Effective Risk for Falls Care Plan

Older patients have higher risks of falling, which is dangerous due to possible disabilities and injuries. Patients who have to stay in the hospital for a long period of time have a number of fall risk factors. However, it is possible to avoid falls in case an effective risk for falls care plan is made for the patients. Every patient is a unique individual with his/her strong and weak sides. That is why it is of utmost importance to take these sides into account while developing the plan.

Ways of Determining the Falls Risks

First of all, it is important to identify the patient's risk. While assessing the situation, it is vital to apply easy assessment criteria, which helps to address the most widespread risks among older patients. Of course, it is not possible to foresee all the possible scenarios, but the risk assessment will definitely assist to reduce the hazards of falling.

The Minimum Data Set refers to the interdisciplinary evaluation tool, which should be used by every nursing home in the country. This tool includes risk factors of falls, like falls history, dizziness, use of particular medication and drugs, etc. The Minimum Data Set has a long list of factors. That is why every nursing home has a one-page evaluation tool so that the patient could be evaluated as soon as possible. This tool includes the following risk factors:

  1. Falls history
  2. Problems with vision
  3. Cognition as well as mental status of a patient
  4. Medications of high risks
  5. Problems with mobility
  6. Impulsivity
  7. Control of bladder and bowel
  8. Recognition of environment and other people
  9. Equipment for ambulatory assistance
  10. Application of attached device like oxygen, catheters and intravenous lines

Intervention of Nurses inRisk for Falls Nursing Care Plan

  1. Evaluate the Environment on a Daily Basis

A nurse should evaluate the patient's environment on a daily basis in order to detect any risk factors and make sure all measures are taken in time:

  • Every finding should be documented according to the standardized checklist.
  • Hospital staff should be informed about the detected risk factors.
  • The environment should be assessed regularly.
  1. Evaluate Multifactorial Falling Risk Factors

As soon as the patient is admitted, has some changes in his/her condition or transferred from another hospital, he/she should be screened and an individual risk for falls care plan should be developed:

  • Patient's falling risks should be assessed using the fall-risk assessment tool
  • Any findings detected should be added to the list of issues, interdisciplinary progress notes and nursing notes.
  • In order to reduce high falling risks, a nurse should inform the hospital staff about the detected findings during the team meeting.
  • Patient's chart should be marked as high fall risk patient.
  • A nurse should inform the patient and his/her family about high fall risks and the developed individual risk for falls care plan.
  • In case a patient should be transferred to another hospital, new staff should be informed about the detected fall risk factors and any measures taken to prevent falls.
  • When a patient is discharged, family members should be informed about possible nursing care plan risk for falls examples, how to reduce the risks of falling and what measures should be taken.
  1. General Precautions of Safety

They should include:

  • Patient's access to call button
  • Application of floor mats
  • Low-rise bed usage
  • Nonskid shoes usage
  • Recommendation off all risk treatment plan
  • Access to urinals, toilet and bedpans
  • Usage of alarms
  • Physical restraints elimination
  • Clutter should be eliminated in areas of high fall risk
  • Increased observation
  • Corrective glasses usage
  • Staff should be aware of proper measures when a patient falls
  1. Patients Who Need Additional Precautions should be Identified:
  • Patients with osteoporosis
  • Patients with hip fracture
  • Patients with mental illness
  • Patients with head trauma
  1. Discussion with Interdisciplinary Team

A plan should be developed together with interdisciplinary team:

  • The physician should be aware of any findings.
  • Preventative measures should be instituted and monitored.
  • When a patient falls, he/she should be checked immediately.
  • Vital signs, consciousness level, and functionality should be checked.
  1. Monitoring:
  • Monitor the patient's fall and compare the results.
  • Analyze patient's falls to national benchmarks.
  • Take improvement measures on a daily basis.
  • Every team member should perform specific duties.
  • Family members should be taught fall prevention techniques.

Steps to Developing Effective Care Plan

  1. Use a standard fall risk evaluation tool. Every finding should be recorded and a list should be compiled.
  2. Inform the hospital team about the findings and develop an individual plan.
  3. In case a patient is at a high falling risk, flag the patient's chart so that every team member is informed about the problem.
  4. Clinical staff as well as patient's family members should be instructed on what measures are to be taken in case of patient's fall.
  5. New staff should be aware of the previous care plan when a patient is transferred to another hospital.
  6. Family should be informed about fall risk prevention measures upon patient's discharge.
Close