Elderly women with osteoarthritis (OA) have a 20% higher risk of bone fractures and experience 30% more falls than those without arthritis. OA results in changes that include bony overgrowth, fluid accumulation, and loosening and weakness of muscles and tendons; all of which may cause pain/swelling, limit movement, and increased fall risk. An increase in the number of falls is the cause of a higher number of fractures (i.e., the more falls one has, the greater the likelihood of a fracture). To guard against fractures, patients with OA should be:

• Properly assessed for both fall and fracture risk.
• Provided with a hip protector to guard against hip fractures.
• Provided with a bedside floor mat to prevent injurious bed falls.

It’s often assumed that restricting patient activity can reduce the risk of falling. This, however, is a mistaken belief. According to recent research (*), hospital patients who fall do not walk around anymore than patients who don’t fall. In fact, keeping patients immobile can backfire; not moving enough can lead to poor muscle tone/decreased balance and increased fall risk.

To examine the incidence of falls among ambulatory and non-ambulatory elderly patients, researchers equipped 35 elderly patients with small electronic devices that recorded every step they took. They determined that there was no difference in the amount of walking between the two groups.

Nevertheless, they did find that falls were associated with delirium and/or poor cognitive function. Additionally, all of the falls took place at night, with 60% of falls related to trips to the bathroom.

Using a fall alarm is a good way to reduce the risk of ‘toileting falls’ at night. Nurses often rely on toileting rounds to detect patients needing to use the toilet. This strategy, however, is not very effective at night (no one wants to wake a sleeping patient and ask them if they need to use the bathroom) or in patients with poor cognition who may not be able to communicate their needs.

(*) Fisher SR, Galloway RV, Kuo YF, et al. Pilot study examining the association between ambulatory activity and falls among hospitalized older adults. Archives of Physical Medicine and Rehabilitation, 2011.

In hospitals and nursing homes across the country, many falls occur during nursing shift changes. The majority of falls occur to patients who are already identified as being at fall risk; those with poor mobility (e.g., gait/balance impairment) and cognitive impairment. The reason for falling? During shift changes, patients are generally left alone and without the supervision, monitoring and care they need. These mishaps create a tremendous liability for management. Key strategies to eliminate falls during shift changes include:

• Provide nurse rounding of high-risk patients during shift changes.
• Discussing high fall risk patients during shift change handoffs.
• Promoting communication between nursing staff, which includes addressing the patient’s:
• Identified fall risk factors
• Current risk condition /fall precautions
• Current fall management care plan

Utilizing fall alarms during shift changes as a safety measure; alarms detect unsafe patient activity/send a signal to nurses that patient’s are engaging in unsafe behavior.

The risk of skin trauma (bruises, abrasions and tears) is great in patients with sensitive skin. Skin trauma frequently occurs during:

• A fall against or bump into furnishings with sharp edges, such as dressers, tabletops, chair frames, wheelchairs, unpadded side rails, and other objects.
• Caregiver assistance with mobility (lifting, turning, positioning and transferring techniques).

Injured Body Part

• The upper extremities (forearm and hand) are most frequently the site of injury, followed by the leg.

Identified Risks

• Advanced age
• High fall risk status
• Sensory loss
• Compromised nutrition
• History of previous skin trauma
• Cognitive impairment
• Dependency
• Poor mobility
• Polypharmacy
• Use of an assistive device
• Decreased vision

Prevention

• Patients should be encouraged to wear long arm sleeves or pants for protection against injury.
• Educate staff on the importance of carefully handling elderly patients with frail skin.
• Encourage proper positioning, turning, lifting, and transferring techniques.
• Provide padding to bed rails, wheelchair arm and leg supports, and any other equipment that may be utilized to protect the patient from accidentally bumping into a hard surface.
• Provide a well-lit environment to minimize the risk of patients/residents bumping into equipment or furniture.

Do you have a problem with skin tears in your fall risk patients? What methods do you use to reduce the risk of skin tears? Your comments are most welcome.

Mobility Problems

• Impaired mobility (i.e., an inability to ambulate and transfer safely and independently) is a major fall risk factor.
• Diseases directly affecting mobility (i.e., strength, flexibility and balance) include acute and chronic conditions that affect the muscular, skeletal or neurological systems and limit a patient’s ability to move about safely.
• Disorders such as stroke, arthritis, diabetes, and Parkinson’s disease may affect a resident’s muscle strength and reaction time. As a result, walking becomes more difficult and balance control and coordination are affected.
• Any weakness or impairment of the legs and/or arms (e.g., from arthritis, muscular weakness, stroke, etc) can inhibit safe transfers, ambulation and balance. Diseases such as arthritis, diabetes, and stroke can alter muscle strength in the legs and arms. As a result, using leg and arm strength while getting out of a bed or up from a chair or toilet becomes much more difficult. This can easily lead to balance loss and increased fall risk.

Risk Reduction Strategies

• Anticipatory care (anticipate patient’s toileting needs, hunger, thirst, etc. and meet those needs, as appropriate)
• Supervision/observation (monitor at-risk patients and provide assistance with ambulation/transfers when necessary). Consider use of fall alarm to assist with monitoring.
• Continuously assess for environmental hazards interfering with safe mobility/eliminate as appropriate
• Beds (adjust to a height that allows patients to transfer easily)
• Chairs (seat height should allow patient to sit and rise easily)
• Bathrooms (install handrails around the toilet for safe transfers)
• A gait belt should be used whenever possible, especially when assisting a patient during transfers/ambulation
• Instruct patients on the proper use of the nurse call bell, including when and how to call for assistance. Consider the use of a fall alarm for those patients non-compliant with use of call bell
• Teach safe transfer techniques from bed, chairs, toilet, and wheelchairs.
• Make sure that canes, walkers, and wheelchairs are in good condition
• Arrange furniture to allow for wide walking/wheeling spaces.

Add to the discussion. What strategies do you use to prevent falls in patients with impaired mobility? Your comments are most welcome.