Chapter 3: Safer Patient Handling, Positioning, Transfers and Ambulation
3.11 Falls Prevention
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- Name four fall prevention strategies that will help keep a patient safe when ambulating in the hospital.
Prevention Strategies |
Safety Measures |
| Look for fall risk factors in all patients. | Identifying specific factors helps you implement specific preventive measures. Risk factors include age, weakness on one side, the use of a cane or walker, history of dizziness or lightheadedness, low blood pressure, and weakness. |
| Follow hospital guidelines for transfers. | Transfer guidelines provide a good baseline for further patient risk assessments. |
| Orient patient to surroundings. | Orient patients to bed, surroundings, location of bathroom and call bell, and tripping hazards in the surrounding environment. |
| Answer call bells promptly. | Long wait times may encourage unstable patients to ambulate independently. |
| Ensure basic elimination and personal needs are met. | Provide opportunities for patients to use the bathroom and to ask for water, pain medication, or a blanket. |
| Ensure patient has proper footwear and mobility aids. | Proper footwear prevents slips.
|
| Communicate with your patients. | Let patients know when you will be back, and how you will help them ambulate |
| Keep bed in the lowest position for sedated, unconscious, or compromised patients. | This step prevents injury to patients should they attempt to get out of bed. |
| Avoid using side rails when a patient is confused. | Side rails may create a barrier that can be easily climbed and create a fall risk situation for confused patients. |
| Keep assistive devices and other commonly used items close. | Allow patients to access assistive devices quickly and safely. Items such as the call bell, water, and Kleenex should be kept close to avoid any excessive reaching. |
Resources:
Canadian Patient Safety Institute. (2015). Reducing falls and injury from falls: Starter kit. http://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/Falls%20Getting%20Started%20Kit.pdf
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
Titler, M. G., Shever, L. L., Kanak, M. F., Picone, D. M., & Qin, R. (2011). Factors associated with falls during hospitalization in an older adult population. Research and Theory for Nursing Practice: An International Journal, 25(2), 127-152. https://doi.org/10.1891/1541-6577.25.2.127
2. A patient is ambulating for the first time after surgery. Is it safe to encourage the patient to ambulate independently?
The nurse must perform a falls risk assessment for all patients. This is particularly important for the first time ambulating after surgery. Considerations of the effects of medication, risk of orthostatic hypotension, and pain must be made. Likely the safest approach is to assist the patient with the initial ambulation post op.
Source:
Potter, P., Perry, A., et al (2019). Canadian fundamentals of nursing (6th ed.). Elsevier; Mosby.
3. Many physiological risk factors can be identified from a routine assessment. Name three risk factors and three prevention strategies to manage these risks. For example, if a patient has frequent toileting needs, a preventive action is to offer assistance to the toilet every hour, and to ensure the call bell is within reach at all times.
Risk Factor |
Prevention Strategies |
| Sensory-perception alteration |
|
| Cognitive impairment (decreased LOC, confusion, lack of safety awareness) |
|
| Poly-pharmacology |
|
| Urinary incontinence |
|
Resources:
Canadian Patient Safety Institute. (2015). Reducing falls and injury from falls: Starter kit. http://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/Falls%20Getting%20Started%20Kit.pdf
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
Titler, M. G., Shever, L. L., Kanak, M. F., Picone, D. M., & Qin, R. (2011). Factors associated with falls during hospitalization in an older adult population. Research and Theory for Nursing Practice: An International Journal, 25(2), 127-152. https://doi.org/10.1891/1541-6577.25.2.127