Learn how to identify risk factors, use a validated tool, implement interventions, and evaluate outcomes to prevent falls and ensure patient safety in various health care settings.

As a nurse, assessing a patient's fall risk is very important. In my experience, the following has assisted: • Medical History Review • Physical Examination • Home Environment Assessment (None slip rugs, stairs) • Medication Review (Certain medications can cause dizziness) • Vision Assessment • Orthostatic Hypotension Assessment • Fall Risk Screening Tools (Morse Fall Scale, Hendrich II Fall Risk Model) • Collaboration with Interdisciplinary Team. • Education and Prevention

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*/ How can you assess a patient's risk for falls?

Falls are a common and serious problem for many patients, especially older adults, in various health care settings. They can cause injuries, complications, and reduced quality of life. As a nurse, you have a key role in preventing falls and ensuring patient safety. Here are some tips on how to assess a patient's risk for falls and plan appropriate interventions.

1 Identify risk factors

Assessing a patient's risk for falls starts with identifying the factors that may increase their likelihood of falling. Common risk factors include age, as older adults often have changes in vision, balance, strength, and cognition; medications such as sedatives, opioids, antihypertensives, and diuretics; medical conditions such as stroke, diabetes, Parkinson's, dementia, or delirium; and environmental hazards like slippery floors, loose rugs, poor lighting, clutter, or lack of assistive devices. All of these can create obstacles or challenges for a patient's movement and stability.

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Peter Kirby, DNP, RN, NPD-BC, CLSSBB

🧑⚕️Nursing Education & Leadership | Thoughtful Leader | Aspiring Nurse Coach | Addiction Recovery Advocate | International Keynote Speaker | 🐾Dog Dad
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As a nurse, assessing a patient's fall risk is very important. In my experience, the following has assisted: • Medical History Review • Physical Examination • Home Environment Assessment (None slip rugs, stairs) • Medication Review (Certain medications can cause dizziness) • Vision Assessment • Orthostatic Hypotension Assessment • Fall Risk Screening Tools (Morse Fall Scale, Hendrich II Fall Risk Model) • Collaboration with Interdisciplinary Team. • Education and Prevention

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Dr. Jonathan V. Llamas, DNP, RN-BC, PMHNP-BC, PHN

LinkedIn's Top Nursing Voice (2024), Nurse.Org's Nurse Icon and Nurse Leader of the Year (2023), Founder of Mind & Heart, Psychiatric Nurse Practitioner at Lifestance, and Chapter President at West Coast University
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Assessing for fall risk is a crucial aspect of nursing care, especially for those working in settings where falls are common, such as hospitals and long-term care facilities. A comprehensive assessment involves considering various factors that may contribute to an increased risk of falls such as: 1). History of Falls 2). Medication Review 3). Mobility and Gait Assessment 4). Sensory Impairments 5). Environmental Factors After assessing these factors, healthcare providers can develop an individualized care plan to address the identified risk factors and implement interventions to reduce the likelihood of falls.

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Peter Kirby, DNP, RN, NPD-BC, CLSSBB

🧑⚕️Nursing Education & Leadership | Thoughtful Leader | Aspiring Nurse Coach | Addiction Recovery Advocate | International Keynote Speaker | 🐾Dog Dad
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Assessing a patient's risk for falls is a crucial aspect of healthcare, particularly for older adults and individuals with certain medical conditions. In my experience, here are some key components of fall risk assessment: Medical History Medication Review Mobility Assessment Cognitive Assessment Vision Assessment Home Environment Evaluation Orthostatic Blood Pressure Measurement Functional Assessment Fall History Use of Assistive Devices Nutrition Assessment Footwear Assessment Once a comprehensive assessment is completed, healthcare professionals can classify the patient's fall risk as low, moderate, or high. Based on the risk level, tailored interventions and preventive measures can be implemented.

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Laura J. Silverstein MSN, RN, WCC, CDP

Administrator/Director Of Patient Services at True Care Home Care
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In my experience, any standardized fall risk assessment will be "adequate". Addressing risk factors, implementing interventions and evaluating what works are also very important in a fall risk assessment. But, the most important thing is to listen to the patient. If you can get them to talk to you in a meaningful way you will gather valuable information that can be used to create an accurate picture of risk. Creating trust and having a meaningful conversation can take practice, but it is the best way to get accurate information that you can use to really help the patient.

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2 Use a validated tool

The second step in assessing a patient's risk for falls is to use a validated tool that can help you quantify the level of risk and guide your interventions. There are many tools available, but some of the most widely used are the Morse Fall Scale, the Hendrich II Fall Risk Model, and STRATIFY. The Morse Fall Scale assesses six factors from 0 to 25, with a total score ranging from 0 to 125. A higher score indicates a higher risk of falling. The Hendrich II Fall Risk Model assesses eight factors from 0 to 5, with a total score ranging from 0 to 16. A higher score indicates a higher risk of falling. STRATIFY assesses five factors as 1 or 0, with a total score ranging from 0 to 5. A higher score also indicates a higher risk of falling.

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3 Implement interventions

The third step in assessing a patient's risk for falls is to implement interventions that can reduce the risk and prevent harm. For instance, educating the patient and family about fall prevention strategies, such as using call bells or wearing non-slip footwear, is important. Additionally, creating a safe and comfortable environment for the patient by removing hazards and adjusting lighting can help reduce the risk of falls. It is also necessary to monitor and modify the patient's medications, as well as assist them with their activities of daily living. Finally, fall prevention protocols should be put in place based on the patient's risk level and individual needs, such as using bed or chair alarms, fall mats, hip protectors, or restraints.

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4 Evaluate outcomes

The fourth step in assessing a patient's risk for falls is to evaluate the outcomes of your interventions and adjust them as needed. You should monitor the patient's vital signs, symptoms, and behaviors, and document any changes or improvements in their risk factors or fall risk score. Additionally, it is important to review the patient's care plan and progress notes, as well as conduct regular audits and incident reports. Analyzing the data and feedback can help identify any trends, gaps, or areas for improvement in your fall prevention practices. Participating in quality improvement initiatives and evidence-based practice projects can also provide valuable insights into how to improve your nursing practice and the quality of care for your patients. By following these steps, you can assess a patient's risk for falls and implement effective interventions to prevent them.

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5 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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*/ How can you assess a patient's risk for falls?

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1 Identify risk factors

2 Use a validated tool

3 Implement interventions

4 Evaluate outcomes

5 Here’s what else to consider

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