RISK FOR

FALL

NURSING
INTERVENTIONS

PRIVATE II
Outline

Epidemiology of falls
Risk factors
Assessment
Falls prevention
 A fall is defined as an event
which results in a person coming
to rest inadvertently on the
ground or floor or other lower
level. Fall-related injuries may be
fatal or non-fatal,though most are
non-fatal.
 KEY FACTS

– Falls are the second leading cause of accidental or unintentional injury deaths
worldwide.
– Each year an estimated 646 000 individuals die from falls globally of which over
80% are in low- and middle-income countries.
– Adults older than 65 years of age suffer the greatest number of fatal falls.
– 37.3 million falls that are severe enough to require medical attention occur each
year.
– Prevention strategies should emphasize education, training, creating safer
environments, prioritizing fall-related research and establishing effective policies
to reduce risk. (WHO, 2018)
The majority of falls result in:
• slight harm such as abrasions
or bruises, however, in 20% to
30% of the cases,

• moderate or serious injuries

occur, such as fractures of the
femur or hip or cranial trauma,
which cause physical limitations
and disabilities, as well as
increasing the risk of death.
In addition to the physical damage, falls can also
have psychological repercussions, expressed by
the fear of falling again and by the loss of
confidence in the ability to walk around safely,
principally in the elderly, which can lead to a
reduction in activities of daily living, a
worsening of the functional decline, depression
and social isolation.
Implementation of favorable fall
prevention program is a vital part of
nursing care in any healthcare
environment and needs a multifaceted
approach. Nurses have a significant role
in educating patients, families, and
caregivers about the prevention of falls
beyond the care continuum
Who are at risk?
 – Age
– Age is one of the key risk factors for falls.
Older people have the highest risk of death or
serious injury arising from a fall and the risk
increases with age.

– Another high risk group is children. Childhood

falls occur largely as a result of their evolving
developmental stages, innate curiosity in their
surroundings, and increasing levels of
independence that coincide with more
challenging behaviours commonly referred to as
‘risk taking’.
Gender
Across all age groups and regions, both
genders are at risk of falls. In some countries,
it has been noted that males are more likely to
die from a fall, while females suffer more non-
fatal falls. Older women and younger children
are especially prone to falls and increased
injury severity. Worldwide, males consistently
sustain higher death rates. Possible
explanations of the greater burden seen
among males may include higher levels of
risk-taking behaviours and hazards within
occupations.
 NURSING
ASSESSMENT
 Assess for circumstances associated to increase the level of fall risk upon
admission, following any alteration in the patient’s physical condition or
cognitive status, whenever a fall happens, systematically during a hospital
stay, or at defined times in long-term care settings. (intrinsic factors)

•History of falls
•Mental status changes
•Age-related physical changes
•Use of mobility assistive devices
•Disease-related symptoms
•Balance and gait
•Sensory deficits
•Medications
History of falls

– A falls history should include determining the number of falls in the past year as
well as their circumstances, including any premonitory symptoms, location,
activity, footwear, use of assistive device (if prescribed), use of glasses (if
typically used), ability to get up after the fall, time of day, any injuries sustained,
and any medical treatment received. Corroboration by a witness can be helpful
in cases of recurrent, unexplained falls, because such falls may be caused by
unrecognized syncope. Documenting a falls history is one of the quality
indicators for fall prevention and management.
Functional assessment

– Assessing a patient’s level of functioning is usually accomplished by asking

standardized questions about difficulties with performing activities of daily
living and instrumental activities of daily living. The risk of falling and the
circumstances and location of falls vary by functional ability.28 People who are
healthier are more likely to fall on stairs, away from home, and during displacing
activities (eg, bending over, reaching up), and are more likely to be seriously
injured if they fall.28 By contrast, people with functional limitations are more
likely to fall at home during routine activities. Gauging functional ability can
help determine the degree of fall and injury risk, indicate risk factors, and
suggest interventions.
 Medications and falls
– A critical part of risk assessment is a medication review. Several classes of medications
increase fall risk. Psychoactive medications in particular are independent predictors of
falls. These medications tend to be sedating, alter the sensorium, and impair balance and
gait. Other medications (eg, antihypertensives, nonsteroidal antiinflammatory drugs,
diuretics) are more weakly associated with falls.
– consider possible effects of treatment for these diseases; many medications increase the
fall risk by causing dizziness, drowsiness, or confusion. Perform a thorough medication
reconciliation to identify potential high-risk drugs, including over-the-counter products
(such as diphenhydramine, commonly used for allergic rhinitis or as a sleep aid). As a rule
of thumb, the more medications a patient uses, the higher the fall risk due to adverse drug
effects and drug-drug or drug-disease interactions
 Assess the patient’s environment for factors known to
increase fall risk ( extrinsic factors)

• unfamiliar setting
• inadequate lighting
• wet surfaces
• waxed floors
• clutter, and objects on the floor.
 Environmental assessment

– Environmental assessment, which is typically conducted by a trained health

professional (eg, occupational therapist [OT]) is intended to identify hazardous
conditions within the home, such as obstacles in pathways or on stairs,
unsupportive or ill-fitting footwear, unsuitable assistive devices, inadequate
lighting, and slippery surfaces. It also identifies hazards outside the home, such
as cracked pavement or sloped yards. Identifying and modifying environmental
factors is an effective intervention as part of a comprehensive multifactorial
approach to preventing falls.
Falls are due to several factors, and a holistic approach to
the individual and environment is important. If a person is
considered at high risk for falls after screening, a health
professional should conduct a falls risk assessment to
obtain a more detailed analysis of the individual’s risk of
falling.
 Nursing Interventions

Fall prevention strategies should be comprehensive and

multifaceted. Prioritize research and public health initiatives
to further define the burden, explore variable risk factors and
utilize effective prevention strategies. Support policies that
create safer environments and reduce risk factors. Promote
engineering to remove the potential for falls, the training of
health care providers on evidence-based prevention
strategies; and the education of individuals and communities
to build risk awareness.
 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.

•Transfer the patient to a room near the nurses’ station.

•Move items used by the patient within easy reach, such as call light,
urinal, water, and telephone.
•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.

•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.

•Guarantee appropriate room lighting, especially during the night.

•Encourage the patient to don shoes or slippers with nonskid

soles when walking.
• Ask family to stay with the patient.

• Make the primary path clear and as straight as possible. Avoid

clutter on the floor surface.

• Teach client how to safely ambulate at home, including using

safety measures such as handrails in bathroom.