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Fall Risk Assessment and Prevention



Risk Factor
Intervention
Assessment Data:
Age > 65
History of falls
Monitor frequently.
Pt should be close to nurses’ station.
Implement fall prevention interventions.
Medications:
Polypharmacy
CNS depressants
BP/HR lowering
Diuretics and
meds that ↑
GI motility
Review medications with physician.
Assess for medications that may affect
blood pressure, heart rate, balance, or
LOC.
Educate about use of sedatives,
narcotics, and vasoactive medications.
Encourage nonopioid pain management.
Mental Status:
Altered LOC or
orientation
Routinely reorient Pt to situation.
Maintain a safe and structured
environment.
Utilize pressure-sensitive alarms in bed
and chairs.
Cardiovascular:
Postural
Change positions slowly.
Review med record for possible changes.
Neurosensory:
Visual impairment
Peripheral
neuropathy
Difficulty with
balance or gait
Provide illumination at night.
Minimize clutter and remove unnecessary
or infrequently used equipment
from room.
Provide protective footwear.
Provide appropriate assistive devices and
instruct on proper use.
GI/GU:
Incontinence
Urinary frequency
Diarrhea
Ensure call light is within easy reach.
Create a toileting schedule.
Provide a bedside commode or urinal.
Unobstructed, well lit path to the
bathroom.
Musculoskeletal:
Decreased ROM
Amputee
Provide ROM exercises and stretching.
Physical or Occupational Therapy consult.
Provide appropriate assistive devices.
Assistive Devices:
Use of cane,
walker, or
wheelchair (WC)
Ensure that assistive devices are not
damaged and are appropriately sized.
Instruct Pt on proper and safe use.
Environment:
Cluttered room
Tubes and lines
Minimize clutter and remove
unnecessary or infrequently used
equipment.
Ensure call light is within easy reach.


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