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Safety in Nursing

Patient falls are common in hospitals and homes. They arise from intrinsic and extrinsic factors. Assessment of patient fall risk factors uses parameters of intrinsic elements such as age, medical condition, history of falls in a patient and extrinsic elements such as the surrounding environment. Through literature review, many studies point at cognitive impairment, environment, history of falls and effect of drugs such as tranquilizers as the leading causes of patient falls. Strategies aimed at preventing and/or reducing patient falls should thus be employed. Expected outcomes from these interventions are that patient falls will be avoided or minimized, and safety will be maintained. The strategies employed should thus majorly focus on the patient and the environment.

Introduction

A fall may be described as an unexpected dropping or coming into contact with a lower position such as ground or floor experienced by an individual. The aspect of falling and its prevention form a critical area of focus in the practice of nursing because the impact of this aspect can be dire to the health of the participant (Kalisch, Dana & Hee, 2012). Patients, owing to their medical condition may be highly susceptible to falls resulting in fatal injuries or even death. The risk of falling may be exacerbated by intrinsic and extrinsic factors. Intrinsic elements responsible for such falls may be cognitive, posture, vision impairment, body balance problems and effects of contraindicated drugs or medication. On the other hand, extrinsic factors include slippery or irregular surfaces, restraint devices, unfitting or inappropriate footwear, poor lighting, and use of unsuitable support devices among others (Micelli, 2008).

Assessment/Analysis

Assessment of the intrinsic and extrinsic risk factors for patients may employ noting parameters such as age. It is commonly evident that advancement in age is more often than not associated with mobility impairment. This may result in unexpected tripping and falls in the elderly. The problem is compounded further by medical conditions that the make frail the elderly patients. Therefore, nurses, both in general practice and nursing homes, should note the relationship between age and level of susceptibility to falls. The history of falls in a patient is also an important assessment parameter. If a patient has had a history of regular falls as a result of intrinsic factors, the nursing professional needs to accord such a patient extra attention to minimize risk of injuries that may result from falls in future (Chang, et al. 2004).

Other common considerations of assessment are functional disabilities and the accompanied use of support devices. A medical dimension employed in assessing the patient’s susceptibility to a fall involves analyzing conditions that are highly linked to falls. These include dementia, Parkinson’s syndrome, diabetes, depression and arthritis. Use of medication, which increases the risk of osteoporosis, should also be carefully studied to ascertain the risk level on the patient. Drugs such as anticoagulants are known to have such effects. Cognitive impairment resulting from brain damage either from physical accidents or disease condition should be assessed to determine its apparent effect on the patient. Deleterious effects on the brain have been associated with causing body imbalance, which may make a patient vulnerable to a fall. Other problems linked to the cognitive impairment include visual impairment. This indirectly reduces one’s judgment based on visual inability to determine distances and surface texture, and hence the probability of falling over (Gray-Miceli, Johnson & Strump, 2005).

Assessment of the environment in which the patient operates is important in an effort to curtail the risk of falling. The most important elements to be considered in this include an inspection of the floor surfaces. A patient whether with intrinsic impairments or not may be at risk of falling if the floor surface on which he/she is walking is uneven in texture. It is the role of the nursing professional to ensure the floor surfaces on which the patient walks is free of spills, wet or increasingly slippery as to cause a fall. Once assessment is done, the nurse is to ensure measures are taken to reduce the chance of a fall by the patient. The clothing worn by the patients should be assessed to ensure it does not raise a risk of tripping. Unfitting clothes given to a patient may inhibit or make their movements inconsistent, increasing the risk of falling. Clothes, which are too long for a patient, should not be given to such a patient as they make locomotion a challenge. Strapped clothes may also be a risk factor. This is because the straps may be too long and get trapped with other objects in the environment leading to loss of balance by the patient wearing them. Any new patient ought to have their garments fitted according to their body sizes to avoid any risks posed by unfitting clothing (Micelli, 2008).

Lighting is another important environmental component that requires consideration in assessment of fall risk factors. Light is an integral part the daily life both for patients and the nurses. Darkness reduces the visual ability of an individual irrespective of how good their eye sight may be. Poor lighting is one of the leading causes of falling accidents. Adequate lighting is of paramount importance to enable a patient to move freely within the environment provided. If the patient suffers from reduced visual ability, he/she may need extra attention in terms of lighting. The assessment of lighting systems in an environment need to be carried out by qualified personnel as in normal circumstances, a non-professional may inaccurately judge the lighting to be adequate when it is not. Excessive lighting is also dangerous as it results in glares. This could damage an individual’s eyes resulting in impaired vision. The illumination systems should be performing optimally at all times and where necessary back-up systems of lighting with a similar lighting quality should be employed. This would in turn greatly reduce falling incidences among the patients (Gray-Miceli, Johnson & Strump, 2005).

Locomotion aids make another important ingredient in successful patient environment. The furniture that the patient uses need assessment to ascertain its durability and functionality. The incidences of falling may be greatly reduced if efforts are made to ensure that table tops, chairs, wooden walking sticks, grab rails and beds are in good condition. Any other supportive aids such as intravenous poles should be closely observed to ensure they are in good condition at all times.

Planning/Literature Review

To identify appropriate articles, EBSCO host, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline, MediText, PubMed, and ProQuest databases were searched using a combination of the terms ‘patient falls’ or ‘patient falls in hospitals’.

According to Vieira, Heritage and Costa (2011), the leading causes of patient falls particularly in hospital settings in geriatric cases were carpet floors, confusion, old age, cognitive impairment, vertigo, medications such as tranquilizers and anticonvulsants, being an amputee, history of falls and the urge for assistance. Other possible causes would be visual and hearing impairments, postural hypotension, urinary incontinence, wrong bed heights, use of bed rails and the apparent fear of falling (Vieira, Heritage & Costa, 2011 pg.796). Their study revealed that falls in geriatric formations range from 15% to 54% in hospital settings. However, this study concluded that there were no unique characteristic among geriatric patients’ falls. Therefore, the precautions taken in other settings could be also applied in this case (Vieira, Heritage & Costa, 2011 pg.797).

An in depth analysis on the falls’ etiology found that out of the numerous risk factors that affected the elderly, the factors that could be pointed as having the strongest influence on these falls were decreased muscle strength, previous falls, visual impairment, depression, medical side effects and balance problems. Another major factor responsible for these falls and hitherto ignored by previous studies was the attitudinal aspect. The authors argue that any study that fails to consider the attitudinal element would register poor results. This is in respect to predicting the number of patients who would fall in hospital settings. The cognitively impaired patients were left out of the study. This is because they were presumed to lack the ability to make sound judgment about their surroundings that could be responsible for the high number of falls. This was done to raise the validity bar for this study. Nevertheless, the study recommends management of the patients through the provision of high quality care as the most effective way to tackle the challenge of injuries resulting from falls both at home and hospital settings (Schonwetter, Sehwan, Kirby, Martin & Henderson, 2010 p. 1361).

Another study carried out in a metropolitan hospital, in Australia, identified bed unit and transferring of patients as being responsible for the highest number of falls. The act of moving the patients was highlighted as high risk activity which could put patients at risk of falling. The study indicated that up to 80% of the falls took place in the rooms occupied by the patients making the bed unit the most high risk area for falls. The other cause that was identified in respect to these falls was the bathroom and toilet especially when patients attempted to walk on their own after toileting or showering. The study also revealed that most of the falls were not witnessed as they occurred. Therefore, the study recommended that the patient be made to understand the need to seek help when necessary since in another part it showed that assisted patients recorded minimal falls. In these cases, the nurse or the patients were using inappropriate aids. Nevertheless, it had been recommended that nurses and their patients learn to use specific mobilizing aids as authorized by specialists irrespective of how complex they could appear (Johnson, George & Duong Thuy, 2011, p. 64).

A method to encourage response was crafted in order to decrease patient falls. This was after noting that patients susceptible to falls were not seeking help from nurses. Combining call bell response with staff awareness resulted in improved response to patient calls. The challenge had been the emotional dilemma patients experienced in regarding to themselves as bothers. The call bell worked as it only involved pressing a button to attract attention. More employment of such methods in hospitals could thus reduce the number of falls (Digby, Bloomer & Howard, 2011 p. 27).

Sicknesses such as cancer have also been identified to increase the susceptibility of patients to falls. This has been attributed to the side effects arising from such processes as chemotherapy. Variations exist in the patients based on gender, functional state, age and the effect of hormone and radiation based therapies. Nonetheless, more research should be done so as to understand if there is certain oncology based risk factors that make such patients susceptible (Allan-Gibbs, 2010 p. 75).

Intervention

The nurses should employ strategies focused on the patient and the environment aimed at reducing and/preventing falls. These include using of standardized fall-risk tools and any other useful assessment tools to determine the risk of falling. The findings should then be communicated with stakeholders concerned. In discussion with these stakeholders, the nurses should aim at reviewing discouraging the use of any substances such as medications that increase susceptibility to falling. The stakeholders could involve family members and caregivers if the patient is receiving home based care. Other efforts would involve constant practicing to improve on mobility and balance maintenance. The risk assessment and any interventions adopted should be communicated in case the patient is being transferred to another setting. If possible, upon discharge the home-based care giver should be provided with information including written material for reference purposes on the most appropriate ways to reduce falling risks in such patients. Referring the patient to run exercises, groups or facilities for rehabilitation could effectively promote quick recovery or improvement in the patient’s overall condition (Rubenstein & Josephson, 2006).

Another intervention strategy entails instituting safety precautions to reduce the risk of falls. This may entail employing measures such as using low-rise bedstead, soft floor carpets to minimize injury in highly susceptible patients, ensuring quick access to call lights and close observation on the patients as they walk around. Reducing the number of physical barriers in the pathways used by the patients, as well as use of non skid shoes or flat, soft sole shoes, has been identified to be of great help. Other basic safety precautions that are helpful include using personal sensor alarms, regulating the times for toileting and locating the washroom facilities in easily accessible areas. The use of certain glasses to aid in walking and increasing mobility program durations as well as teaching theoretically what the patients should do is effective (Micelli, 2008).

Constant changes in the environment according to emerging demands in patients are an appropriate intervention strategy. Routine check on the patient care surroundings forms the basis for instituting the necessary corrective changes. The empirical checklists may be used as a basis to inform on the change that is most appropriate for a certain situation. Evaluation strategies to improve the environment safety can be easily drafted by interacting with experts such as risk assessment managers and housekeeping department. This may include considering the patients with certain needs who would require extra safety measures (Micelli, 2008).

Intervention may also include training of staff on handling the patients. The patients who are likely to experience falls, such as those with impaired judgment, osteoporosis, and/or hip fractures, may need more specialized attention. Therefore, the nursing staff needs to receive training and instructions from experts on what to do in case of a fall by such a patient.

Evaluation

The expected outcomes from these interventions are that patient falls will be avoided, and safety will be maintained. In case of a fall, the patient will not develop any serious complications; in addition, they will know the risks associated with falling. Through information acquired, the patients will be enlightened on how to avoid falls when discharged. It will also be possible to assess and treat any adverse problems arising from a fall. At the same time, the nursing staff shall possess knowledge and skills to identify, treat and/or manage patients at risk of falling or those who have suffered a fall. It will also be possible for the nurses to incorporate into their practice, a deeper understanding of assessment procedures and other management approaches. This is aimed at reducing or preventing falls within the hospital setting. With adequate skills, the nursing staff will be able to educate the patients ready for discharge. The education will focus on the best strategies to avoid future falls while appreciating the patients’ experience of falling with reference to their functional, emotional, and physical status.

Conclusion

Falls and their prevention are major areas of focus in the nursing profession. The risk of falling may be aggravated by intrinsic and extrinsic factors in patients. The risk of falling can be determined by analyzing different parameters such as age, the medical condition of the patient, history of falling in the patient and the environment in which the patient is in. Therefore, strategies should be employed focused on the patient and the environment with an aim to reducing and/ or preventing falls.

References

Allan-Gibbs, R. (2010). Falls and Hospitalized Patients With Cancer. Clinical Journal Of Oncology Nursing, 14(6), 784-792.

Chang, J. T., et al. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomized controlled trials. British Medical Journal, 328(7441), 680.

Digby, R., Bloomer, M., & Howard, T. (2011). Improving call bell response times. Nursing Older People, 23(6), 22-27.

Gray-Miceli, D., Johnson, J. C., & Strump, N. E. (2005). A step-wise approach to a comprehensive post-fall assessment. Annals of Long-Term Care: Clinical Care and Aging, 13(12), 16–24.

Johnson, M., George, A., & Duong Thuy, T. (2011). Analysis of falls incidents: Nurse and patient preventive behaviours. International Journal Of Nursing Practice, 17(1), 60-66.

Kalisch, B., Dana, T. & Hee, L.K. (2012). Missed Nursing Care, Staffing, and Patient Falls. Journal of Nursing Care Quality. 27 (1), 6-12.

Micelli, D. (2008). Nursing Standard of Practice Protocol: Fall Prevention. Hartford Institute for Geriatric Nursing. Web.

Rubenstein, L. Z. & Josephson, K. R. (2006). Falls and their prevention in the elderly: What does the evidence show? Medical Clinics of North American, 90 (5), 807–824.

Schonwetter, R. S., Sehwan, K., Kirby, J., Martin, B., & Henderson, I. (2010). Etiology of Falls among Cognitively Intact Hospice Patients. Journal Of Palliative Medicine, 13(11), 1353-1363.

Vieira, E., Freund-Heritage, R., & da Costa, B. (2011). Risk factors for geriatric patient falls in rehabilitation hospital settings: a systematic review. Clinical Rehabilitation, 25(9), 788-799.

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