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Allyson Grutter, RN PCCN Ferris State University

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1 Allyson Grutter, RN PCCN Ferris State University
Preventing Falls Allyson Grutter, RN PCCN Ferris State University

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

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

4 Basic Fall Assessment 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 Tool Get up and Go Test
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 20-29 Variable mobility >20 Impaired mobility 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 20-24 = risk for falls Maximum score is 28 (Tenetti Assessment Tool: Description, n.d.) (Hamilton County Fall Prevention Task Force, n.d.)

6 Try This: A Best Practice Approach to Fall Prevention
Fall Risk Assessment for Older Adults

7 Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model
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 Hendrich II Fall Risk Assessment Scoring
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 Hendrich II Fall Risk Assessment
Protocol Trial Performed on 84 year old woman with multiple hospitalizations over past 2 years Hendrich II Fall Risk Assessment: Hendrich II Fall Risk Assessment Risk Factor Scale Score Confusion, disorientation, impulsivity Yes 4 Symptomatic depression 2 Declining health, unable to perform ADL’s independently, loss of control Altered elimination 1 Frequent UTI’s, unable to walk to bathroom alone, Dizziness, Vertigo, Sway path, Loss of balance Male Gender No Any prescribed antiepileptics Any prescribed benzodiazepines Ativan and Zanax for anxiety r/t social phobias Get up and Go test Unable to rise without assistance during test Total Score 13

11 Score Interpretation 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 Fall Risk Assessment at Metro Health Hospital
Risk Factor Scale Score History of Falls Yes No 25 Secondary diagnosis 15 Ambulatory Aid Furniture Crutches/Cane/Walker None/Bedrest/Wheelchair/Nurse 30 IV/Saline lock 20 Gait/Transferring Impaired Weak Normal/Bedrest/Immobile 10 Mental Status Forgets Limitations Oriented to own ability 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 Total Score High Risk 45 and higher Moderate risk 25-44 Low Risk 0-24 (Metro Health Hospital, 2011)

13 “Try This” Protocol vs. Metro Health Protocol
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


15 Is Change needed at Metro??
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 Determining Success of the new “Try This” protocol at Metro Health
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 References 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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