Falls among the elderly can have severe consequences, including life-threatening hip fractures. As an experienced hospice registered nurse case manager, I understand the importance of fall prevention, especially in private homes, personal care homes, and assisted living facilities. This article aims to provide practical tips for reducing falls in these settings by following the nursing process: assessment, diagnosis, planning, implementation, and evaluation.
According to the CDC, over three hundred thousand people over 65 suffer from hip fractures each year due to falls. Those of you who have taken geriatric patients who have had recent broken hips know the seriousness of how this type of injury impacts your patients; often, hip fractures are a death sentence to the elderly. In my own experience, head and femur fractures are just as deadly. Therefore, I find it particularly important to reduce the risk of falls for all my patients. The fall risk is typically lower in the hospital and skilled nursing facilities. Thus, this article will focus on tips to reduce falls in private homes, personal care homes, and assisted living facilities.
As you grow and bloom in your nursing practice, it will benefit you always to remember the nursing process: assessment, diagnosis, planning, implementation, and evaluation. As it relates to fall prevention, the application of this in general is as follows:
Assessment: Identifying Fall Hazards
Environmental Assessment
Identify fall hazards like oxygen tubing, throw rugs, and misplaced equipment.
Ensure proper lighting during the day and night.
Patient Assessment
Evaluate muscle coordination, gait, strength, vision, and assistive devices.
Consider relevant patient diagnoses that may increase fall risk, such as dementia or heart disease.
Diagnosis: Understanding Fall Risks
Frequency of Declines
Assess the patient’s illness velocity by examining the frequency of declines over the past six months.
Background: A geriatric patient with a terminal illness of senile degeneration of the brain with an unrelated (to the terminal) diagnosis of cervical dystonia where the patient has frequent bilateral upper tremors involving the patient’s face, neck, and arms to fingers and COPD. The patient’s medications include 325 mg Acetaminophen x2 tabs BID for pain, 250 mg Cipro daily for UTI prophylaxis, 10 mg Donepezil for dementia, and 40 mg Simvastatin for high cholesterol. The patient also has been getting (for years per family) 1 mg Ativan daily and 3 mg Ativan HS. The patient used to be on several high blood pressure medications that were discontinued several months prior related to the medications causing hypotension. The patient is on two liters of continuous oxygen for COPD. The patient uses a rollator for ambulation.
Situation: You were in to see the patient for a regular visit, and you found out that staff had found her on the floor near her chair. Staff reported, “The patient is stubborn and refuses to use the call bell.”
Assessment: You find the patient in their room at 11:00 AM. They have oxygen tubing under one foot and are caught up in the wheels of the rollator as they sit on their chair. They are AOX 2, groggy, and deny any discomfort. Your inspection finds no injuries.
Can you identify some immediate fall risks? Let me walk through what our team identified (let me know if you agree, disagree, or find more):
I asked the question about the need for continuous oxygen. Tested hypothesis by getting SPO2 at the start of the visit along with respiration rate and effort. Turn off the oxygen, and one hour later (monitoring the patient throughout), get a current SPO2, respiration rate, and effort. For our test, the patient went from 97% on two liters to 92% on room air without a change in respiration rate or effort; the patient also denied being short of breath. Had the test failed, the next step would have been looking at ways to get the patient off continuous oxygen, such as starting an oral steroid, scheduled DuoNeb treatments, and the like; and should those have failed, looking at using portable oxygen tanks during the day and only using the oxygen concentrator at night.
Obtain orders from the doctor to discontinue Donepezil as this medication is for early-to-mid stage dementia and is on the Beers list for having a side effect of increased falls. Also, ask for the discontinuation of the Ativan due to the patient’s grogginess at 11:00 am in the morning while having a reasonable PRN dose of Ativan to help wean the patient off the Ativan.
Obtain orders from the doctor for a chest x-ray two view to rule out pneumonia and to obtain a urinalysis to rule out a UTI.
Now, both tests in number 3 came back negative; therefore, ask the doctor to discontinue Cipro due to polypharmacy burden (beers criteria).
Obtain an order for a chair and bed alarm.
Work with the family and the personal care home to see if the patient can be moved to a room closer to the nursing station.
Would there be anything else that you would recommend or do?
Let me end by sharing an acronym I used to learn how to think critically when a patient’s condition changes (please remember that a fall, even without injury, is a change of condition): DOGi. I picture a doggy playing with a ball in the grass.
D = Drugs (medications). What new medications were introduced before the change of condition? What medications (even if they have been taking them for years) might contribute to the change of condition? Is mediation on the Beers Criteria?
O = What’s the patient’s oxygenation (SPaO2)? Low oxygenation often leads to confusion, restlessness, fatigue, and weakness.
G = Glucose. What’s the patient’s current glucose reading? Are they hypo or hyperglycemic? How does their current reading compare to their baseline? (Let’s remember that patients who are chronic diabetics with poor compliance/management may experience hypoglycemia symptoms with numbers we might consider normal, which is why it’s so important to compare their current reading to their normal baseline.)
i = Infection. When a person has an infection, especially in the geriatric population, they often have signs and symptoms of delirium.
What tools and resources do you use to help you identify fall risks and take steps to reduce the risk of falls?
Conclusion
Preventing falls in personal and private care homes is crucial to ensuring the well-being of elderly patients. By following the nursing process and using tools like DOGi, healthcare professionals can identify fall risks and implement effective strategies to reduce them, providing safer patient care.
