Impact: Mitigates a major internal risk factor for falls.

Patient and Family Education

Empowering patients and their families is a critical component of successful fall prevention. Informed individuals are more likely to participate actively in their own care and follow safety protocols.

Educating for Safety

• Review the Care Plan: Explain the patient's specific fall risks and the measures being taken to prevent them.
• Teach Safe Practices: Instruct patients on how to safely get out of bed, use assistive devices, and call for help when needed.
• Reinforce Understanding: Periodically review this information, especially with patients who have memory issues or cognitive impairment.

Conclusion

Ultimately, the question of which actions should the nurse take to prevent falls has a multi-layered answer that combines assessment, environmental safety, medication review, and education. By consistently applying these strategies, nurses can significantly reduce fall incidents, protect patient well-being, and improve overall healthcare outcomes. For more evidence-based practices and resources on patient safety, visit authoritative sources like the Agency for Healthcare Research and Quality (AHRQ). For further resources on hospital patient safety and fall prevention, visit the AHRQ website.

Frequently Asked Questions

What is the most crucial action a nurse should take first to prevent falls?

The most crucial initial action is to conduct a thorough and accurate fall risk assessment. This identifies the patient's specific risk factors, allowing the nurse to tailor a personalized prevention plan.

How often should a nurse assess a patient's fall risk?

A nurse should assess a patient's fall risk upon admission, after any significant change in their condition, and regularly throughout their stay according to hospital policy, often at the beginning of each shift.

Which medications increase the risk of falls?

Medications that can increase fall risk include sedatives, hypnotics, opioids, diuretics, and certain antihypertensives. Nurses should closely monitor patients receiving these drugs for side effects like dizziness or lightheadedness.

Can repositioning a patient's bed prevent falls?

Yes, a simple but highly effective action is to keep the bed in the lowest possible position. This minimizes the distance to the floor should a patient roll or attempt to get out of bed independently.

What role does the patient's family play in fall prevention?

The patient's family is a valuable part of the care team. Nurses should educate them on the patient's fall risk and the importance of using the call bell. They can also assist with supervision and reinforcement of safe practices.

How can a nurse ensure a patient with dementia doesn't fall?

For patients with cognitive impairment, nurses should use strategies like placing the patient in a room close to the nursing station, using bed or chair alarms, and ensuring a predictable, calm environment to reduce confusion and wandering.

What should a nurse do if a patient with a known fall risk insists on getting up alone?

The nurse should engage in therapeutic communication, explaining the risks involved. If the patient persists, the nurse should call for assistance to help the patient move safely, utilize bed or chair alarms, and if necessary, reposition the patient closer to the nursing station for better observation.