Fall prevention
Fall Risk Assessment includes:
Fall history – if the patient has fallen in the past year and what cause the fall?
a) Lack of coordination
b) Patient weakness
c) Related to an injury
Advanced age (greater than 80 years are at a higher risk)
Multiple illnesses
a) Diabetes - lost sensation
b) Decrease coordination
c) Cardiovascular diseases – decrease endurance
Generalized weakness (osteoporosis or bed ridden long periods at a time)
Gait and postural stability
Drug assessment (polypharmacy)
Urinary incontinence (huge safety issue is the elderly falling during the night going the
restroom)
Communication/visual impairment
Alcohol/substance abuse
Change of shift/mealtime in hospital/nursing home (Falls usually happen during shift
change or at night).
There is hourly rounding to addresses the 3P’s:
a) Positioning
b) Pain
c) Potty
Home at nighttime fall risk increase
a) Clutter in pathway to the bathroom
b) Proper lighting (hard to see) be carefully of the light changes, light to bright or
bright to light. (momentary blindness)
c) No area rugs (wall to wall carpet okay)
d) No waxed floors
e) Assistance devices
f) Check for steps, or stairs they must navigate, that there are banisters
g) Bathroom safety bars
Room close to the nursing station and equipment works (good lighting, canes, walkers
and especially the call light and it can be reached)
Takes two people to get a patient up from bed, have them sit and dangle legs before
getting up
Have patient lead with strong leg and arm, never weak side.
Gait belt for ambulation
Have patient assume a wide base of support when standing or with walker for balance
and posture.
If patient getting out of be properly position the chair
If using a cane need proper height, have patient dangle arms on side and cane should
come up to the patient’s wrist level, hold cane with the strong hand, will move the cane
with the weaker leg forward at the same time with the cane, and one step at a time
With a walker, both hands on the walker, wide base of support, lift the walker
approximately two feet forward, and take small steps forward toward the walker
Patient Immobility
Age related risk factors and skin integrity
The limitation in independent, purposeful physical movement of the body or of one or
more extremities
Immobility in the elderly, which leads to pressure, shear, and friction, is the factor most
likely to put an individual at risk for altered skin integrity.
Elderly patients skin integrity increases due to:
a) Dry skin
b) Skin becomes thins
c) Fragile
d) Lose elasticity
e) Loses padding
f) Loses hydration
g) Becomes flaky
h) Under nourished and dehydrated
i) Weakness
j) Decrease endurement
k) Dementia
l) Diminished sensation
Nursing Actions:
a) Repositioning a patient at least every two hours
b) If patient is in a chair or wheelchair they need to be reposition very hour
c) No rubber donuts while sitting, use gel pads
d) Always support bony prominent with pillows, heal protectors and make sure that
those prominent areas are supported. (elbows, back cervical spine and shoulders)
e) Never massage any bony prominent or while moving a patient do not drag the
heals
f) Foot-drop - is a peripheral nerve injury that affects a patient's ability to lift the
foot at the ankle. (to prevent wear high top tennis shoes and frequent skin
assessments)
g) Meticulous skin care, skin is clean, dry, soft soaps, tempered warm water, and
never rub skin dry with a towel, need to pat the skin dry use skin barriers in areas
that tend to be moist like folds, and peri areas.
h) Use moisturizer on heals
i) No powder or talc’s ever used
j) ROM helps with circulation and helps prevent contractures
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