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Allyson Grutter, RN PCCN Ferris State University.

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Presentation on theme: "Allyson Grutter, RN PCCN Ferris State University."— Presentation transcript:

1 Allyson Grutter, RN PCCN Ferris State University

2 A fall is an unexpected event in which the participant comes to rest on the ground, floor, or lower level (Grey-Miceli, 2008)

3  Cognitive impairments  Vision loss  Balance impairment  High risk medications  Urinary incontinence  Use of assistive devices  Inappropriate Footwear  Slippery floors  Poor lighting

4  Assess the patient and the patient care environment on admission and routinely for possible risk factors and take appropriate corrective action if able  Use standard or empirically tested Fall Risk tools in addition to other assessment tools such as the Tinetti Test or the Timed Get up and Go test  Include patient’s family and interdisciplinary team in identifying and reducing risk factors based on your assessments (Grey-Meceli, 2008)

5 Tinetti Assessment ToolGet up and Go Test  A minute test based on the ability of the patient to follow specific tasks related to gait and balance  0 = Most impairment  2 = Most independent  Scoring system: ◦ 19 or less = high risk for falls ◦ = risk for falls ◦ Maximum score is 28  Have the person sit in the chair with their back to the chair and their arms resting on the arm rests  Ask the person to stand up from a standard chair and walk a distance of 10 ft.  Have the person turn around, walk back to the chair and sit down again  The patient is given 1 practice and then 3 trials with the average time taken from them Seconds Rating <10 Freely mobile <20 Mostly independent Variable mobility >20 Impaired mobility (Hamilton County Fall Prevention Task Force, n.d.)(Tenetti Assessment Tool: Description, n.d.)

6 Fall Risk Assessment for Older Adults

7  Developed by nurses  Intended for use in the acute care setting to identify adults at risk for falls  Screens for primary prevention of falls and is integral in post-fall assessments for secondary prevention of falls

8 Hendrich II Fall Risk Model Designed for quick administration and based on the following 8 independent risk factors:  Confusion, disorientation, impulsivity  Symptomatic depression  Altered elimination  Dizziness, vertigo  Gender (being male proves to be an independent risk factor and automatically scores a 1)  Administration of antiepileptics (includes dosage changes or cessation)  Administration of benzodiazepines  Poor performance in the “Get-Up- and-Go” test of rising from a seated position

9  Patients with a score of 5 or greater are at high risk for falling and will require precautionary interventions  A score of 16 is the highest  As risk factors change, so will the score thus continual assessments on the patient are necessary  A video with Ann Hendrich, MSN, RN, FAAN, that further discusses assessment scoring can be found online at (Hendrich, 2007)

10  Performed on 84 year old woman with multiple hospitalizations over past 2 years  Hendrich II Fall Risk Assessment: Hendrich II Fall Risk Assessment Risk FactorScaleScore Confusion, disorientation, impulsivityYes4 Symptomatic depressionYes2 Declining health, unable to perform ADL’s independently, loss of control Altered eliminationYes1 Frequent UTI’s, unable to walk to bathroom alone, Dizziness, Vertigo, Sway path, Loss of balance Yes1 Male GenderNo0 Any prescribed antiepilepticsNo2 Any prescribed benzodiazepinesYes1 Ativan and Zanax for anxiety r/t social phobias Get up and Go testUnable to rise without assistance during test 4 Total Score13

11  Patient score = 13; Equates to High Risk for Falls  Interventions: ◦ Due to altered elimination, regular toileting patterns will be established of every 2 hours ◦ Discuss with interdisciplinary team any alternatives to pain control since Fentanyl and Vicodin can cause dizziness and/or loss of balance and patient is on both medications ◦ Ensure pathways in room are clear of debris and cords ◦ Fall risk arm band placed on patient and sticker placed outside of patients door for other staff to know she is a fall risk

12  RN to assess patient fall risk at time of admission using the Morse Fall Risk Assessment  A re-assessment is warranted when there is any change in the patient’s status (surgery, progression of disease, fall, etc)  Patients at high risk for falls receive a yellow arm band and wear yellow socks; a falling star magnet is placed outside of door to alert other staff of fall risk Risk FactorScaleScore History of FallsYes No 25 0 Secondary diagnosis Yes No 15 0 Ambulatory AidFurniture Crutches/Cane/Walker None/Bedrest/Wheelchair/ Nurse IV/Saline lockYes No 20 0 Gait/TransferringImpaired Weak Normal/Bedrest/Immobile Mental StatusForgets Limitations Oriented to own ability 15 0 RiskTotal Score High Risk45 and higher Moderate risk25-44 Low Risk0-24 (Metro Health Hospital, 2011)

13  The Hendrich II Fall risk assessment is designed to be administered quickly  This assessment focuses on 8 key factors where the Morse fall risk only uses 6 factors  It takes into account that being male increases the likelihood of falls; possibly due to the fact that men are more likely to take risks than are women

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15  I think the Hendrich II Fall Risk Assessment would be an excellent alternative to the Morse Fall Risk as it is more in depth yet can also be administered quickly  While studies on this fall risk are limited, the initial reports have been positive and hundreds of hospitals have converted to it  This assessment can also be built into an electronic health record as EPIC is used at all Metro Health facilities

16  Data Collection at 3, 6, & 12 months ◦ Number of Falls ◦ Number of patients labeled “At Risk” for falls ◦ Number and circumstances of patients that fell who were not deemed “At Risk”  Is further Nursing education required?  Does the Hendrich II Fall Risk let some patients who are truly “at risk” fall through the cracks?  Compare with data over the previous year statistics when we were using Morse Fall Risk Assessment

17  Gray-Miceli, D. (2007). Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model. try this: Best Practices in Nursing Care to Older Adults, (8),. Retrieved February 8, 2012, from  Gray-Miceli, D. (2008). Nursing Standard of Practice Protocol: Fall Prevention. Retrieved February 9, 2012, from  Hamilton County Fall Prevention Task Force. (n.d.). Timed Get up and Go Test. Retrieved from  Hendrich, A. (2007). Predicting Patient Falls: Using the Hendrich II Fall Risk Model in clinical practice. American Journal of Nursing, 107(11), Retrieved from  Metro Health Hospital. (2011). Fall/Injury Prevention Policy.  Tenetti Assessment Tool: Description. (n.d.). Retrieved from


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