Nursing action in the prevention of falls

Set of activities planned by the nurse for patients at risk of injury from falls.

Objectives:

– Prevent falls in the hospitalized patient. – Establish precautions in patients at risk of injury due to falls. – Educate patient and family on fall prevention measures.

Patients at risk:

Elderly at high risk for falls are considered to be persons over 75 years of age, or 70-74 years of age with one or more of the following factors: cognitive impairment, impaired balance, gait, muscle weakness, use of psychotropic or cardiological medications (benzodiazepines, antihypertensives, etc.) and use of 4 or more medications.

Equipment:

– Bed. – Bars. – Walkers, crutches, canes, etc. – Scissors.

Material:

– Mechanical restraints. – Nursing records.

Procedure:

– Preserve the patient’s privacy. – Inform the patient. – Request the collaboration of the patient and family. – Assess the risk of falling (using the Downton scale): if the patient uses assistive devices correctly, if barriers have been placed to prevent falls, if the height of the bed is adequate, if the patient is restless or agitated, if the patient is taking medications that increase the risk of falls. – Lock the wheels of chairs, beds or other devices. – Place objects within easy reach of the patient without straining. – Keep crib railings in an elevated position when the caregiver is not present, if appropriate. – Teach in the use of appropriate and properly fitted footwear during the hospital stay. – Identify the characteristics of the environment (lighting, type of floor, etc.) that may increase the possibility of falls. – Remove from the patient’s room the material that may cause falls. – Monitor the patient’s ambulation and assist the unstable patient in ambulation. – Provide devices to assist ambulation in order to achieve stable mobility (cane, crutches, walker, etc.). – Check that the bed is braked. – Instruct the patient to ask for help when moving, if needed. – Use bed rails, if needed. – Maintain restraint measures, if needed, as a last resort. – Maintain adequate lighting to increase visibility. – Teach the patient to get out of bed progressively and slowly. – Continually assess the patient’s safety. In case of a fall: – Transfer the patient to the bed. – Call for help if necessary. – Reassure the patient and family after the fall. – Assess the existence of injuries, and if there are any, notify the physician. – Monitor the level of consciousness. – Administer the necessary care in relation to the injury caused. – Detect the cause of the fall. – Plan the necessary care to prevent another fall. – Record in the nursing documentation: time, circumstances of the fall and care given. – Record the measures taken in the nursing documentation.

Observations:

In the prevention of falls, it is essential to identify the patient at risk, as well as to know the causes that provoke them.