Question

What are 6 nursing interventions that can be used to help with care for a patient who is a fall risk?

Answer 1

Follow the following safety interventions:

Secure locks on beds, stretcher, & wheel chair. Keep floors clutter/obstacle free (especially the path between bed and bathroom/commode). Place call light & frequently needed objects within patientreach. Answer call light promptly.

The nurse will keep the patient’s bed in the lowest position at all times.

-The nurse will use the bed and chair alarm as needed.

-The nurse will assess the patient need to use the bathroom every two hours.

-The nurse will move the patient close to the nurses station for closer observation.

Interventions	Rationales
For the patient in the hospital or long-term care setting:
For patients at risk for falls, provide signs or secure a wristband identification to remind healthcare providers to implement fall precaution behaviors.	Signs are vital for patients at risk for falls. Healthcare providers need to acknowledge who has the condition for they are responsible for implementing actions to promote patient safety and prevent falls.
Transfer the patient to a room near the nurses’ station.	Nearby location provides more constant observation and quick response to call needs.
Move items used by the patient within easy reach, such as call light, urinal, water, and telephone.	Items that are too far from the patient may cause hazard and can contribute to falls.
Respond to call light as soon as possible.	This is to prevent the patient from going out of bed without any assistance.
See to it that the beds are at the lowest possible position. If needed, set the patient’s sleeping surface as adjacent to the floor as possible.	Keeping the beds closer to the floor reduces the risk of falls and serious injury. In some healthcare settings, placing the mattress on the floor significantly reduces fall risk.
Use side rails on beds, as needed. For beds with split side rails, leave at least one of the rails at the foot of the bed down.	According to research, a disoriented or confused patient is less likely to fall when one of the four rails is left down.
Avoid the use of restraints to reduce falls.	Studies demonstrate that regular use of restraints does not reduce the incidence of falls.
Guarantee appropriate room lighting, especially during the night.	Patients, especially older adults, has reduced visual capacity. Lighting an unfamiliar environment helps increase visibility if the patient must get up at night.
Encourage the patient to don shoes or slippers with nonskid soles when walking.	Nonskid footwear provides sure footing for the patient with diminished foot and toe lift when walking.
Familiarize the patient to the layout of the room. Limit rearranging the furniture in the room.	The patient must get used to the layout of the room to avoid tripping over furniture.
Provide heavy furniture that will not tip over when used as support when patient is ambulating. Make the primary path clear and as straight as possible. Avoid clutter on the floor surface.	Patients having difficulty in balancing are not skilled at walking around certain objects that obstruct a straight path.
Bed and chair alarms must be secured when patient gets up without support or assistance.	Audible alarms can remind the patient not to get up alone. The use of alarms can be a substitute for physical restraints.
Provide the patient with chair that has firm seat and arms on both sides. Consider locked wheels as appropriate.	When patient experiences weakness and impaired balance, this chair style will be useful and easier to get out of.
Collude with other health care team members to assess and evaluate patient’s medications that contribute to falling. Examine peak effects for prescribed medications that affect level of consciousness.	A review of the patient’s medications by the prescribing health care provider and the pharmacist can identify side effects and drug interactions that increase the patient’s fall risk. The more medications a patient takes, the greater the risk for side effects and interactions such as dizziness, orthostatic hypotension, drowsiness, and incontinence. Polypharmacy in older adults is a significant risk factor for falls.
Consider using sitters for patients with impaired ability to follow direction who are at risk for falls.	Sitters are effective for guaranteeing a secure, protected, and safe environment.
Allow the patient to participate in a program of regular exercise and gait training.	Studies recommend exercises to strengthen the muscles, improve balance, and increase bone density. Increased physical conditioning reduces the risk for falls and limits injury that is sustained when fall transpires.
Inform patient the advantage of wearing eyeglasses and hearing aids and to have these checked regularly.	Hazard can be reduced if the patient uses appropriate aids to promote visual and auditory orientation to the environment. Visual impairment can greatly cause falls.
Consider physical and occupational therapy sessions to assist with gait techniques and provide the patient with assistive devices for transfer and ambulation. Initiate home safety evaluation as needed.	The use of gait belts by all health care providers can promote safety when assisting patients with transfers from bed to chair. Assistive aids such as canes, walkers, and wheelchairs can provide the patient with improves stability and balance when ambulating. Raised toilet seats can facilitate safe transfer on and off the toilet.
Provide high-risk patients with a hip pad.	These pads when properly worn may reduce a hip fracturewhen fall happens.
If patient has a new onset of confusion (delirium), provide reality orientation when interacting. Have family bring in familiar items, clocks, and watches from home to maintain orientation.	Reality orientation can help prevent or decrease the confusion that increases risk of falling for clients with delirium.
Ask family to stay with the patient.	This is to prevent the patient from accidentally falling or pulling out tubes.
Avoid use of wheelchairs as much as possible because they can serve as a restraint device.	Most people in wheelchairs do not move. Wheelchairs, unfortunately, serve as a restraint device.
Improve home supports.	Many community service organizations provide financial assistance to make older adults make safety environments in their homes.
Teach client how to safely ambulate at home, including using safety measures such as handrails in bathroom.	This will help relieve anxiety at home and eventually decreases the risk of falls during ambulation.