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Course: Fundamentals of Nursing�Topic: Accident and Injury Prevention

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Student Learning Outcomes

Learners will be able to:

Describe the nurse’s role in the prevention of accidents and falls.�
Identify clients who are at risk for falls

Discuss the nurse’s role in the use of restraints

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Definition of “Fall”

Currie, 2008

“an event which results in a person coming to rest unintentionally on the ground or lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard”

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Nurse’s Responsibility

Assess for fall risk.

Reassess as necessary.
Implement universal fall precautions for every client.

Report all falls.
Knowledge of organization’s policy and procedures regarding falls, risk assessment, and documentation.

Lunsford & Wilson, 2015

Contact info: info@nursesinternational.org

The nurse is the first line when determining the fall risk of a client. An initial assessment when the client arrives on the floor should be conducted, as well as reassessments when necessary. Reassessment occurs after a fall occurs or if the client’s level of care changes -- such as change of mental status or development of change of client status. The nurse should also report all falls and document as appropriately. Knowing the organization’s policy and procedures will determine how the fall assessments are charted and documented, what specific interventions should be implemented dependent on fall risk score, fall risk tool, and how often documentations should occur.

Lunsford, B., & Wilson, L. D. (2015). Assessing your patients’ risk for falling. American Nurse Today, 10(7), 29-31. Retrieved from https://www.myamericannurse.com/wp-content/uploads/2015/07/ant7-Falls-630_Assessing.pdf

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Assessing Fall Risk

Lunsford & Wilson, 2015

When to assess for fall risks

New admission
Transfer client
After a previous fall
Changes in client care

Different tools to determine risk level
Taking client history

History of fall within last year
Impaired gait or mobility
Utilization of mobility devices
Altered mental status
Medications

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The nurse should assess for fall risks at these four points.

Dependent on work setting, there may be different tools to determine the fall risk level. Approximately 50 fall risk assessment tools exist. Examples include the Morse Fall Scale (MFS) and the St. Thomas Risk ASsessment Tool in Falling Elderly Inpatients (STRATIFY).

Determining the client medical history can assist in determining fall risk. Mobility devices can include, but not limited to, a cane, walker, wheelchair, or crutches. Medications that can influence fall risk is blood pressure medications, over the counter medications for aiding in allergies or sleep, or multiple medications with increased risk of drug to drug interactions.

Lunsford, B., & Wilson, L. D. (2015). Assessing your patients’ risk for falling. American Nurse Today, 10(7), 29-31. Retrieved from https://www.myamericannurse.com/wp-content/uploads/2015/07/ant7-Falls-630_Assessing.pdf

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Fall Risk Factors

“ABCS Fall Injury Risk” (Dykes et al., 2018)

A: Age & frailty → Increases risk if over 85 year old, or increased frailty
B: Bones → Client history of osteoporosis or a previous fracture
C: anti-Coagulation → If the client is taking anticoagulants or has a known bleeding disorder
S: Surgery → Client has a recent surgery

These factors increase the risk of falls and injury potential.

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Fall Prevention Strategies

(Spring Arbor University, 2019; Lunsford & Wilson, 2015)

Universal Precautions

Room orientation to client
Remove clutter and barriers within room and on floor
Create clear pathways for moving in room
Call light and client items within reach
Bed in lowest position and locked
Hourly rounding
Non-slip footwear on client

High Risk Additional Precautions

Identifiable fall risk identification
Potential staff member at bedside

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Universal precautions should be implemented for every client, every time, no matter level of risk.

Additional precautions may be implemented for high risk clients, can be determined through organization’s specific policies or procedures. An example of fall risk identification is a wristband indicating high risk. A potential staff member, or sitter, may be needed to sit at bedside if there is high risk of injury to client.

Spring Arbor University. (2019, March 26). Advanced nursing and your role in fall prevention. Advanced Nursing and Your Role in Fall Prevention. https://online.arbor.edu/news/advanced-nursing-and-your-role-fall-prevention

Lunsford, B., & Wilson, L. D. (2015). Assessing your patients’ risk for falling. American Nurse Today, 10(7), 29-31. Retrieved from https://www.myamericannurse.com/wp-content/uploads/2015/07/ant7-Falls-630_Assessing.pdf

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Fall Implications

Potential for increased length of stay in hospital.

Injury potential.

Increased possibility of discharge to somewhere other than home.

Loss of hospital funding.

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Case Study - Part 1

A new client arrives on the unit after falling at home and the nurse is taking the initial admission assessment. The nurse finds that the client arrives in their wheelchair, is alert and oriented times , and is currently not taking any medications. After gathering the client’s information, does the nurse classify this client as a high or low fall risk? What factors determined your classification? What interventions should the nurse immediately implement?

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Definition of “Restraint”

“measures used to restrict freedom, limit the activity, or control the behaviour of a person or a portion of their body”

College & Association of Registered Nurses of Alberta, 2020

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Types of Restraints

Physical

Nurse or provider holding client’s arms, legs, or body with their hands.

Chemical

Medication given to client for management.

Mechanical

Use of equipment to limit client mobility: wrist ties, side rails.

Environmental

Not allowing client to leave room.

College & Association of Registered Nurses of Alberta, 2020

Contact info: info@nursesinternational.org

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Nurse Consideration for Restraint Use

Understand organization’s policy and procedures on utilizing restraints.
Ensure there is an active order written.
Assessing client condition for need of restraints.
Continual assessment of client during restraint use and proper documentation.
Know alternatives to restraints.

College & Association of Registered Nurses of Alberta, 2020

Contact info: info@nursesinternational.org

Although a physician orders the restraint, nurses play a key role in the safety of the client before and during use of restraints. The organization should have specific policy and procedures regarding restraints, and it is the nurse’s responsibility to have knowledge on them. These policy and procedures should outline the proper use, assessments needed, and documentation needed. The nurse’s knowledge on the need of restraints should include the indication of restraint and if there are other techniques that can be implemented prior to restraints. The nurse should properly document client’s condition on the set intervals to maintain safety. Knowledge of restraint alternatives should be known in order to minimize restraint uses.

College & Association of Registered Nurses of Alberta. (2020). Restraints. Standards and Learning Restraints. https://nurses.ab.ca/standards-and-learning/restraints

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Restraint Alternatives

Behavior de-escalation techniques.

Bedside sitter.

Involving family in care and decision making.

Anticipating client behavior.

Start with least intrusive restraint initially.

College & Association of Registered Nurses of Alberta, 2020)

Contact info: info@nursesinternational.org

Alternatives to restraints should be utilized prior to initiating use of restraint. Behavior de-escalation techniques are often provided in trainings or orientations to the organization. A nurse may be able to calm the client and avoid the uses of restraint. A bedside sitter, often a staff member, but sometimes a family member, can sit at the bedside of the client. This provides supervision and may be able to prevent the use of restraints. This may also relate to providing the family in care in the decision making, where family members may step in to help assist. Also, it is important to update the client and/or family in the use of restraints to provide the client the best autonomy. Through anticipation of client behavior, the client may be able to be calmed down. An example is clustering care by not continually waking the client up if this is an instance that they become disoriented or potentially harmful. If restraints are necessary, assessment of the least restrictive restraint appropriate should be done. Starting with the least intrusive restraint may minimize harm to client and also protect the client’s autonomy.

College & Association of Registered Nurses of Alberta. (2020). Restraints. Standards and Learning Restraints. https://nurses.ab.ca/standards-and-learning/restraints

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Case Study - Part 2

The nurse comes in for their shift the next day and is assigned to the same client. During the nurse handoff at the client’s bedside, the nurse now finds the client with all four side rails up on the client’s bed and soft wrist restraints on. The nurse did not see any restraint orders during their pre-shift order review. When questioning the side rails and soft wrist restraints to the previous nurse, they said that because the client was high fall risk and they raised all the rails and put on the soft wrist restraints for client protection.

What should the oncoming nurse do immediately and throughout their shift to promote safety?

Identify the types of restraint used.

Contact info: info@nursesinternational.org

Due to there not being any current or previous orders of restraint use on this client, the nurse should lower one side rail and remove the soft wrist restraints. If there is proper indication for these restraints, a physician order must be placed and documented. Also, the oncoming nurse should think of implementations to do during their shift. Hourly rounding and universal fall precautions should be completed. Additionally, continual reassessment throughout the nurse’s shift should be done if restraints are indicated or if other safety protocols can be put into place. An example may be utilization of a sitter if there is potential harm.

The restraints are the bed side rails because all four are up and also the soft wrist restraints. These are both mechanical restraints because they are types of equipment being utilized to keep the client in the bed.

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References:

College & Association of Registered Nurses of Alberta. (2020). Restraints. Standards and Learning Restraints. https://nurses.ab.ca/standards-and-learning/restraints

Currie, L. (2008). Fall and Injury Prevention. In R.G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 195-250). Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK2653/

Contact info: info@nursesinternational.org

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References:

Dykes, P.C., Adelman, J., Adkison, L., Bogaisky, M., Carroll, D.L., Carter, E., Duckworth, M., Herlihy, L., Hurley, A.C., Khasnabish, S., Kurian, S., Lindros, M.E., Marsh, K.F., McNinney, T., Ryan, V., Scanlan, M., Spivack, L., Shelley, A., & Yu, S.P. (2018). Preventing falls in hospitalized patients. American Nurse Today, 13(9), 8-13. https://www.myamericannurse.com/preventing-falls-hospitalized-patients/

Lunsford, B., & Wilson, L. D. (2015). Assessing your patients’ risk for falling. American Nurse Today, 10(7), 29-31. Retrieved from https://www.myamericannurse.com/wp-content/uploads/2015/07/ant7-Falls-630_Assessing.pdf

Spring Arbor University. (2019, March 26). Advanced nursing and your role in fall prevention. Advanced Nursing and Your Role in Fall Prevention. https://online.arbor.edu/news/advanced-nursing-and-your-role-fall-prevention

Contact info: info@nursesinternational.org

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