[PPT]FALLS PREVENTION STRATEGYnursing.moh.gov.my/wp-content/uploads/2018/05/2-FALL... · Web viewFALL PREVENTION FOR NURSES BAHAGIAN KEJURURAWATAN KEMENTERIAN KESIHATAN MALAYSIA Bahagian

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FALL PREVENTION FOR NURSES

BAHAGIAN KEJURURAWATANKEMENTERIAN KESIHATAN MALAYSIA

Bahagian Kejururawatan, Kementerian Kesihatan Malaysia

Jan 2018mcheesn Jan 2018

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INTRODUCTION• Did you know… In Malaysia : Falls is a major health problem in the elderly because it cause significant morbidity & mortality. Overall, 19.1% of elderly reported experienced of fall. Falls were higher among female(19.5%) than males (18.7%)

MJM, Vol 70 Supplement 1 Sept 2015


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21.9% are elderly >75years and among rural (21.2%) more than urban dwellers(17.8%)

43.7% are those elderly with diabetes living in rural areas. (A.K.Azidah et.al)

60% fallers experienced resultant injury that needed medical attention in the preceding 12 months

By ethnicity, the highest prevalence of falls was among: Indians(19.8%), Malays(19.4%),Chinese(18.9%), & others (17.3%) respectively.


Samb…


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Contributing Factors to higher risk for falls:

Taking more than one medications Consumed alcohol Having heart disease


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The Goals of a prevention program are to :1. Decrease the incidence of falls2. Decrease severity of falls3. Increase mobility & function4. Improve environmental safety5. Provide comprehensive assessment6. Enhance staff knowledge7. Improve the patient’s confidence


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Why do patients fall ?• Combination of factors such as:

- Unstable gait or balance- Urinary frequency- Sedatives- Impaired vision

- Hyperactivity (Paediatric) - On IV devices• Poor mobility & confusion often contribution• Environmental hazards (eg. wet floor) (National Patient Safety Agency, 2007)


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Who Fall?• Who are the most vulnerable? - Children & Older patients, especially >65 years.• What were they doing? - Most occur while patients are walking. - particularly when using toilets or commode.• How many falls are witnessed? - A minority of falls are witnessed - When witnessed, will staff be able to prevent the patient from falling?

(National Patient Safety Agency, 2007)Bahagian Kejururawatan, Kementerian

Kesihatan Malaysia

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OBJECTIVES1.All staff must know the importance of fall risk assessment?

2.What are the areas of fall risk that are identified by using the Morse Fall Scale(MFS) & Humpty Dumpty Fall Scale(HDFS)?

3.How to use the MFS & HDFS to Plan interventions to prevent patients from falling?


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Why Implement Falls Risk Prevention Strategies?• Falls risk assessment : - Helps identify risk prone individuals.

- Aims to reduce the number and severity of falls.• Falls risk assessment is consistent with:- - the Morse Fall Scale Assessment & the Humpty Dumpty Falls Scale assessment. - to meet the required organizational Practices (Malaysian Pt Safety Goals No.9)


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What are the Fall Risk Assessment tools? The Morse fall Scale & Humpty Dumpty Falls Scale is a Fall Risk Assessment tool that predicts the likelihood that a patient will fall.

Must be done daily and with change in the patient’s status/condition.

Provides the information needed to assist in the interventions to prevent falls.


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What are the areas of fall risk that are identified by the Morse Fall scale?

• Based on 6 main factors History of falling Secondary diagnosis Ambulatory Aids IV Therapy/ IV devices Gait Mental Status


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Instructions :

• Unconscious patient : - Mark Risk as Low - Educate family - Reassess as condition changes and weekly


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History of Falling• Score 25 points…

If patient has fallen during this hospitalization. If patient has immediate history of falls within the past 3 months

• Score 0 if none of the above are true.


1. History of Falling NoYes

025

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Secondary diagnosisScore 0 - if only 1 active medical diagnosis

Score 15 - if more than 1 medical diagnosis is active for current admission.


2. Secondary Diagnosis NoYes

015

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Ambulatory AidsScore 0 - if patient walks without a walking aid or uses a

wheelchair or is on bed rest and does not get up at all.

Score 15 - if patient uses crutches or a walker.

Score 30 - if the patient walks clutching onto furniture for support (e.g needs help, but does not ask or does not comply with order for bed rest).


3. Ambulatory Aids

None/bed rest/nurse assistCrutches/cane/walkerFurniture

0

1530

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Intravenous Devices/ Urinary catheterScore 0 - if the patient does not have an IV

line/cannula, or is not attached to an equipment such as a syringe pump or a drop mate.

Score 20 - if the patient has an IV line, or is attached to equipment (e.g monitoring equipment or / Urinary catheter.


4. IV Line/ cannula NoYes

020

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Gait Score 0 - if the patient has a normal gait. Walks with head erect. Arms swinging freely at the side. Striding without hesitation.

Score 10 - if the patient has a weak gait. Stooped, but able to lift head without losing balance. If furniture is required and use as a guide. Short steps, may shuffle.


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Samb… Score 20 - if patient has an impaired gait.

Difficulty rising from chair (needs to use arms; several attempts to rise. Heads down; watches ground while walking. Cannot walk without assist; grabs at furniture or whatever available. Wheelchair; score according to gait used at transfer.


5. Gait NormalWeakImpaired

01020

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Transferring to wheelchair?How well would this person transfer on his/her own?What type of gait is used?

Unable and does not attempt to transfer = 0

Wriggles, jiggles, slips and slides = impaired = 20

Poor transfer/gait if done on own = impaired= 20

Able to transfer, but weak / with weak gait =10

Strong, safe transfer, independently able = 0


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Mental Status : Score 0 - if patient’s mental status is normal and judges own ability to ambulate accurately

Score 15 - if patient is considered to overestimates his/her abilities or forgetful of limitations

Assess by asking the patient : - “Are you able to go to the bathroom alone or do you need assistance?”


21Bahagian Kejururawatan, Kementerian

Kesihatan Malaysia

Normal: patient response is consistent with orders.

Overestimates/forgets limitations: patient response is inconsistent with ambulation order


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1. Calculate Risk Level for Morse Fall ScaleNo Risk 0Low Risk 1 – 24Moderate Risk 25 – 45High Risk > 45

2. Calculate Risk Level for Humpty Dumpty falls Assessment Scale

Low Fall Risk = 7-11(Initiate Low risk Standard Protocol)High Fall Risk = ≥12 (Initiate High risk Standard Protocol)

Remember : No risk assessment tool can predict 100% of patients who will fall.

Never underestimates the power of clinical judgment.


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How often is risk for fall assessment done? On admission or transfer Daily re-assessment After a fall When patient’s condition changes

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History of Falling

Nursing Assessment Goal :

Intervention strategy: Develop a strategy to prevent recurrence Develop patient-specific fall intervention plan Alert staff about the circumstances of the 1st fall Conduct rounds every 2 hours to check on patient

Morse,J, 2009



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Secondary DiagnosisNursing Assessment Goal :

To determine drug interactions from pharmacy

Intervention Strategies:

Consult with Doctor and pharmacy Adjust medications accordingly by the attending doctor.

Morse,J 2009

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GAITNursing Assessment Goal :

To assess impairment of gait & balance

Intervention Strategies:1. Refer to physiotherapy for exercise2. Walk patient regularly and provide a safe route to the bathroom3. Remind patient to use call bell when in need of assistance, to use

the handrail and plan a route4. Inform family about limitation and plan for fall intervention

Morse,J 2009



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Ambulatory AidNursing Assessment Goal:

To assess appropriate aids

1. If wheelchair is used, observe transferring technique.2. Provide appropriate aids, and that they are used correctly.3. Avoid “rushing to the bathroom” by providing bowel and

bladder routine

Morse,J 2009

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Intravenous (IV)Nursing Assessment Goal:

To maximize safe ambulation, reduce urinary urgencyIntervention Strategies:

1. Assess fluid balance, hypotension.2. If using pole as walking aid, provide walker and assist with ambulation.3. Remind patient of physical limitations.4. Provide bladder routine if urinary urgency present.

Morse,J 2009


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Mental StatusNursing assessment Tool:

To improve orientation & acceptance of changed abilitiesIntervention Strategies:

1. Observe frequently, place patient in room by the nursing station.

2. Frequently reorientation and remind patient of place.

3. Do not leave unattended in diagnostic areas.

4. Implement bowel & bladder program.

5. Involve family for observations & planning care.

MorseJ, 2009


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Definitions for the Humpty Dumpty Falls Assessment Scale


The Humpty Dumpty falls assessment scale requires judgement and individualization to each patient.AGE: Parameter can be based on chronological or developmental age of Patient

Parameter

Criteria Score

Less than 3 years old 4AGE 3 to less than 7 years old 3

7 to less than 13 years old 213 years and above 1


Gender : Self explanatory

Parameter Criteria Score Gender Male 2

Female 1


Diagnosis – (Associated with symptoms that put patient at risk for falls)

If patient has multiple, secondary or underlying diagnosis, then the score is based on the highest acuity diagnosis.(eg. Sickle cell pt with h/o strokes or seizures would receive the higher neurological score)


Eg. of diagnosis include but are not limited to –

o Score 4 - Neurological – seizures, head traumas, hydrocephalus, cerebral palsy, etc. This would include patients being worked up for neurological diagnosis.

o Score 3 - Alteration in oxygenation – Alteration in oxygenation goes beyond respiratory diseases and may include dehydration, anaemia, anorexia, and syncope.

o Score 2 - Psychiatric/ Behavioural disorders – can include mood disorders (major depression, bi-polar disorder) and impulse control disorders/hyperactive.


o Score 1 - Other diagnosis – anything that does not fall into the other categories (eg. Include but not limited to cellulites, orthopaedics)

Parameter

Criteria Score

DiagnosisNeurological Diagnosis 4

Alteration in oxygenation (resp diagnosis, dehydration, anaemia, anorexia,syncope/dizziness etc.

3

Psychiatric/ Behavioural disorders

2

Other diagnosis 1


Cognitive impairments –1. Awareness of one’s ability to function and

perform ADLs2. Not necessarily based on age rather on

physiologic components that affect cognitive awareness.

o Score 3 - Not aware of limitations – can be any age group and is dependent on inability to understand the consequences to their actions.(eg. Severe head trauma , infancy)


o Score 2 - Forgets limitations- can be any age group. The child has the ability to be aware of their limitations however do to the factors such as age, diagnosis, current presenting symptoms or current alteration in function (such as weakness or hypoglycaemia) the child forgets their limitations. Can include children prone to temper tantrums.

o Score 1 - Orientated to ability – Able to make appropriate decisions, understanding consequences of actions.


Parameter Criteria ScoreCognitive

ImpairmentsNot aware of Limitations 3

Forgets Limitations 2

Orientated to own ability 1


Environmental Factors –o Score 4 – History of Falls – during admission

or previous admission.o Infant or toddler placed in bed – Inappropriate

placement of infant /toddler in a bed versus a proper placement in a crib.

o Score 3 – Patient uses assistive devices – includes but not limited to crutches, walkers, canes, splints.

o Infant /Toddler in crib placement.


o Furniture/Lighting-multiple pieces of furniture or pumps/low lighting in the room.

o Score 2 – Patient placed in bed – appropriate bed placement.

o Score 1 – Outpatient area – in-patient receiving services in an out patient area.


Parameter Criteria Score

Environmental

Factors

History of Falls orInfant-Toddler placed in bed

4

Patient uses assistive devices or Infant-Toddler in Crib or Furniture/Lighting

3

Patient Placed in bed 2Outpatient Area 1


Response to Surgery/Sedation/Anesthesia –Patient received one within the allotted time frames. No including bedside procedures without anaesthesia.o Score 3- within 24 hourso Score 2- within 48 hourso Score 1- More than 48 hours /None

Parameter Criteria ScoreResponse to

Surgery/Sedation/Anesthesia

within 24 hours 3

within 48 hours 2

More than 48 hours /None 1


Medication Usages- The purpose of this section is to identify patients who may be at risk for alteration in level of consciousness due to medications that affect cognitive awareness.

Medications that are included in any for the medications categories are included, including medications for seizures.Score 3 – for multiple usage of sedatives / hypnotics/Barbiturates/ Phenothiazines/Anti depressants/Laxatives/Diuretics & Narcotics


Score 2 – one of the medications listed aboveScore 3 - Other Medications / None

Parameter

Criteria Score

Medication usage

Multiple usage of:Sedatives(exclude ICU patients sedated and paralysed)Hypnotics\Barbiturates/ Phenothiazines/Antidepressants/Laxatives/Diuretics & narcotics

3

One of the medications listed above

2

Other Medictions eg. Skin ointment / none

1

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Implement Low Risk Standard Interventions

1. Orientation to room.2. Call bell is within reach. Educate patient /family on its functionality. 3. Bed at low position, brakes on.4. Side rails x 2are up, assess large gaps such as patient could get extremity or other

body part entrapped.5. Ensure secure, non-slip foot wear for ambulating patients.6. Environment clear and items within reach of patient.7. Walking aids/ commodes/urinals/bedpan is accessible and near patient’s bedside.8. Assess eliminations need and assist as needed.9. Placed existing equipment/items on patient’s stronger side.10. Assess adequate lighting, leave nightlight on.11. Increase frequency of observation if patient is unable to call.12. Patient and family education available especially to parents and patient.13. Document fall prevention teaching and include in plan of care.

Morse,J 2009


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Conduct High Risk AssessmentAssess for contributing factors and document issues on progress notes.

1. Impaired vision & /or impaired hearing 2. UTI3. Urinary frequency4. Postural hypotension, vertigo5. Muscle weakness and unsteady gait /balance6. Delirium7. Pain8. Medications


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Implement High Risk Standard interventions


1. Identify patient with high risk signage ( Red colour)2. Educate patient/parents/relative of falls protocol

procedures.3. Check patient hourly to 2 hourly.4. Accompany patient with ambulation.5. Placed patient in appropriate bed.6. Consider moving patient closer to nurse’s station.7. Evaluate medication administration time.8. Remove all unused equipment out of the room.9. Keep door open at all times 10.Keep bed in the lowest position.11.Document in nursing narrative notes and plan of care.

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Remember the ABC’s of Lowering Fall Risk

1. Assist with ambulation

2. Initiate BATHROOM routine

3. Remind patient/relative to CALL for assistance

4. If patient is unable to call, increase observation

For detailed fall preventive measures, please refer to :

“Reference Guide for Nurses in Prevention of Patient Fall” (MOH/P/BKT/2.18(GU)


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References1. Morse, J.(2009). Morse Fall Scale

2. Morse Fall scale Practice Module. Developed by Jacqueline Crandall,

RN(EC), M.Sc.N./ CHPCN (C)

3. Morse,J.(1977).Preventing Patient Falls. CA: Sage Publishing Co.

4. Norhafizah Sharil,Noor Ani Ahmad,et al. Falls among older

aduts:Findings from screening at the Ministry of Health Malaysia

primary Care Clinics. MJM, Vol 70 Supplement 1 September 2015

5. National Patient Safety Agency (2007). Slips,

Trips and falls in Hospitals.

http://www.npsa.nhs.uk/nrls/alerts-and-directives-guidance/slips-tripspfalls/

6. Morse,J.(1977).Preventing Patient Falls. CA: Sage

Publishing Co.


http://www.npsa.nhs.uk/nrls/alerts-and-directives-guidance/slips-tripspfalls/

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Thank you for listening !


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[PPT]FALLS PREVENTION STRATEGYnursing.moh.gov.my/wp-content/uploads/2018/05/2-FALL... · Web viewFALL PREVENTION FOR NURSES BAHAGIAN KEJURURAWATAN KEMENTERIAN KESIHATAN MALAYSIA Bahagian