Falls and Fall Risk ReductionChapter 15Copyright © 201.docx

Falls and Fall Risk Reduction
Chapter 15
Copyright © 2018, Elsevier Inc. All rights reserved.
Leading cause of morbidity and mortality for people older than
65 years of ageFalls and subsequent injuries result in physical
and psychosocial consequencesA nursing-sensitive quality
indicatorFalls in nursing homes are termed sentinel events and
must be reported to the Centers for Medicare & Medicaid
Services
Falls and Fall Risk Reduction
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Hip fractureMore than 95% of hip fractures among older adults
are caused by fallsAssociated with considerable morbidity and
mortalityTraumatic brain injury (TBI)Falls are the leading cause
of TBI for older adultsFallophobiaLoss of confidence that leads
to reduced physical activity, increased dependency, and social
withdrawalAn important predictor of general functional decline

and a risk factor for future falls
Consequences of Falls
*
Etiology is multifactorialMay indicate neurologic, sensory,
cardiac, cognitive, medication, or musculoskeletal problems or
impending illnessEpisodes of acute illness, infection, or
exacerbations of chronic illness are times of high fall risk
Majority occur from a combination of intrinsic and extrinsic
factors that combine at a certain point in time
Fall Risk Factors
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Intrinsic factorsReduced vision and hearingUnsteady
gaitCognitive impairmentAcute and chronic illnessesEffects of
medicationExtrinsic factorsLack of support equipment in the
bathtub and at the toiletHeight of the bedFloor conditionsPoor
lightingInappropriate footwearImproper or inadequate assistive
devices
Factors Contributing to Falls
*
Institutional settingsLimited staffingLack of toileting
programsUse of restraints and side railsInadequate staff
communication and trainingIncomplete patient

assessmentsEnvironmental issuesIncomplete care
planningInadequate organizational culture of safety
Factors Contributing to Falls (Cont.)
*
Especially observed in those older than
85 years of ageAre indicative of an underlying pathological
condition such as arthritis, diabetes, dementia, Parkinson’s
disease, stroke, alcoholism, and vitamin D deficiencySome
underlying pathological conditions cause neurologic damage
and result in gait problems
Gait Disturbances
*
Deformities and ill-fitting footwear can cause gait
problemsContributing factors include neglect of corns, bunions,
overgrown toenails, loss of fat cushioning, poor arch support,
excess weight-bearing activities, obesity, or uneven distribution
of weight on the feetNurse must assess the feet for clues of
functional ability and identify problems
Foot Deformities
*
Declines in depth perception, proprioception, and normotensive
response to postural changes contribute to fallsPostural changes
in the pulse rate and blood pressure occur with postural

hypotensionPostprandial hypotension occurs after the
consumption of a carbohydrate-filled meal and is more common
in those with diabetes or Parkinson’s disease
Postural and Postprandial Hypotension
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Those with dementia and delirium are at an increased risk for
falls and major injuries if falls occurScreening tools can be used
to identify cognitive impairments
Cognitive Impairment
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A significant relationship exists between vision and hearing and
fallsRisk factors include poor visual acuity, reduced contrast
sensitivity, decreased visual field, cataracts, and use of
nonmiotic glaucoma medicationsFormal vision assessment is an
important intervention to identify remediable visual problems
Vision and Hearing
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A number of medications are implicated in increasing fall
riskReview all medications, including over-the-counter and
herbal medications and limited to those that are essential
Provide patient teaching related to fall risk, appropriate dosing,
and drug–drug and drug–alcohol interactions

Medications
*
Fall risk assessment is an integral part of primary health care
for the older personAdults may be apprehensive about sharing
information regarding a fall because of the fear of losing their
independenceScreening tools can be used to determine the risk
for falling
Implications for Gerontological Nursing and Healthy Aging
*
Perform an initial fall assessment on admission, after any
change in condition, and at regular intervals during a
stayAssessment of the older adult at riskNursing assessment of
the patient after a fallAssessment of the environment and other
situational circumstances upon admission and during
institutional staysAssessment of the older adult’s knowledge of
falls and their prevention
Fall Assessments
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*

Morse Fall ScaleNot for use in long-term care
facilitiesPerformance-Oriented Mobility AssessmentHendrich II
Fall Risk ModelValidated with skilled nursing and
rehabilitation centersMinimum Data Set (MDS) 3.0Includes
information about the history of falls and hip fractures, as well
as an assessment of balance during transitions and walking
Fall Risk Assessment Instruments
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Determining the reason for a fall occurred provides information
about the cause of a fall and ensures that appropriate plans can
be instituted to prevent future fallsIncludes a fall-focused
history, fall circumstances, medical problems, and medication
review, as well as mobility, vision and hearing, neurologic, and
cardiovascular assessments
Postfall Assessment
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One-size-fits-all approach does not workInterventions depend
on the person’s changing conditionType, timing, and frequency
of the interventions are tailored to the personEducation about
fall prevention is an important intervention for patients,
families, and the community
Interventions for Fall Prevention
*

*
*
May be of benefit when part of a multifactorial programHome
safety assessment and modification interventions are effective
in reducing the rates of falls in community-dwelling older
adultsIn institutional settings, the patient care environment
should be assessed routinely for extrinsic factors that may
contribute to falls and corrective action taken
Environment Modifications
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Many devices are available for specific conditions and
limitations CanesWalkersWheelchairsCan also improve
functional ability and independenceEducation is essential
because improper use of these devices can lead to an increased
fall risk
Assistive Devices
*

*
Interventions the nurse may implement to help prevent falls
include (Select all that apply.)
keeping the call light within reach.
rounding on the patient every 1 to 2 hours.
reducing fluid intake after the evening meal.
using a bed alarm if the patient is disoriented.
teaching the patient to change positions slowly.
Question
*
A, B, D, E—Reducing fluid intake after the evening meal does
not reduce fall risk. Fluid volume deficit may actually increase
the risk because of syncope.
Answer
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Physical restraintManual method that uses either a physical or a
mechanical device and is designed to reduce the ability of the
patient to move his or her arms, legs, body, or head
freelyChemical restraintDrug or medication is used as a
restriction to manage the client’s behavior or movement, which
is not a standard treatment or dose of a medication

Restraints and Side Rails
*
Do not protect patients from falling, wandering, or removing
tubes and other medical devicesCan cause serious injury and
deathAre associated with higher death rates, injurious falls,
nosocomial infections, incontinence, contractures, pressure
ulcers, agitation, and depressionMay cause fear and agitation in
those with a history of trauma
Consequences of
Physical Restraints
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No evidence suggests that using side rails deceases the risks for
or the rates of fallsSide-rail restraint is defined as the two full-
length or four half-length raised side railsIf a patient is able to
use the half- or quarter-length upper side rail to assist in getting
in and out of bed, then he or she is not considered to be
physically restrained
Side Rails
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Is the standard of practice and an indicator of quality care in all
health care settingsShould not be used to manage behavioral
symptoms of hospitalized older adults with delirium What
works for one patient may not work for another; assessment is

keyStaff education regarding restraint-free care is important
Restraint-Free Care
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*
Gerontological nurses need to be knowledgeable about fall risk
factors and fall risk reductionHealth promotion interventions
can help maintain fitness and mobility in older adultsKnowledge
of the home environment and risk factors for falls is a must
*
If a patient is able to use the half- or quarter-length upper side
rail to assist in getting in and out of bed, then this patient is
considered to be placed in a form of physical restraints.
True
False
Question
*
B—If the patient uses a half- or quarter-length upper side rail to

assist in getting in and out of bed, it is not considered a
restraint.
Answer
*
Chapter 16
Promoting Safety
Must be multifaceted and individualized to the areas of
identified risks Particularly important for older adults who are
at risk for falls and is recommended in evidence-based protocols
for fall risk reduction
Home Safety Assessment
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*
Exposed to temperature extremes in dwellings can impose a
serious risk to older persons with declining physical
healthOlder individuals are vulnerable to environmental

temperaturesThermoregulationHyperthermiaHypothermia
Environmental Temperatures
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Influenced byNeurosensory changesMedicationsEconomic,
behavioral, and environmental factorsDiminished
thermoregulatory responses and abnormalities in production and
response to pyrogens contribute to differences in fever
responses between older and younger patients
Thermoregulation
*
Body temperature increases above normal ranges because of
environmental or metabolic heat loadsRisk
factorsAdministration of diureticsLow fluid intakeThose with
cardiovascular disease, diabetes, or peripheral vascular
diseaseCertain medications
Hyperthermia
*
*
Core temperature of less than 35°C (95°F)Affects all body

systems but most concern for cardiac and respiratory
functionOlder adults at risk for numerous reasonsCardiac,
respiratory, and musculoskeletal impairmentsExcessive alcohol
usePoor nutritionInadequate housingCertain medicationsSurgery
Hypothermia
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*
Recognize clinical signs and severity of hypothermia and
hyperthermia Keep frail elders in environments with appropriate
temperatures for comfort and prevention of problemsMonitor
body temperature and pay particular attention to lower or higher
than normal readingsAdvocate for community resources
*
Which patient assessment data does the nurse recognize could
contribute to an older adult’s risk of hyperthermia?
Has a history of osteoarthritis
Takes furosemide 40 mg daily
Bathes daily with a hot shower
Keeps room temperature at 72°F
Question

*
B—Patients receiving diuretic therapy have a higher risk of
hyperthermia.
Answer
*
Older adults are at great risk during and after disasters and have
the highest casualty rate during disaster eventsOlder adults are
vulnerable to natural disasters because ofLimited mobility
Social isolation Cognitive impairment Institutionalization
Natural Disasters
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Critical link in the ability to remain independent and
functionalLack of accessible transportation may contribute to
social withdrawal, poor nutrition, depressive symptoms, and
health decline With age, the risk for impairments that affect
driving skills increases because of disease-related and normal
aging changes
Transportation Safety
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Assessment should include evaluation of whether an individual
can drive, feels safe driving, and has a driver’s licenseThere is
no gold standard for determining driving competencyDriving
evaluations are offered by various community agencies
*
*
Hold promise for improving quality of life, decreasing the need
for personal care, and enhancing independence Assistive
technology is any device or system that allows a person to
perform a task independently, easier, and saferGerotechnology
describes assistive technologies for older people
Emerging Safety Technologies
*
Use of electronic information and telecommunication
technologies to support long-distance clinical health care,
patient and professional health-related education, public health,
and health administrationIncludesRemote monitoring
devicesSmart medical homes
Telehealth
*

Advancements improve the quality of life, decrease need for
personal care, and enhance the ability to live
independentlyTelemedicine allows for managing medical
problems in the home or other settings, thereby reducing health
care costsDevices are available to monitor gait and to detect
balance problems
Emerging Technologies
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Can lead to enhanced health and well-being Components
includeAddresses basic needsOptimizes physical health and
well-beingMaximizes independence Provides social and civic
engagement
Elder-Friendly Communities
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A nurse counseling an 85-year-old person regarding modifying
driving habits would include
playing music will help keep you alert.
limit driving to familiar places close to home.
driving in heavy traffic is fine as long as it is not raining.
if you have a passenger, you may drive at any time of the day.
Question
*

B—Encourage older adults to modify their driving habits, such
as not driving on unfamiliar roads, during rush hour, at dusk or
at night, in inclement weather, or in heavy traffic. Distractions
should be minimized.
Answer
*

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