Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Parameters of Assessment
- Assess and document all older adult patients for intrinsic risk factors to fall:
- Advancing age, especially if older than 75
- History of a recent fall
- Specific co-morbidities: dementia, hip fracture, type II diabetes, Parkinson's disease, arthritis, and depression
- Functional disability: use of assistive device
- Alteration in level of consciousness or cognitive impairment
- Gait, balance, or visual impairment
- Use of high-risk medications (Chang et al., 2004 [Level I])
- Urge urinary incontinence (Brown, Vittinghoff, & Wyman, 2000 [Level III])
- Physical restraint use (Capezuti et al., 2002 [Level III])
- Bare feet or inappropriate footwear
- Identify risks for significant injury due to current use of anticoagulants such as Coumadin, Plavix, or aspirin and/or those with osteoporosis or risks for osteoporosis (Resnick, 2003 [Level VI]).
- Assess and document patient-care environment routinely for extrinsic risk factors to fall and institute corrective action:
- Floor surfaces for spills, wet areas, and unevenness
- Proper level of illumination and functioning of lights (night light works)
- Table tops, furniture, beds are sturdy and are in good repair
- Grabrails and grab bars are in place in the bathroom
- Use of adaptive aides work properly and are in good repair
- Bedrails do not collapse when used for transitioning or support
- Patient gowns/clothing do not cause tripping
- Intravenous (IV) poles are sturdy if used during ambulation and tubing does not cause tripping.
- Perform a post-fall assessment (PFA) following a patient fall to identify possible fall causes (if possible, begin the identification of possible causes within 24 hours of a fall) as determined during the immediate, interim, and longitudinal post-fall intervals. Because of known incidences of delayed complication of falls, including fractures, observe all patients for about 48 hours after an observed or suspected fall ("Guideline for the prevention," 2001 [Level VI]; Emergency Care Research Institute [ECRI], 2006 [Level VI]; Gray-Miceli et al, 2006 [Level III]):
- Perform a physical assessment of the patient at the time of the fall, including vital signs (which may include orthostatic blood pressure readings), neurological assessment, and evaluation for head, neck, spine, and/or extremity injuries.
- Once the assessment rules out any significant injury:
- Obtain a history of the fall by the patient or witness description and document
- Note the circumstances of the fall: location, activity, time of day, and any significant symptoms
- Review of underlying illness and problems
- Review medications
- Assess functional, sensory, and psychological status
- Evaluate environmental conditions
- Review risk factors for falling ("Guideline for the prevention," 2001; American Medical Directors Association [AMDA], 1998; ECRI, 2006; University of Iowa Gerontological Nursing Interventions Research Center [UIGN], 2004; Resnick, 2003 [all Level VI])
- In the acute-care setting, an integrated multidisciplinary team (consisting of the physician, nurse, health care provider, risk manager, physical therapist, and other designated staff) plans care for the older adult, at risk for falls or who has fallen, hinged on findings from an individualized assessment (ECRI, 2006; Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2006 [both Level VI]).
- The process approach to an individualized PFA includes use of standardized measurement tools of patient risk in combination with a fall-focused history and physical examination, functional assessment, and review of medications ("Guideline for the prevention," 2001; AMDA, 1998; Resnick, 2003; UIGN, 2004 [all Level VI]). When plans of care are targeted to likely causes, individualized interventions are likely to be identified. If falling continues despite attempts at individualized interventions, the standard of care warrants a reexamination of the older adult and their falls.
Nursing Care Strategies
- General safety precaution and fall prevention measures that apply to all patients, especially older adults:
- Assess the patient care environment routinely for extrinsic risk factors and institute appropriate corrective action.
- Use standardized environmental checklists to screen; document findings.
- Communicate findings to risk managers, housekeeping, maintenance department, all staff and hospital administration, if needed.
- Re-evaluate environment for safety (ECRI, 2006 [Level VI]).
- On admission, assess/screen older adult patient for multifactorial risk factors to fall, following a change in condition, on transfer to a new unit, and following a fall (ECRI, 2006 [Level VI]):
- Use standardized or empirically tested fall-risk tools in conjunction with other assessment tools to evaluate risk for falling (e.g., Tinetti Performance Oriented Mobility, the Timed Get Up and Go Test, [Tinetti, Williams, & Mayewski, 1986] [Level II]; "Guideline for the prevention," 2001 [Level VI]).
- Document findings in nursing notes, interdisciplinary progress notes, and the problem list.
- Communicate and discuss findings with interdisciplinary team members.
- In the interdisciplinary discussion, include review and reduction or elimination of high-risk medications associated with falling.
- As part of falls protocol in the facility, flag the chart or use graphic or color display of the patient's risk potential to fall.
- Communicate to the patient and the family caregiver identified risk to fall and specific interventions chosen to minimize the patient's risk.
- Include patient and family members in the interdisciplinary plan of care and discussion about fall-prevention measures.
- Promote early mobility and incorporate measures to increase mobility, such as daily walking, if medically stable and not otherwise contraindicated.
- Upon transfer to another unit, communicate the risk assessment and interventions chosen and their effectiveness in fall prevention.
- Upon discharge, review with the older patient and or family caregiver the fall risk factors and measures to prevent falls in the home. Provide patient literature/brochures if available. If not readily available, refer to the Internet for appropriate Web sites and resources.
- Explore with the older patient and/or family caregiver avenues to maintain mobility and functional status; consider referral to home-based exercise or group exercises at community senior centers. If discharge is planned to a subacute or rehabilitation unit, label the older adult's mobility status, functional status, and other forms of activity in the home to increase gait or balance on the transfer form.
- Institute general safety precautions according to facility protocol, which may include:
- Referral to a falls prevention program
- Use of a low-rise bed that measures 14 inches from floor
- Use of floor mats if patient is at risk for serious injury, such as osteoporosis
- Easy access to call light
- Minimization and/or avoidance of physical restraints
- Use of personal or pressure sensors alarms
- Increased observation and surveillance
- Use of rubber-sole heeled shoes or nonskid slippers
- Regular toileting at set intervals and/or continence program; provide easy access to urinals and bedpans
- Observation during walking rounds or safety rounds
- Use of corrective glasses for walking
- Reduction of clutter in traffic areas
- Early mobility program (ECRI, 2006 [Level VI])
- Provide staff with clear, written procedures describing what to do when a patient fall occurs.
- Identify specific patients requiring additional safety precautions and/or evaluation by a specialist, or:
- Those with impaired judgment or thinking due to acute or chronic illness (delirium, mental illness)
- Those with osteoporosis, at risk for fracture
- Those with current hip fracture
- Those with current head or brain injury (standard of care)
- Review and discuss with interdisciplinary team findings from the individualized assessment and develop a multidisciplinary plan of care to prevent falls (Chang et al., 2004 [Level I]).
- Communicate to the physician or advance practice nurse important PFA findings (ECRI, 2006 [Level VI]).
- Monitor the effectiveness of the falls prevention interventions instituted.
- Following a patient's fall, observe for serious injury due to a fall and follow facility protocols for management (standard of care).
- Following a patient's fall, monitor vital signs, level of consciousness, neurological checks, and functional status per facility protocol. If significant changes in patient's condition occurs, consider further diagnostic tests such as plain film x-rays, CT scan of the head/spine/extremity, neurological consultation, and/or transfer to a specialty unit for further evaluation (standard of care).
Table: Interventions to Decrease Risk for Falls
| Risk Factors |
Nursing Interventions to Decrease Risk for the Individual
|
| History of Falls |
Identify the patient as being at risk for falls: may use sticker on chart or door |
| Fear of Falling |
Encourage patient to verbalize feelings
Strengthen self-efficacy related to transfers and ambulation by providing verbal encouragement about capabilities and demonstrating to patient his/her ability to perform safely
|
| Bowel and Bladder Incontinence |
Set up regular voiding schedule (every 2 hours or as appropriate based on patient need)
Monitor bowel function and encourage sufficient fluids and fiber (eight 8-ounce glasses daily and 24 grams of fiber)
Utilize laxatives as appropriate
|
| Cognitive Impairment |
Evaluate patient for reversible causes of cognitive impairment/delirium and eliminate causes as relevant
Monitor resident with cognitive impairment at least hourly with relocation of the patient such that nursing staff can observe/monitor regularly
Encourage family member to hire staff or stay with patient continuously
Utilize monitoring devices if accessible (i.e., bed/chair or exit alarms)
|
| Mood |
Encourage verbalization of feelings
Evaluate patient's ability to concentrate and learn new information
Encourage engagement in daily activities.
Refer to geriatric psychiatry as appropriate
|
| Dizziness |
Monitor lying, sitting and standing blood pressures and continually evaluate for factors contributing to dizziness
Encourage adequate fluid intake (eight 8-ounce glasses daily)
Set up environment to avoid movements that result in dizziness/vertigo
If diabetic, monitor blood sugars and facilitate interventions to maintain appropriate blood sugars
|
| Functional Impairment |
Encourage participation in personal care activities at highest level (i.e., if possible encourage ambulation to bathroom rather than use of bedpan)
Refer to physical and occupational therapy as appropriate
Facilitate adherence to exercise program when indicated and remind exercise is the best way to prevent future falls
|
| Medications |
Review medications with primary health care provider in the acute care setting and determine need of each medication
Ascertain that medications are being used at lowest possible dosages to obtain desired results
|
| Medical Problems |
Working with primary health care provider in acute care settings augment management of primary medical problem such as Parkinson's Disease or congestive heart failure or anemia
Assure patient that medical problems are not a reason to remain in bed and prevent participation in functional activities
|
| Environment |
Remove furniture if patient can't sit on it and have his or her feet reach the floor
Remove clutter
Make sure furniture and any assistive devices used are in good condition
Make sure lighting is adequate
Make sure safety bars are available in bathrooms
AVOID rails and restraints
If the individual has fallen out of bed (particularly more than once) alter the environment so that the mattress is on the floor.
|
Reprinted with permission from Springer Publishing Company. Source: Resnick, B. (2003). Preventing Falls in Acute Care. In Mezey, M., Fulmer, T., Abraham, I. (Eds.); Zwicker, D., (Managing editor). Geriatric Nursing Protocols for Best Practice, 2nd edition. Springer Publishing Company, Inc.
Follow-up Monitoring of Condition
- Monitor fall incidence and incidences of patient injury due to a fall, comparing rates on the same unit over time.
- Compare falls per patient month against national benchmarks available in the National Database of Nursing Quality Indicators.
- Incorporate continuous quality improvement criteria into falls prevention program.
- Identify falls team members and roles of clinical and nonclinical staff (ECRI, 2006 [Level VI]).
- Educate patient and family caregivers about falls prevention strategies so they are prepared for discharge (Resnick, 2003 [Level VI]; UIGN, 2004 [Level VI]).
Definitions:
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
