The Role of Nurses in the Elderly Fall Prevention Care Plan
A Nurse has got a major role in preventing falls in Elderly population. From the time of admission to the hospital to the time of discharge she can categorize the patients in to low risk, moderate risk and high risk. From that category she can formulate a care plan to prevent fall in the hospital, at home and in the community.
Falls can be due to multiple reasons. Patients who take benzodiazepines, antipsychotic, diuretics, anti-depressants, narcoleptics, opioids, insulin, oral hypoglycemic, anti -coagulants, cardiac and hypertensive will lead to disorientation, giddiness and fatigue.
Patients who have dementia, hip fracture, Parkinsonism, stroke, osteoporosis, arthritis and depression should not be left alone. Patients who have urinary and fecal incontinence need bladder and bowel habit retraining, diaper care to prevent rash/pressure sore. In addition patients who have visual impairment, functional disability and prior history of fall should have appropriate intervention to prevent further falls.
Nurse can initiate fall prevention care plan for the above mentioned patients as follows:
1. Toileting needs: To ask the patients every one to two hours whether he/she needs to use the bathroom, answer call light promptly, remind the patient to ask for assistance and reorient to call night if necessary, eliminate side rails and asses need for bedside commodes and individual toileting schedule and/or bowel and bladder training.
2. Syncopal Episodes: To evaluate postural hypotension and/or cardiac arrhythmia and consult with physician, review medications with pharmacy consultant and physician, consider fluid volume deficit then evaluate intake and output, teach the patients to change the position slowly, especially from lying to sitting to standing, maximize the patient’s time out of bed as much as clinically possible to increase tolerance, keep the bed in the low position, assist with all transfers, consider use of TED hose and perform a nutrition consultation.
3. Environmental hazards: Eliminate potential hazards such as uneven surfaces, debris or water on the floor, keep the light and water within the reach, keep eyeglasses within reach and ensure adequate lighting .
4. Weakness/Unsteady gait: Evaluate for possible therapeutic interventions, remind patients to request assistance, keep call light within reach, confer with rehabilitative services and the interdisciplinary team and assist the patient to obtain and wear appropriate, non-skid shoes.
5. Sensory/perception deficits: Frequently reorient the patient to the environment, keep furniture and other objects in the same position, evaluate presence and adequacy of glasses and hearing aids, assess the environment to maximize safety, consult with vision/hearing specialist as needed, refer to occupational therapy and consider a conference with rehabilitative services.
6. Knowledge deficit: Ensure assistive equipment is used appropriately, be sure the patient is comfortable with adaptive and assistive devices, ensure the resident is able to use the call light. If the light is difficult to press, consider a foam pad call light or other adaptive call lights and ensure frequent visitors are aware of the use of assistive devices.
Once the care plan is formulated among the three categories (low risk, moderate risk and high risk) then appropriate staffs are delegated to perform the task. In all the categories the nurse should maintain the safe unit environment which includes removal of excess equipment/supplies/furniture from rooms and hallways, coil and secure excess electrical and telephone wire/cords, clean all spills in patient room or in the hallway immediately and place a signage to indicate wet floor danger.
For low risk individuals apart from maintaining above mentioned safe unit environment the following safety interventions should be taken:
i) Orient the patient to surroundings, including bathroom location, use of call light.
ii) Keep bed in lowest position during use unless impractical (when doing a procedure on a patient)
iii) Keep the top two side rails up.
iv) Secure locks on beds, stretcher and wheelchair.
v) Keep floors clutter/obstacle free (especially the path between bed and bathroom/commode)
vi) Place call light and frequently needed objects within patient reach.
vii) Answer call light promptly
viii) Encourage patient/family to call for assistance as needed.
ix) Assure adequate lightening especially at night.
x) Use proper fitting non-skid footwear.
For moderate risk individuals apart from maintaining safe environment as mentioned earlier and follow low risk intervention plus institute flagging system.
Institute Flagging system:
a. Apply fall risk arm band
b. Falling star (yellow) outside the patient’s door
c. Falls risk sticker on the medical record and monitor and assist patient in following daily schedules:
• Suprevise/assist bedside sitting, personal hygiene and toileting as appropriate.
• Reorient confused patient as necessary.
• Establish elimination schedule and use of bedside commode if appropriate.
Evaluate the need for:
• Physical therapy consult if patient has history of falls and or mobility impairment.
• Occupational consult.
For high risk individuals apart from maintaining safe environment as mentioned previously follow low and moderate fall risk interventions plus institute flagging system:
1. Apply fall risk arm band.
2. Falling star(red) outside the patient’s door.
3. Falls risk sticker on the medical record.
• REMAIN WITH PATIENT WHILE TOILETING
• Observe 6o minutes unless patient is on activated bed or chair alarm.
• When necessary transport throughout hospital with assistance of staffor trained care givers. Consider bedside procedure.
Evaluate need for following measure going from less restrictive to more restrictive:
• Moving patient to room with best visual access to nursing station.
• Activated bed/chair alarm
• 24 hour supervision
• Physical restraint – only with authorized prescribed order.
Once the patient is ready to go home the nurse should make a home safety assessment by following above mentioned guidelines and then transfer the patient to a safe home with proper caregiver if necessary. At community level the nurses can address the senior citizen group on fall prevention and safe mobility.