FALLS

Falls

Welcome back to the Nursing School Week by Week Podcast. I'm your host Melanie, and today we're gonna talk about a basic one but a big one. We’re talking about falls. We're gonna get into what constitutes a fall, because it may not be exactly what you think a fall is but it would still count as a fall. We're gonna get into what makes a person more likely to have a fall; we're gonna get into what we as nurses can do to help prevent falls, and we're also going to touch a little bit on the good and bad of placing so much importance on preventing falls. Before we jump in, I want to talk a little bit about Picmonic who is partially sponsoring this episode blah blah blah blah blah. 

All right, so let's jump into falls. What is a fall? A fall is technically an event that results in a person coming to rest on the ground or on another lower level. And that doesn't sound so bad right? But this is really important because according to the CDC falls are the leading cause of death in adults 65 and up and falls are the most common cause of traumatic brain injuries and most hip fractures are caused by falling. If you have an elderly person, and they sustain a fall, their quality of life after that is usually significantly changed. They can't bounce back the way that a younger person would. They don't heal as fast; they may not heal completely ever from that fall and so their range of mobility could be changed, their ability to ambulate to get around to do their activities of daily living on their own, all of that can be changed from a fall that can happen in a second. So we as nurses need to do what we can to prevent those falls from happening. Alright, some factors that cause falls. The main risk factor for falls is being 65 and older. So if you're elderly you're much more likely to have a fall. Um, if you have some kind of artificial lower limb like an artificial leg or if you use assistive devices like a walker or cane or a wheelchair than you are much more likely to have a fall. If you live alone and you’re elderly, if you have any kind of lower body weakness, if you have vision problems, hearing problems, if you're having balance difficulties. And we also see falls in postop patients. Whether they're older or younger postop patients cause they can be disoriented coming out of whatever sedative was used to keep them under during their procedure, and also you know before the surgery maybe they had for use of their of all their limbs and then after the surgery they don't temporarily, but they're used to being able to use all of those limbs. So they could have a fall. Some other factors that can cause falls is the environment. Certain hazards in the environment, like a lot of clutter on the floor, or throw rugs. Throw rugs, especially with older people. Some elderly people have kind of a shuffle in their gate or, you know, maybe they don't lift their feet up all the way when they step. So a throw rug would be a big hazard for them, and sometimes the throw rug can get bunched up and even that can cause a fall. Cause an elderly person could try to bend over or get down on the floor to fix that throw rug and that could cause a fall. Another environmental hazard is insufficient lighting and this can be a big one in the hospital as well, especially if you're working night shift. Some patients will have to urinate in the middle of the night and maybe they don't wanna wait, they don't want to use the call light, they don't wanna wait for staff to get there. Um, or maybe they don't have the call light near them, or maybe they just don't know what button to push to turn the lights on at night, so they'll try to get up and make their way to the bathroom in the dark and sustain a fall that way. Some other factors that can cause falls are cognitive factors, like being disoriented or having confused patients. Maybe delirious patience, or patients with dementia. Or even just a lack of sleep; we all know it's so hard to sleep in the hospital, and even just that lack of sleep in an elderly person can cause them to be confused and disoriented and more likely to have a fall. Another factor is polypharmacy; and that means being on multiple medications. Most of our patients are on four or more medications. A lot of them will be on narcotics, sedatives, antidepressants; those three especially put you at a greater risk for falls. Narcotic,s sedatives, and antidepressants. And also a lot of these medications can cause something called orthostatic hypotension; especially your blood pressure medications. Orthostatic hypotension is when you have an abnormal decrease in blood pressure that occurs when a patient goes from a lying down position to a standing position. And you could imagine that if you stand up, and it’s happened to all of us right? You stand up too fast and you get a little lightheaded? That's what is happening to a lot of our patients right before they fall. They get orthostatic hypotension. And the way we as nurses would assess whether the patient has orthostatic hypotension is we would measure their blood pressure while they're lying down, and then have them stand up and measure their blood pressure and pulse after one minute of standing, and then again after three minutes of standing, and if there's drop in their blood pressure of more than 20 mmHg, it's considered abnormal; or a drop of more than 10 mmHg with her diastolic blood pressure. 

All right, so in the hospital there is something that we can do to assess our patients to find out and to kind of label them as high fall risk or not. The main one that you'll be using is called the Morse Fall scale and it's used to identify risk factors for falls in hospitalized patients. It asks a series of questions and gives points for each one, so for example, if the patient has a history of falling you would check that box and that would give them 25 points. If they have two or more secondary medical diagnoses, that would give them like 15 points. So like, let's say they came in to have a surgery but they also have diabetes and afib that would give them 15 points because they have two or more secondary medical diagnoses. Then part of the risk assessment is looking at any ambulatory aids that they use. Do they use crutches, a cane, a walker, any of those would give them 15 points. Do they use furniture? Like they don’t actually have an ambulatory device that they use but they kind of cruise around touching the furniture with each step, that would give them 30 points. Um, do they have an IV in place? That would give them 20 points. Is their gait, when they're walking, is there a gait weak or impaired? Those would both give them points. What is their mental status like? Do they kind of forget their own limitations? That would give them 15 points. Are they kind of over-confident in their physical abilities? And then the computer is going to count up the total score. If it's less than 25, then they are low fall risk. If it's 24 to 45 they’re a moderate risk. If it's over 45 than they are a high fall risk. And you will see on some units, hospitals now have kind of gotten to the point where they treat pretty much all the patients, if not all the patients as a high fall risk. Which I can see good and bad to that.  Good because everyone working there, all the staff, gets used to implementing all of the fall risk precautions on every patient. But bad because, you know, when everyone's exceptional then no one's really exceptional right? So if everyone's labled a high fall risk, then are we really being extra careful with the patients that are truly a high fall risk? Or are we kind of expecting them to have the same abilities as athletic Betty Sue who came in and you know, she was labeled a high fall risk, but really she was ambulating just fine. So I can see good and bad with just sort of blindly labeling everyone as a high fall risk. 

Then going back to the patient's medications, we wanna especially pay attention to those patients that have medications that affect their blood pressure, and their level of consciousness, because those are the ones that are most associated with having the highest fall risk. Like the ones that you really want to be on the lookout for are any patients that are on antipsychotics, anticonvulsants, and benzodiazepines. Those are the patients that are at the highest risk when looking at their medications. And then some other ones that are concerning would be any cardiac medications, antidepressants, and diuretics. If you think about it, if you're putting someone on a diuretic, they're going to be having to get up very often to go to the bathroom, if they don't have some sort of Foley catheter in place. That's why we usually try to give diuretics in the morning so that they're getting up a lot during the day to urinate. But sometimes it's still working on them at night, and that can be a risk for sure for falls; if they're having a get up at night and find their way to the bathroom multiple times. Another thing to look at is their clothing. Are they wearing unsafe clothing? Are they  wearing like pants that are a little too long that could get under their foot and they could slip on. Um, are they wearing really baggy clothing that could snag on the corner of the table? Are they wearing slippery socks without that skid proof bottom, or nonskid bottoms? 

So what are some nursing interventions that we can put in place to help decrease the risk of falls? We can make sure that if your patient is a high fall risk, that they are labeled as such. Meaning, it’s policy in most hospitals that high fall risk patients will wear a yellow wristband that says high fall risk. And they’ll also often have some kind of door sign or indication on the door to let everyone know that the patient in that room is a high fall risk. If we're very concerned, we can make sure that that patient gets a room right next to the nurses station. So that if the patient really needs to get up out of bed; maybe this patient is a confused patient and won't know how to operate the call light system to call for help; so maybe we want to put that patient right next to the nurses station so that we can hear when they're just calling out for help, and we can go to them quickly before they try to get up on their own. And we do, for all the patients, whether they're high fall risk or not, we want to make sure that they have their call light within easy reach. Um, and if they have a urinal, we want to make sure that’s in easy reach. If they're not NPO, make sure they have some water right there; and the phone if they need their phone. And when a patient uses the call light and calls for a nurse to come help them, we need to come quickly, as quickly as we can. And I know, saying that, if you have worked in the hospital as a nurses aide, you may be rolling your eyes right now because that's not always possible. The unit may be understaffed, or may just have particularly needy patients that day; and sometimes, you know, you can't be in two places at one time, so you do your best. But as much as possible, we want to get to the patients as quickly as we can when they're using their call light. Because we don't want them trying to get up on their own, because that's when the accidents happen. And I know it happens a lot; The patients gets so frustrated because they’'ll be like well I’ve been using my call light. I’ve been waiting here for 20 minutes, so I got tired of waiting and you gotta go you gotta go so I got up and tried to go. But let's try to prevent that from happening by answering the call light quickly. 

Alright, another intervention that’s pretty easy for nurses to do, is to leave the bed in the lowest possible position. And this just helps with, I mean, it does help prevent a fall, but if a fall happens, if they do fall out of their bed at least they don't have as far to fall and there's hopefully less damage that will be done. Another thing is, we want to use bed and chair alarms for fall risk patients. And these are just usually little plastic things that are easy to wipe down and clean, and you can put it on the bed before you even make the bed up before you even put the sheets on. Put it under a sheet or a towel or something on the chair and it plugs into the wall or into the bed and actually some of these beds now come with built-in bed alarms, and a lot of them you can even set to be very sensitive, so they go off when the patient just even like barely starts to get up and then other ones you can set to be less sensitive so they won't go off until the patient is out of bed. But for a high-risk patient this is important to use the chair and bed alarms. Because if a high risk patient does get out of bed, we want to know about it as soon as possible so we can rush in there and hopefully prevent a fall from happening. If nothing else, we can find them on the floor quickly so they're not laying there for an hour with a fractured hip. And it’s also, on some level,  preventative for patients trying to get up out of bed on their own. Because if they know that, if they try to get up is really loud really annoying alarm is going to sound and everyone's going to know that they didn't wait for the nurse to come, then that's enough for a lot of patients to just wait for someone to come and help. To turn off the alarm first and help them out of bed. 

All right, another thing that we as nurses can do to help prevent falls is to raise the side rails up on the bed. And I I say this, but at the same time, I want you to remember you can't raise all four and leave all four up, because that is technically considered a restraint and you would need to have an order from the doctor to use a restraint on the patient. But you can put three of the side rails up and leave like one of the rails at the foot of the bed down. Or a lot of times you'll the nurse will have put two of the side rails up on one side and then on the other side of the bed, pushed the bedside table up right up next to the bed, so that bedside table is kind of serving as a bed rail on that side. Alright, another thing we wanna do is encourage the patient to wear their nonskid slippers or shoes while walking. This can prevent a lot of falls.  Now I will say, if they have like Parkinson's, iff they have a bad like foot drop or bad shuffle to their gate it's probably better for them not to wear those nonskid socks because that can make them more likely to fall. But for most patients we want them wearing the nonskid socks to give them a little bit more traction when they're walking. We wanna make sure we keep their pathways clear and avoid clutter on the floor. And this can sometimes be difficult. Some patients like to bring a lot of stuff from home and like to have their family members bring a lot of things, especially if you're dealing with like a chemo patient, or a patient that's been in the hospital for a long time; they tend to accumulate things and try to make that room kind of homey for them. Which is understandable but we as nurses need to do our best to keep the pathways clear of clutter and tripping hazards. Another thing that we can do as nurses and as nurses aides is to use the gait belts for ambulation. So anytime you get a Hi-Risk fall patient up, use that gait belt. I know when you're new, it’s like, “I don’t even know, am I putting it on backwards? Am I putting it through the teeth the right way?” Um, but the more you do it the more comfortable you will become with it and before you know it you'll be able to whip that gait belt on in no time at all. But it is important to use that gait belt, because that's very helpful in stabilizing the patient while they're getting up and walking, and if they get dizzy or you do you need to lower them down, it's much easier to lower them down to the floor with the gait belt on. We also want to be suggesting and using any assistive devices that they have, like a walker if there's a walker in the room, or a wheelchair, when the wheelchair is what they're used to using. We want to use that. I know a lot of patients like to use the IV pole to hang onto while they walk, um, and I have done that before especially if the patient kind of insists on it. But it's really my preference to have the patient use the walker while I hold onto the IV pole. Because the IV pole is not, it’s  not an assistive device, it's sort of a false sense of security that we're giving to our patients. And we want to have our patients avoid trying to carry objects while they're walking if they're high fall risk. So if they're walking they need to just be focusing on walking step by step. You know, they may be using walker; they definitely don't need to be trying to walk while holding a couple of water or while holding towels to go to the bathroom, or any other supplies. So it's best if we can keep their hands free while they're walking. We also want to educate the patient. Educate them that they are a high fall risk. And I know it can be, when you're new, it can be uncomfortable to talk about that because on some level it can feel like you're insulting them. A lot of patients, even when they're elderly and obviously a high fall risk can get a little defensive about that and feel like, you know, “I’m independent, I can do it on my own.” But we do want to educate them, and you can put it like, “This is something I can go over with all my patients; everyone in the hospital is at a different level of fall risk, according to the medications that they're using, or the procedures that they're getting.” Um, but you want to educate them and, you can even go so far as to tell them the number of like where they are on the scale of high fall risk. I used to write the number on the little whiteboard in their room. So you say, you know you are at a level 80% high fall risk. This means you’re in the very high fall risk categorie, so we need to do these following things to help keep you safe. And make sure that you use your call light. Make sure you call, don't fall. And sometimes that's enough for a patient to hear that coming from you as a nurse and you know usually if you can get the unit on board, it's not just coming from you. It’s coming from the nurse that came before you, and the nurse that’s coming after you. And so, when a patient here is this consistent message of call, don't fall, then they're more likely to comply. 

I do have some mixed feelings about kind of the culture that we have on a lot of units around preventing falls. Even though falls are pretty common for hospitalize older adults, the center for Medicare and Medicaid has identified falls as a never event. Which puts a lot of pressure on hospitals to get zero Falls. And I feel like this can lead to a fear of falls for nurses that could impact how often they even try to ambulate their patients. And we know that early ambulation, like after a surgery, after a procedure, early ambulation is so important. We need to get them up and moving.  Get their muscles moving and get their blood flowing to prevent DVT's prevent pulmonary embolisms. Just lying in bed, I believe is a risk factor in itself for so many issues and so my fear is that when units place so much emphasis on preventing falls, that it puts this fear in nurses that makes them not want to comply with the get up as tolerated order. Or the ambulate three times a day order, and it also makes nurses feel blamed for any falls that do occur on their watch when we know that falls are very common for hospitalized older adults. But when you put that kind of pressure on nurses, it could have the negative impact of making them not want to take that risk of getting the patient up. And a fall is defined as any occurrence in which the patient descends to the floor. And this can be frustrating because it’s counted against the unit even if they were intentionally lowered to the floor to prevent injury. So even if the patient didn't technically fall, like on their own, even if the nurse was ambulating them around the unit and they got a little dizzy and there was no chair around, so the nurse decided to intentionally lower them down to the floor; because they're much less likely to hurt themselves if they're already sitting on the floor; even that is technically considered by Medicare and Medicaid to be a fall. So just knowing that, and the nurse knowing just kinda the mountain of paperwork that she or he will have to fill out if a fall happens, um, and knowing that at shift change, the charge nurse is going to get up in front of all the the nurses on the unit, give a little speech about how we did have zero falls for the last three months but now you know Suzanne's patient in room 38 had a fall toda,y so now the clock is reset. So just knowing that, I think that is enough to make nurses not want to get their patients up, to not want to ambulate them; when ambulating is so so important for their recovery for their health. So I can kind of see both sides of it. I just think it's important for management on units to to implement fall precautions in such a way that doesn't place the blame for a fall if it does happen, on the nurses. But anyway, that was just my little soapbox but I'm off it now. 

Alright you guys, I hope that was helpful in giving you a better idea of  what we as nurses can do to prevent falls and the importance of preventing falls, but also at the same time letting you all know that falls do happen. And they will happen. We can do a lot to try to prevent them, but when you're dealing with an elderly population that's in the hospital for a reason, you're going to have some falls. But with that said, we need to do everything we can to keep our patients safe and injury free. Alright you guys, I hope y'all have a great rest of your week and I will talk to you again next time.