Planning for Community Change
March 17, 2021
Essentials of Advanced Nursing Roles and Interprofessional Practice
March 17, 2021



Grand Canyon University



To maintain patient safety.

To reduce the risk of injury.

To determine the way of the falls occurrence.

To implement fall prevention program



unexpected falling down from high position to lower position with or without injury due to physical or mental effect. Near Fall: sudden loss of balance with incomplete fall which include slips, stumbles, or strip with ability to control .

Fall Continues

Most Causing to Falls Individual

Loss of consciousness. • Orthopedic disorders. • Hypoglycemia. • Anemia, Vision • Hypotension. • Drugs action. • Post operative (sedation). • Aging and sleeping habits • Paralysis, TIA, CVA Environmental • Unsafe higher position. • Beds side rails. • unlocked wheel chair. • Water in the floor. • Wire connections. • Steps or stairs. • Walker. • Interfering Clothes

Patient Fall Injury Levels

None: No injury. • Minor: minor injury with abrasion or bruise treated by dressing, limb elevation, topical medication. • Moderate: injury lead to Suturing or limping treated by bandage, splinting, muscle or joint strain. • Major: which leads for casting, skin traction and surgery, may need neurological and vascular attention. • Death: the patient died as a result of serious injury. • UTD: unable to determine from the documentation .

Patient Fall Injury Level Contd.

All in-patients will be assessed for the risk of fall upon admission. • Reassessment is indicated for all of the following conditions: – post operative. – following procedural sedation. – after administer medication. – after blood transfusion. – transferring patients between 2 units. – after recording incident of fall. – any changing in ambulatory status or elimination status, • Applying Risk Fall procedure for patients – Hendrich 11 Fall risk for Adults. – Humpty Dumpty Scale for Pediatrics. • Standard fall precaution shall be implemented for all patients. • Reporting and documenting any fall occurrence. • All Falls patients should be classified according to level of Injury

Post Fall Protocol

Post Fall Protocol of Care- Implement the following intervention after any fall: • First Aid. • Ensure that patient is safe from further danger . • ask for help. • don’t reposition the patient until the patient is ready to do so. • move the patient safely with attention to moving and handling. • complete the post fall assessment Form • Reporting. • Patient and Family Education.

Standard Fall Precaution for Low Risk Patients

Orient the surrounding environment.

Provide Medication Information.

Instruct patient to call for assistance.

Instruct to use the rubber – soled shoes or non – slip footwear to prevent slipping. •

Secure call bell, phone, bed table. • Ensure the clothes are not interfere with the patient mobility.

Maintain the bed in the lowest position and ensure bed and wheelchairs are looked.

Put side rails

Conduct regular environmental rounds in all areas surrounding the patients to decrease the risk of falls.

Keep bathroom light on and the floor dry.

Fall Precaution

Standard Fall Precaution for High Risk Patients

Apply all low and moderate interventions. • Place a high risk for fall sticker/ label on the patient charts and patient room.

Raise Both upper and lower side rails. • Place mattress on floor.

Review the medication. • Assess the need of physical therapy consultation. •

Assess the need for 1:1 monitoring as needed.

Patient and Family Education

Educate both about the risk of falling, Safety Issues, and their Mobility Limitation.

Teach patient to make position changes slowly.

Emphasize how important the family to be involving tin the patient safety.

Emphasize on what patient can do to be healthy, active, and independent

Fall Precaution

Standard Fall Precaution for Moderate Risk Patients

Identify as falls risk on medical record and include in shift endorsement. • Assist and supervise ambulation, Reinforce to always call for assistance.

Conduct hourly safety checks. • Perform regular pain assessment

Offer assistance to the bathroom or use bedpan hourly while awake.

Evaluate for reversible causes- Orthostatic B.P – Monitor Blood Sugar . – Adequate Hydration • Check the patients after the visitors leave always.

Don’t lower the bed side rails if any nurse rise it up.

Patient Education.

Family Education.

Apply Fall Risk Hand Band


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Kim, M., Mallory, C., & Valerio, T. (2020). Statistics for evidence-based practice in nursing. Jones & Bartlett Publishers.

Levin, R. F., Levin, R., & Feldman, H. R. (2012). Teaching evidence-based practice in nursing. Springer Publishing Company.

Malloch, K., & Porter-O’Grady, T. (2009). Introduction to evidence-based practice in nursing and health care. Jones & Bartlett Publishers.