Question

A) Address one of the posts (#1,#2 below) by identifying which of the nursing interventions listed would be the most effective.

B) Please provide a rationale for your assessment of their interventions.

#1) Identify clients likely to fall by placing a “fall precaution” sign on the doorway and using a “high-risk fall” armband and room sign to alert staff for increased vigilance and mobility assistance. (Ackley & Ladwig, 2014) having these procedures in place during admission alerts the nursing staff of the increase risk for falls and notifies them to be on high alert around these clients in the event that they look unstable, to help them with ambulation or activity.

#2) Routinely assist the client with toileting on his own schedule, always on awakening, before bedtime, before administering sedatives. (Ackley & Ladwig, 2014) Having a regular toileting schedule helps the client from falling by preventing the confused client going into the bathroom alone and potentially falling. Refer to physical therapy for strengthening exercise, gait training, and help with balance to increase mobility. (Ackley & Ladwig, 2014) Balance, gait training and strengthening exercise can help improve K.B.’s muscle coordination and help prevent falls.

Answer 1

Ans) 1) Fall Risk Assessment. The Johns Hopkins Fall Risk Assessment Tool (JHFRAT) was developed as part of an evidence-based fall safety initiative. This risk stratification tool is valid and reliable and highly effective when combined with a comprehensive protocol, and fall-prevention products and technologies.

- Morse Fall Scale. (Adapted with permission, SAGE Publications) The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient's likelihood of falling. A large majority of nurses (82.9%) rate the scale as “quick and easy to use,” and 54% estimated that it took less than 3 minutes to rate a patient.

• 5 Proven Approaches to Reduce Fall Risk:
- Medications Review: Certain types of medications are known to increase falls in seniors, and many of them are surprisingly common.
• Check Blood Pressure While Sitting and Standing.
• Gait and Balance Evaluation.
• Home Safety Assessment and Modification.
• Vitamin D, 1000 IU per day.

2) Physical therapists can help prevent falls with evaluation and development of individualized treatment plans including exercises to improve strength, mobility, and balance. Maintaining physical activity is critical in helping to prevent falls.

- Individualized Exercise Programs

An individualized exercise program helps improve your strength, balance and flexibility. It can also help improve certain risk factors for falls, such as:

Poor balance
Weak leg muscles
Vision problems
Peripheral neuropathy
Certain prescription medicines can also affect your balance.

Physical therapists will create an exercise program designed especially for you and your body. Your program might include one or more of these exercises:

Weight training
Dance steps
Walking in circles or figure-8s
Obstacle courses
Walking sessions to improve endurance
You might participate in these exercises at a physical therapy location or at home, depending on your abilities. Your exercise program is designed to be safe and effective. Always follow your physical therapist’s recommendations to ensure your safety.

Assistive Devices:
Assistive devices like canes and walkers can help prevent falls. Your physical therapists can help you decide if you need and assistive device, take measurements to ensure you get the right one and teach you how to use the device safely.

Home Risk Assessment:
Certain aspects of your home and home decor may increase your risk for falls. Your physical therapist can help you make your home safer using a home risk assessment. During the assessment, the physical therapist may encourage you to make small changes to your home, such as:

Removing rugs or add nonskid rug liners
Reorganizing the kitchen or closets so commonly used items are easy to reach
Ensuring all stairs have handrails on both sides
Adding lighting to make it easier to see
Placing grab bars in the bathroom to make it easier to stand up
Fall Prevention Resources
Your physical therapist will use a multidisciplinary approach to preventing falls by connecting you with other health professionals who can help. These professionals may include:

Optometrists or ophthalmologists for vision concerns
Pharmacists for balance issues related to medicines
Ear, nose and throat physicians for inner-ear balance problems
Cardiologists for heart and vascular programs that affect balance
Orthopedic surgeons for bone and muscle conditions.