Ifanyofthesemedicalfactorsarepresent,gotoStandardFallPreventionInterventions:Agitation/Delirium-infection,toxic/metabolic,cardiopulmonarychange,CNS,dehydration/bloodloss,sleepdisturbanceMeds(dose/timing)-psychotropics,CVagents(digoxinespecially),anticoagulants(increasedriskofinjury),anticholinergic,bowelprepOrthostatichypotension,autonomicfailureFrequenttoiletingImpairedmobilityImpairedvision,inappropriateuseofassistivedevice/footwearHistoryofFalls(CV/lightheaded-dizzy,Dysequilibrium-lossofbalancewithnoabnormalmotionsensation,Vestibular/Vertigo,Weakness-Musculoskeletal/giveway,combination,other)Psychotropics,digoxin,type1aantiarrhythmic,diuretic(thiazides>loopdiuretics)Antihistamines/benzodiazipines-withdrawalhasshowndecreaseinfallsrisk,assessforsleepdisorder,avoidroutinePRNorders-trynon-pharmacologicalapproachesincludingquietsleepprotocolsonunitsAntidepressants-TricyclicshigherriskthanSSRI,butSSRI'shaveriskaswell,highlevelofphenytoin;lowdosamitriptylineaffectsgate;gabapentin10-25%ADRCardiacdrugs/antihypertensives-iforthostatic(dropinsys>20mmin3min)andsymptomaticAnticoagulants-subduralhematomasarerare;avoidonlyifveryunstablegaitorbalance,concurrentuseofalcohol,orotherdrugsthatinteractandincreasebleeding,ornon-compliantwithregimenorlabfollowupDrugstreatingnocturia(considertamsulosinduetolowerriskoforthostasis)Nursingfallriskassessment,diagnosesandinterventionsarebasedonuseoftheMorseFallScale(MFS)(Morse,1997).TheMFSisusedwidelyinacutecaresettings,bothinhospitalandlongtermcareinpatientsettings.TheMFSrequiressystematic,reliableassessmentofapatient'sfallriskfactorsuponadmission,fall,changeinstatus,anddischargeortransfertoanewsetting.MFSsubscalesincludeassessmentof:1.Historyoffalling;immediateorwithin3monthsNo=0Yes=252.SecondarydiagnosisNo=0Yes=153.AmbulatoryaidNone,bedrest,wheelchair,nurse=0Crutches,cane,walker=15Furniture=304.IV/HeparinLockNo=0Yes=205.Gait/TransferringNormal,bedrest,immobile=0Weak=10Impaired=206.MentalstatusOrientedtoownability=0Forgetslimitations=15RiskLevelMFSScoreActionNoRisk0-24NoneLowRisk25-50SeeStandardFallPreventionInterventionsHighRisk=51SeeHighRiskFallPreventionInterventionsRiskFactorsMuchworkhasbeendonetoidentifytheriskfactorsassociatedwiththelikelihoodofapatientfalling.Theseriskfactorsaregenerallycategorizedintoextrinsic(factorsoutsideofthepatient'sbody)andintrinsic(patient'sinternal,psychologicalfactors).ExtrinsicFactors:HazardousactivitiesTimeofdayExternallightingClutterSpoilsLooseelectricalcordsIntrinsicFactors:MuscleandstrengthweaknessGaitandbalancedisordersVisualdisturbancesCognitiveimpairment/MentalstatusalterationsDizziness/VertigoPosturalhypotensionIncontinencePolypharmacyAgeChronicdiseaseSafetyEducationSafetyeducationforpatientsandfamiliesrequiresinvolvementofallteammembers.Determinewithinyoursettingavailabilityofindividualandgroupfallpreventionresourcesthatincludepatient/familyeducationmaterials,individualandgroupeducationandexerciseclasses,andcommunityresources.StandardFallPreventionInterventionsInterventionssuggestedforimplementationinthisflipbookincludebothstandardandhighriskinterventionsspecifictothepatient'sfallriskscore.Patientswhoarescored"lowrisk"ontheMorseFallScale(scoreof25-50)willhavethefollowinginterventionsimplementedbytheNursingStaff.NursingStaffDirectCare:Assesspatient'sfallriskuponadmission,changeinstatus,transfertoanotherunitanddischarge.Assignthepatienttoabedthatenablesthepatienttoexittowardhis/herstrongersidewheneverpossible.Assessthepatient'scoordinationandbalancebeforeassistingwithtransferandmobilityactivities.Implementbowelandbladderprogramstodecreaseurgencyandincontinence.Usetreadedsocksforallpatients.AllStaff:Approachpatienttowardsunaffectedsidetomaximizeparticipationincare.Transferpatienttowardsstrongerside.Education:ActivelyengagepatientandfamilyinallaspectsofFallPreventionProgram.Instructpatientinallactivitiespriortoinitiatingassistivedevices.Teachpatientuseofgrabbars.Instructpatientinmedicationtime/dose,sideeffects,andinteractionswithfood/medications.Equipment:Lockallmoveableequipmentbeforetransferringpatients.Individualizeequipmentspecifictopatientneeds.Environment:Placepatientcarearticleswithinreach.Providephysicallysafeenvironment(eliminatespills,clutter,electricalcords,andunnecessaryequipment).Provideadequatelighting.MedicalStaff:Evaluateandtreatgaitchanges,posturalinstability,spasticity.Initiatetreatmentforimpairedvision,hearing.Evaluatemedicationprofileforfallrisk.Evaluateandtreatpain.Evaluateandtreatorthostatichypotension.Assessandtreatimpairedcentralprocessing(dementia,delirium,stroke,perception)HighRiskFallPreventionInterventionsTheseinterventionsaredesignedtobeimplementedforpatientswithmultiplefallriskfactorsandthosewhohavefallen.Theseinterventionsaredesignedtoreduceseverityofinjuriesduetofallsaswellastopreventfallsfromreoccurring,supplementingstandardfallpreventioninterventions.NursingStaffEquipment:?Consideruseof:technologyforfallprevention.(SeeTechnologysection),non-skidfloormat,raisededgemattress.Environment:ClearpatientenvironmentofallhazardsMedicalStaff:ReviewmedicationsforfallriskandadjustasindicatedCVagents-iforthostatic(dropinsystolic>20mmin3minutes)andsymptomaticoDiscontinueHCTZ,liberalizesodiumindietoIfACEinhibitorappropriate,useagentwithlessrenalmetabolism(fosinopril)oIfCalciumchannelblocker-NOTnifedipineoIfBblocker-notcardioselective/notmetoprolol/atenolol;usepindolol/propranololConsiderreferraltoservicessuchasphysicalmedicineandrehabilitation,audiology,ophthalmology,cardiology.Optimizetreatmentofunderlyingmedicalconditions.Evaluateandtreatforpain.Evaluatecircumstancessurroundingfallforextrinsicandintrinsiccontributingfactors.Education:ExerciseNutritionHomesafetyPlanforemergencyfallnotificationprocedure.PostFallAfterapatientfalls:NursingAssessforinjuries(e.g.abrasion,contusion,laceration,fracture,headinjury)anddetermineLevelofInjury(0,1,2,3).(SeeDefinitions)Obtainandrecordsitting/standingvitalsigns.Assessforchangeinrangeofmotion.AlertPhysician.Followorganizationalpoliciesforpatientmonitoring.Documentcircumstancesinmedicalrecord.Completeincidentreport.Assessintrinsicandextrinsicfactors.Notifyallteammembersofpatientfall.Considertechnologytopreventrepeatfall(seeTechnology).MedicalAssessandtreatanyinjury.Initiatediagnosticandtreatmentinterventionsforcontributingcauses.Determineprobablecauseoffall(history,physicalfactors,medications,laboratoryvalues).Consultappropriateservices.Evaluateandtreatforpain.Fall-RelatedOutcomesPatientOutcomesIncreasedknowledgeaboutfallsIncreasedstrength,balance,andmobilityIncreasedabilitytocompensateforsensory,balancelossIncreasedfunctionalindependencewithuseofexercisesandassistive/adaptivedevicesIncreasedconfidenceinabilitiesReducedseverityoffall-relatedinjuriesProperhydrationPropernutritionProgramOutcomesInterdisciplinaryapproachtofallpreventionandmanagementIncreasedavailabilityofexpertsinfallpreventionandmanagementSystematicprogramdeploymentandevaluationDocumentation?Documentcircumstancesinpatientmedicalrecord.oPatientappearanceattimeofdiscoveryoPatientresponsetoeventoEvidenceofinjuryoLocationoMedicalprovidernotificationoMedical/nursingactionsCompleteincidentreport?NotifyNurseManagerordesigneeDefinitionsFallLossofuprightpositionthatresultsinlandingonthefloor,groundoranobjectorfurnitureorasudden,uncontrolled,unintentional,non-purposeful,downwarddisplacementofthebodytothefloor/groundorhittinganotherobjectlikeachairorstair.FallResponseTeamFallResponseTeamsarecomprisedofinterdisciplinaryteammembersthatareactivatedfollowingafalltoevaluatecircumstancessurroundingafallwiththegoalofreducingriskfactorsandpreventingarepeatfall.Thisteamexaminestheenvironment,equipment,fallprogramelements,andresourcesincludingstaffing,surveillance,communications,andknowledgeofriskfactorsthatmayhavecontributedtotheevent.TheTeammakesimmediaterecommendationstoreducefallrisksforanindividualpatient.LevelofInjury0=None=MinorInjury(abrasion,bruise,minorlaceration)=MajorInjury(hipfracture,headtrauma,armfracture)=DeathPostAdmissionFallOccurrenceAfallthatoccursafterapatientisadmittedtoaninpatientsetting.SlipLossofbalanceasaresultofslipperysurfacethatdoesnotresultinafall.StumbleLossofbalanceduetokneesgivingwayorotherreasonsbutdoesnotresultinafall.TripLossofbalanceduetoaspecificobstaclethatdoesnotresultinafall.TechnologyToconsidertechnologiesforFallPrevention,refertotheNationalCenterforPatientSafetywebsite.Examplesinclude:Bedand/orchairalarms.Alarmsatexits.Nursecallsystemsandcommunicationsystems.Lowbedsforpatientsatriskforfalls.Videocamerasurveillance.FallsandBedrailsFallpreventionprogramsemphasizebedrailreduction.Bedrailscontributetopatientfallriskbycreatingbarrierstopatienttransferinandoutofbeds.Useofbedrailsmustbeassessedspecifictoindividualpatientneeds.Whenpossible,usealternativepillowsandpositioningdevicestoavoidtheuseofbedrails.ReferencesDepartmentofVeteransAffairs.(1996,June).Clinicalpracticeguidelines:Thepreventionandmanagementofpatientfalls.Tampa,Fl:Author.Hendrich,A,Nyhuis,A,Kippenbrock,T,etal,(1995).Hospitalfalls:Developmentofapredictivemodelofclinicalpractice.AppliedNursingResearch,8.129-139.HoskinA.F.(1998).FatalFalls:TrendsandCharacteristics.StatisticalBulletin,Apr-Jun,10-15.Maki,B.E.(1997).Gaitchangesinolderadults:Predictorsoffallsorindicatorsoffear?JournalofAmericanGeriatricsSociety,45,313_20.MorseJ.(1997).Preventingpatientfalls.ThousandOaks,CA:Sage.NationalSafetyCouncil.1999.ReportonInjuriesinAmerica.Itasca,IL.Rawsky,E.(1998).Reviewoftheliteratureonfallsamongtheelderly.Image,30(1),47-2.Steven,J,&Olson,S(1999,October).Checkforsafety.Ahomefallpreventionchecklistforolderadults.Atlanta:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,NationalCenterforInjuryPreventionandControl.Tideiksaar,R(1997).Fallinginoldage.Itspreventionandmanagement.(2nded).NewYork:SpingerPublishing.VANationalCenterforPatientSafety(NCPS).(2000).VISN8PatientSafetyCenter.(January2001).Proceedings:PromotingPatientFreedomandSafety:PreventingFalls.VISN8PatientSafetyCenterofInquiry:St.PeteBeach,FL.VISN8PatientSafetycenterofInquiry.(1998).Forsuggestionstoimproveorbroadenthisalgorithm,pleasecontactDr.PatQuigley,AssociateDirector,ClinicalDivision,VISN8PatientSafetyCenterofInquiry,Tampa,Florida.E-mail:PatriciaQuigleyReturntotopofpageHighRiskFa