Fall Risk Assessment and Prevention

Fall Risk Assessment and Prevention
Risk Factor	Intervention
Assessment Data ■ Age >65 years ■ 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 affect 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 safe and structured environment. ■ Utilize pressure-sensitive alarms in bed and chairs.
Cardiovascular ■ Postural hypotension	■ 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 toileting schedule. ■ Provide bedside commode or urinal. ■ Unobstructed, well-lit path to the bathroom.
Musculoskeletal ■ Decreased ROM ■ Amputee	■ Provide ROM exercises and stretching. ■ PT or OT consult. ■ Provide appropriate assistive devices.
Assistive Devices ■ Use of cane, walker, C or W	■ 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. Remove unnecessary or infrequently used equipment. ■ Ensure call light is within easy reach.

Preventing Falls
Skilled Nursing Facility	At Home
■ Identify and report unsafe conditions in facility. ■ Advise residents to avoid alcohol and sedatives. ■ Refer unsteady residents to PT/OT for evaluation. ■ Teach residents on use of correct assistive devices. ■ Review medication record. ■ Emphasize need to change body position gradually. ■ Encourage strength and ROM exercises. ■ Teach about appropriate attire (e.g., sturdy shoes with thin, nonslip soles). ■ Inform provider about recent changes in hearing, vision, or physical abilities. ■ Notify provider of untoward effects of meds.	■ Arrange furniture to ensure unobstructed pathway. ■ Keep all pathways well lit. ■ Avoid using throw rugs. ■ Excess cords should be coiled and next to wall. ■ Install overhead lights and light switches at top and bottom of stairs. ■ Fix uneven or damaged steps and install handrails on both sides of entire length of stairs. ■ Use steady step stool with a grip bar and keep often-used items at waist level. ■ Install grab bars in tub and in bathroom next to toilet. ■ Ensure bathroom floor and tub have nonslip surfaces.