Transcript Mercy Hospital Fall Prevention Education

Mercy Hospital Fall
Prevention Education
Developed by: Terri Mathew RN, BSN
Clinical Educator
Professional Development Department
Definition of a Patient Fall?
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Mercy’s policy defines a fall as:
An unplanned descent to the floor (or
extension of the floor, e.g. trashcan or other
equipment) with or without injury to the
patient including, those that occur as a result
of physiological reasons (fainting),
environmental reasons (slippery floor),
assisted falls- when a staff member attempts
to minimize the impact of the fall.
Statistics
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Falls account for 1.6 million injuries in
persons over age 65, and approximately 160,
000 if these occurred in healthcare
institutions.
About 30% of these falls result in serious
injuries and the costs of treating these injuries
equals $1.08 billion annually or
approximately $15, 000-$30, 000.
Statistics
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The median age of a patient who falls in the
hospital is 58. Thus, patient falls clearly is not
a problem exclusive to the elderly.
Patient fall can be classified as 1) accidental
falls 2) anticipated physiological falls and 3)
unanticipated physiological falls. Most patient
falls are predictable and preventable.
Extrinsic Factors
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Factors that comprise conditions related to the
environment, such as flooring conditions,
wheel chair locks, lighting, bedrails, room
design, clutter, floor surfaces, footwear,
clothing, linen, and assistive devices.
Intrinsic Factors
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Elimination Issues
History of Falls, depression, dizziness/vertigo,
confusion
Visual problems, unstable gait
Medications such as, anti-arrhythmic,
antidepressants, hypnotics, benzodiazepine
and major tranquilizers
How Do We Address Fall Risk Factors?
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Address both extrinsic and intrinsic fall risk
factors is necessary to fully optimize patient
safety.
Responsibility for assessing patients for
intrinsic fall risks rests squarely with nurses
who assess the patients.
Hendrich II Fall Risk Model
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The model contains only eight risk factors and
requires only a few minutes to complete.
The risk factors are confusion/disorientation,
impulsivity, symptomatic depression, altered
elimination, dizziness/vertigo, gender (male),
administration of antiepileptic medications,
benzodiazepine medications and the
assessment of their ability to get up and go!
Confusion/Disorientation/Impulsivity
4 points
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The following are observational patterns or
behaviors are impulsive behavior,
hallucinations, agitation, inappropriate
behavior, patients who are not alert or
oriented to person, place or time and patient is
unable to retain or receive instructions.
Symptomatic Depression
2 Points
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Some behaviors or symptoms that will qualify a
patient as depressed: Feelings of helplessness,
hopelessness, tearfulness, inappropriate
behavior, flat affect, lack of interest, general loss
of interest in life events, melancholic mood,
withdrawn and the patient states he/she
depressed.
Altered Elimination
1 Points
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Incontinence
Urgency
Diarrhea
Frequent urination
Nocturia
Any toileting self-care deficit
Dizziness/Vertigo
1 point
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The patient may report the room is spinning
Patient seems to sway when standing still
Male Gender
1 Point
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Research showed this gender factor to be an
independent fall risk factor. The reason may
be culture-based, men may be more likely to
take risks, go it alone and ignore instructions
or may not want female nurse to assist them.
This factor does not apply to pediatric male
patients.
Fall Risk Medications
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Patients that are on Antiepileptic or
Benzodiazepines will score 2 points for the
antiepileptic and 1 point for the
benzodiazepines.
These medications can cause dizziness and
altered elimination.
Get Up and Go Test: “Rising from a Chair”
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Ability to rise in a single movement-No loss of
balance with steps (0 points)
Pushes up to a standing position successfully in one
attempt (1 point)
Multiple attempts to rise to a standing position but is
successful (3 points)
Unable to rise without assistance during the test (4
points) (or if a medical order states the same and or
complete bed rest is ordered) If unable to assess
please document in medical record
Hendrich II Fall Risk Model
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Assess patients upon admission
At least once a shift and sooner if the
condition of the patient changes from the last
assessment.
If the patient’s care transitions to another
caregiver.
Elements of a Fall Prevention Program
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Assess and Reassess Fall Risk
Maintain a Safe Environment
Monitor Gait and Mobility
Meet Elimination Needs
Deliver Patient and Family education
Interdisciplinary Team Management
I. Assess and Reassess Fall Risk
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Continuous reassessment of patients is critical
to an effective fall prevention program
The model calls for an initial assessment at
admission, followed by routine reassessment
each shift, or sooner, if a patient condition
changes.
II. Maintain a Safe Environment
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Identify individual patient care plan and safety
needs of patients based on their eyesight, hearing,
cognition, gait and balance
Remove or correct harmful hazards, such as,
bedside table, commodes, unlocked bed wheels,
IV tubing coiled on the floor, and linen on floor.
Patient does not have call light, bedside table, eye
glasses, food, drink and phone.
II. Maintain a Safe Environment
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Don’t block the patient’s view and path to the
bathroom, commode or other equipment used
for elimination
Provide adequate lighting and ensure night
lights work
Implement the use of bed alarms or tabs
monitors if patient in a chair
III. Monitor Gait and Mobility
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Patient who wants to sit down into a chair or
bed using a walker: Have the patient grasp the
walker firmly, and then, back up toward the
chair or bed until the patient feels it with the
backs of his/her legs. Have the patient put one
hand on the walker and the other hand on the
armrest or surface of the chair or bed, slowly
sit down and slide backward into a safe sitting
position.
III. Monitor Gait and Mobility
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Patients ambulating or transferring: Use a gait
belt to assist in patient movement. Explain to
the patient the purpose of the belt and that the
belt will be removed after transfer. Put the gait
belt around the waist over clothing, with the
buckle in front.
IV. Meet Elimination Needs
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Implement scheduled toileting matched with
the patient’s needs and or about two hours
after meals and before bed. Be aware of
patients receiving diuretics
Stay with a fall-risk patient when the patient
is in the bathroom or on the commode
Keep the call light within easy reach of the
patient and ensure it is secured to the patient.
Respond immediately to patient requests.
V. Deliver Patient and Family Education
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Provide the patient, family members and/or
significant other with practical information
drawn from the principles of an effective fall
prevention program
Provide information to the family about
extrinsic and intrinsic risk factors
Instruct the patient/family or significant other
to exercise precaution in the event of a fall at
home
Use Interdisciplinary Team
Management
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Fall prevention team must be multidisciplinary
in nature
Caregivers must work together to address the
most common opportunity for falls
What Should I Do If A Patient Falls?
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Patient Assessment
Notification and Communication
Patient Monitoring
Documentation
I. Patient Assessment
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Check vital signs (Apical and Radial Pulses)
Assess cranial nerves
Check skin for pallor, trauma, circulation,
abrasion, bruising and sensation
Assess for sensation and movement in lower
extremities
Assess for subtle cognition changes
I. Patient Assessment
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Assess pupils and orientation
Observe for leg rotation, hip pain, shortening of the
extremity, and pelvic or spinal pain
Note any pain and points of tenderness
Determine patient’s perception of the cause of the
fall.
If a server injury is suspected, stabilize the patient
position and do not move him/her from the floor
until a physician has arrived and completed a
medical assessment, and given orders
II. Notification and Communication
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Report to the physician
Notify family or guardian
Fill out an incident report or falls report
Communicate the fall to all staff
Follow hospital policy
If the fall results in a sentinel event follow
hospital policy for reporting
III. Patient Monitoring and
Reassessment
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After the patient is rescued, perform frequent
neurological checks and vital sign checks,
including orthostatic vital signs.
Accompany the patient if he/she leaves the
unit for radiology or other interventions.
Note all assessment findings and document in
medical record.
IV. Documentation
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Document before the fall occurs
After the Fall document all observations, if
available, of the fall, patient statement and
recollection of the event, medical and nursing
assessments, notifications based on individual
health system policies, interventions
following the fall and reassessments
following the fall, and classification of the fall
In Summary
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Fall Prevention is everyone’s responsibility
and is a team effort
Not one piece of a falls prevention will
prevent all falls but all pieces of the program
will prevent falls