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.