Fall Precautions lesson 1

A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. Falls and injuries at hospitals are the most common adverse event reported in hospitals and a major concern to healthcare personnel, patients, and their families leaving many unanswered questions. Why are falls increasing in the elderly patients? What can nurses and nurse assistants do to prevent or reduce the frequency of falls?

Falls are common and costly. In 2000, more than 2.6 millionolder adults experienced a fall-related injury, and their healthcosts related to fall injuries were estimated to exceed $19billion. Falls leads to patient functional decline, increase in hospital’s length of stay, and increased hospital costs by added tests like computed tomography to rule out head trauma or bleed after a fall, and for labor cost for bedside sitter monitoring by a nurse aide. Among older adults, falls remain in the top 10 causes of death and are among the most common causes of serious work related injuries and deaths among the elderly. Statistics show that approximately one in every three adult over 65 years old fall each year. Almost 30% of these falls results in serious injuries.

Being hospitalized and being in unfamiliar surroundings places many Patients at risk for falls. The most frequent time for patients falls is early morning, during change of shifts and after meals so nursing staff should be especially vigilant during these critical times.  When a patient falls in the hospital, you will often hear a staff member say, “I knew he is going to fall, I knew it”. This is because most patients falls are really not a surprise. In most cases, someone has already noticed the risk factors of the patient in relation to falls. Most likely this is a patient who is impulsive, is not using his call light for assistance, and has already attempted to get out of bed by himself.

Patient factors that contribute to falls include age-related changes in postural control, impaired gait, decreased visual acuity, medications, the presence of acute and chronic diseases that affect sensory input, the central nervous system, and coordination. Osteoporosis is also an important factor—pathologic fractures often precede a fall.

Other risk factors for falls include vitamin D status, cognitive status, physical decline, and mobility impairment. Risk factors for falls include use of medications like narcotics, sedatives, hypnotics, antidepressants, anti-hypertensives, and diuretics. Other non-pharmalogical factors are unfamiliar environment, sensory deficits, cognitive status, physical decline, and mobility impairment. Environmental factors include poor lighting, obtrusive furniture, slippery floors, loose floor coverings, and bathrooms without handrails or grab bars. The most common risk factors were gait imbalance, confusion due to new surroundings, orthostatic hypotension related to medications, decreased cognition, urinary incontinence, pain or discomfort, and polypharmacy.

Risk Factors Include Individuals who:

• Have fallen before
• Have cognitive impairment
• Have mobility impairment
• Are incontinent
• Have medications affecting balance/cognition and polypharmacy
• Have sensory deficits
• Are confused, agitated or disoriented
• Are recovering from surgery
• Are older
• Have poor vision
• Use a walker, cane, or crutches
• Are unwilling or unable to use the call button to ask for assistance.

Additional factors that affect patient safety (Secondary diagnoses);

• Advanced age
• Motor deficits – paresis or paralysis
• General/LE weakness/Deconditioning
• Poor balance/Impaired gait
• Sensory deficits – tactile, visual, hearing
• Acute confusional state/dementia or deliriums
• Impaired cognitive function (disoriented, inability to learn or recall information)
• Inability to follow direction
• Impulsive behavior, restless, agitated
• Medication and side effects such as, but not limited to anesthetics antihistamines, anti-diabetics, benzodiazepines, narcotics, sedatives, hypnotics, anti-depressants, psychotropics, anti-hypertensives, diuretics, cathartics, and anticoagulants. Patients taking 3 or more medications are at higher risk for falls.
• Unfamiliar environment
• Non-compliance with safety precautions
• Use of assistive devices for ambulation
• Orthostatic changes/dehydration/volume depletion
• Impaired communication
• History of incontinence (bowel or bladder)

Patients should be assessed and reassessment should occur every shift and with the following conditions:

• Medications that may affect blood pressure or alertness
• Mental status change
• 30-60 minutes after prn medications that may contribute a fall.
• Fatigue
• Changes in urinary or bowel elimination patterns
• Change in clinical condition
• After a fall