Potential for Falls
Potential for Falls
Category / Primary Body System
- Musculoskeletal / Safety
Problem
- Patient is at risk for falls due to decreased muscle strength.
Goal
- Patient will not experience any falls with injury for the next 90 days.
Plan/Approach
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Risk Assessment
- Assess for risk of falls on admission, quarterly, and as needed to identify and address potential hazards.
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Call Light Accessibility
- Ensure the call light is within reach and check the patient frequently if they are unable to use it to call for assistance.
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Toileting Needs
- Monitor the patient for toileting needs to prevent falls related to urgent or frequent trips to the bathroom.
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Physical and Occupational Therapy
- Arrange for PT/OT evaluation and treatment as needed to improve muscle strength, balance, and mobility.
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Medication Management
- Administer medications as ordered and monitor for side effects that could increase fall risk, such as dizziness or sedation.
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Lab Monitoring
- Conduct lab tests as ordered to monitor for conditions that might contribute to fall risk (e.g., electrolyte imbalances, anemia).
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Psychological Support
- Provide a psych consult as needed to address any cognitive or emotional issues that might contribute to fall risk.
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Assistance with Mobility and Transfers
- Assist the patient during mobility and transfers to ensure they are safe and supported.
Rationale
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Risk Assessment
- Regular assessment helps identify changes in fall risk and allows for timely interventions.
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Call Light Accessibility
- Ensuring the call light is within reach provides the patient with a quick way to request assistance, reducing the risk of unassisted movements.
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Toileting Needs
- Monitoring toileting needs helps prevent falls that can occur when patients rush to the bathroom unassisted.
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Physical and Occupational Therapy
- PT and OT can help strengthen muscles, improve balance, and teach safe mobility techniques.
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Medication Management
- Monitoring for medication side effects helps prevent falls caused by adverse reactions.
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Lab Monitoring
- Regular lab tests can detect underlying health issues that might increase fall risk.
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Psychological Support
- Addressing cognitive and emotional factors can help reduce fall risk related to confusion, anxiety, or depression.
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Assistance with Mobility and Transfers
- Providing assistance ensures that the patient moves safely, reducing the risk of falls during transfers and ambulation.
Actions
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Risk Assessment
- Perform fall risk assessments on admission, quarterly, and as needed, documenting findings and implementing appropriate interventions.
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Call Light Accessibility
- Ensure the call light is within easy reach and check frequently on patients who are unable to use it.
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Toileting Needs
- Monitor and assist with toileting needs, ensuring timely assistance to prevent unassisted movements.
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Physical and Occupational Therapy
- Schedule PT/OT evaluations and follow through with treatment plans to improve strength and mobility.
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Medication Management
- Administer medications as prescribed, monitoring for and documenting any side effects.
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Lab Monitoring
- Draw labs as ordered, reviewing and reporting results to the healthcare team.
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Psychological Support
- Coordinate psych consults and follow through with recommendations to address cognitive and emotional health.
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Assistance with Mobility and Transfers
- Assist the patient with mobility and transfers, using gait belts or other assistive devices as necessary.
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