To reduce likelihood of falls while maintaining dignity and independence
action taken below
Ensure call bell explained and in reach. Consider alternatives for patients
unable to recall use of call bell, e.g., use brass bell, move bed in sight of
in reach but may forget, will probably call her daughter's name instead;
moved within earshot of nurses' station.
Ensure eyesight is checked and patient is wearing glasses if needed. Can the
patient identify pen/key from bed length away? If eyesight is too poor to
identify objects, ask the treating medical provider to review. Ensure
glasses/hearing aid are worn or within reach.
broken in fall at home; family has ordered replacement and hopes to provide
it tomorrow. Has fair distance vision without them. Have suggested that the
family order a spare pair too.
bedrails. Assess the need for bedrails (refer to policy). If patient is likely
to fall from bed, ensure bed is at the lowest possible height unless this
would reduce mobility or independence. Consider use of special low bed.
not appropriate as this patient can mobilize on her own, even though
unsteady, and might be confused enough to climb over. Bed set at right height
for safe move from sitting to standing.
Check for medication associated with fall risk, such as antidepressants,
sleeping tablets, sedatives, and antipsychotics. Ask the pharmacist to review
and make recommendations to treating medical provider (do not stop abruptly).
temazepam 15 mg qhs for some years; will discuss with pharmacist.
Determine the patient's level of mobility and whether actions should be
taken to improve or maintain mobility.
in supervised mobility protocol with nursing assistant. Currently able to
ambulate 50 feet with front wheeled walker daily.
team. Ensure medical staff, physical therapist, occupational therapist,
social worker, and others on the team are aware of the patient's risk,
frequency, nature, and seriousness of falls (local protocol or pathway would
cover expected actions by team members, e.g., cognitive evaluation,
osteoporosis check, mobility aid review).
physician aware of patient's fall risk. Physical and occupational therapy
referral sent on 11/14/11. Fall risk noted on discharge plan.
Check footwear for secure fit, nonslip sole, no trailing laces. Ask relatives
to supply safer replacement or supply new slippers from ward stock. Consider
slipper socks in bed for patients at risk of falling at night.
does not have footwear. Provided with new slippers from ward stock.
Place patient in most appropriate place on the ward for his or her needs,
e.g., close to nurses' station, close to toilet, in quietest area
(considering other patients' needs as well).
nearest toilet and within earshot of nurses' station.
Consider lighting best for patient, e.g., bedside lamp left on overnight,
night light in bathroom.
overhead lamp on low overnight.
Does the risk of falls appear to be associated with patient's need to use
toilet? If so, a routine of frequent toilet visits may help prevent falls.
the patient has frequency/urgency; being treated for urinary tract infection.
Will offer toilet every hour while patient is awake.
Provide falls education brochure to patient/family, engage them in care plan,
find out contact wishes in event of fall.
and daughter have falls education brochure, and care plan has been explained.
Contact wishes entered into chart.