c


c

c


c c c


 BY 200 Ȃ B ORTHOPAEDIC AND SPINAL

CORD INJURY WARD
APPLICATION: This applies to the nursing department of King Saud Medical Complex,Riyadh.

Statement of purpose:
1. To establish procedural guidelines in the prevention of patient falls.
2. To ensure high quality of nursing practice
3. To enable the nurses to function in a consistent and standardized manner.
4. To enhance patient safety.

DEFINITION:

FALL Ȃ a sudden, uncontrolled, unintentional, downward displacement of the body to the

ground or other object excluding falls resulting from violent blows or other purposeful actions.

NEAR FALL Ȃ a sudden loss of balance that does not result in a fall or other injury.
This can include a person who slips, stumbles, or trips but is able to regain balance rather than
Falling.

ASSISTIVE DEVICE Ȃ any tool used with the mobility and provide support to patients who are
unable to ambulate independently
(ex., standard walker, rolling walker, crutches, standard cane, quad cane, wheelchair).
POLICY:
1. To determine fall risk, patients are assessed by licensed nurse:
Î At the time of admission
Î Every shift thereafter
Î With any change in patient condition
Î With any change in level of care; and following a fall
2. Implement standard fall prevention interventions as the routine standard of care
For all patients who are not identified to be at moderate or high risk.
3. Initiate, as appropriate, safety interventions and an individualized plan for patients at
moderate or high risk for fall based on individual patient assessment.
4.Inform all members of the healthcare team who have direct patient contact when a patient
is assessed to be at moderate or high risk for fall.
5. Rectify unsafe conditions immediately. The staff members who identify the problem fix it
or notify the appropriate staff and verify that they arrive and correct the situation.
6. Data is collected at regular intervals and benchmarked internally and externally, with the
goal of reducing falls and fall-related injuries. Data on patient falls is monitored and analyze
in an effort to:
Î identify trends;
Î enhance patient care and safety; and
Î improve organizational performance.
÷
÷
÷ 
 
 

d

   
d

 




 
PRINCIPLES OF ASSISTING PATIENT OUT OF BED:
1. Reassure the patient of his personal safety against injury and over-exertion.
2. If necessary, get additional help to assist you in ambulating the patient.
3. Support the affected side or extremities of the patient when ambulating and moving.
4. Do not over tire the patient; increase time up in the chair and ambulation gradually.
5. Lock all wheelchair or litter wheels before transferring the patient to bed.
6. Stabilize the footstool, when it is utilized.
7. Place a signal cord or call light button within easy reach of the patient while he is up.
8. Check on the patient frequently.

PREPARING TO AMBULATE THE PATIENT:

1.Review the patients medical record for an authorizing physicians order.
2. Review the patients nursing care plan for information regarding the following:
- physical limitation
- mechanical requirement being utilized, that is, I.V. infusion pump, chest drainage set,etc.
- distance patient is to ambulate
- length of time patient is to be out of bed.
- frequency patient is to get out of bed.
3. Review the nurseǯs notes to identify the patients previous tolerance of the activity specified.
4. Explain the rationale for getting out of bed to the patient.
5. pre-medicate for pan prior to getting out of bed, if necessary.
6. Ensure that the patient is appropriately clothed, including footwear.
AMBULATING PATIENT USING GAIT BELT:
1. Wash hands.
2. Explain what you are doing to the client.
3. Assist the client to sit on the edge of the bed.
4. Pause and allow the client to sit on the edge of the bed for a few moment to regain
balance.
5. Assist client to put on socks and non skid shoes.
6. Put a gait belt around the clientǯs waist.
7.Stand in position of good body mechanics.
8. Assist the client to a standing position by straightening your legs as you lift with the gait
belt and the client pushes down with his hand on the mattress.
9. Pause to allow the client to regain balance.
10. Walk with client by placing one hand on the gait belt in front of his waist and your other
hand in back under the gait belt. Walk on the weaker side, encourage client to hold the
handrails if available with strong hand.
11. Walk in the same pattern as the client (both step with left foot at the same time).
Assist the client to step forward with strong foot first.
12. Walk the client the distance instructed by supervisor or as indicated by the service plan.
NOTE: IF THE CLIENT LOSES WEIGHT BEARING ABILITY, PULL THE CLIENTǯS BODY
INTO THE ALIGNMENT WITH YOUR HIP/THIGH AREA BY USING THE LARGE
MUSCLE S OF YOUR LEGS.
13. Return the client to the bed or chair.
14. Make sure the client is comfortable.
15. Remove the gait belt.
16. Wash hands.
17. Record observation.

AMBULATING CLIENT WITH A WALKER:

1. Wash hands.
2. Explain to the patient what you are doing.
3. If using a hospital bed, lower the bed to the lowest level.
4. Assist the client to sit on the edge of the bed.
5. Pause and allow the client to sit on the edge of the bed a few moment to regain her
balance.
6. Assist the client in putting on socks and non skid shoes.
7. Apply gait belt
8. Stand in a position of good body mechanics.
9. Assist the client to a standing position by straightening your legs as you lift with the gait
belt and the client pushes down with her hand on the mattress.
10. Instruct the client to position her body within the frame of the walker.
11. Instruct the client to move the walker forward by lifting it up moving it forward, and
setting it down.
12. Instruct the client to take a step forward with the weak leg.
13. Instruct the client to move strong leg forward.
14. Instruct the client to take a short steps and keep her head up and eyes looking forward.
15. Walk the client the distance instructed by the supervisor as indicated in the service plan.
16. Return the client to bed or a chair. To ambulate backward, the client steps back with her
strong foot, takes step back with her weak foot then the walker is moved back. Have the
client feel for the arm of chair or top mattress with her hand.
17. Assist the client into the chair or bed, make sure the client is comfortable.
18. Wash hands.
19. Record observation.

AMBULATING CLIENT WITH CANE:

1. Wash hands.
2. Explain what you are doing to the client.
3. Lower the bed to the lowest level, assist client to sit on the edge of the bed.
4. Pause and allow the client to sit on the edge of the bed a few moment to regain balance.
5. Assist the client in putting on socks and non skid shoes.
6. Apply a gait belt.
7. Stand in a position of good body mechanics.
8. Assist the client to a standing position by straightening your legs as you lift with the gait
belt and the client pushes down with her hand on the mattress.
9. Instruct the client to move the cane forward and a little to the outside of her strong legs.
client should use the cane on her stronger side.
10. Instruct the client to take short steps and keep her head up and eyes looking forward.
11. Instruct the client to move he weaker foot forward to line up evenly with the tip of the cane.
12. Instruct the client to put weight on the cane and weak foot while swinging her strong foot
forward.
13. Walk in the same pattern as the client (both steps with left foot at the same time)
14. Walk the client the distance instructed by the supervisor or as indicated in the service plan.
15. Return the client to bed or chair.
16. Make sure the client is comfortable.
17. Wash hands.
18. Record observation.
PREVENTING PATIENT FALL:
1. EDUCATE THE PATIENT TO GET OUT OF BED ON THE DOMINANT SIDE.
Î create a safe patient room environment by:
a. placing the light within reach
b. placing the telephone and personal items within reach.
c. clearing any clutter from tables, chairs, and floors.
d. positioning furniture, equipment, and assistive devices so they are accessible on the
patientǯs dominant side.
e. placing telephone and electrical cords, excess furniture, and unnecessary equipment out
of the way.
f. maintain bed in low position unless contraindicated by condition.
g. when side rails are in use, leave at least one rail in the down position on the patientǯs
dominant side unless contraindicated.
h. lock moveable transfer equipment (bed wheels, wheelchair)
i. encourage the use of non-slip footwear.
j. provide adequate lighting.
2. Moderate falls risk interventions
Î all STANDARD interventions
ÎCommunicate patientǯs risk level to all members of the healthcare team who have direct
patient contact
ÎRe- orient confused patients if possible.
- take patient off specialty bed if patient is confused, disoriented, or agitated and if not
contraindicated by physical condition
- assess patientǯs bowel and bladder elimination needs and provide a plan of care to
address frequency, urgency, and incontinence.
- supervise elimination and provide assistance as needed (establish an individual
toileting plan as appropriate, provide a bedside commode, as appropriate).
- supervise and assist with personal hygiene, and consider use of a shower chair.
- encourage use of assistive devices and mobility aids.

3. High fall risk intervention

Î All STANDARD and MODERATE fall intervention
Î Remain with the patient while toileting
Î Consider the patient to a room with best visual access from the nursing station.
Î Consider the use of bed alarms.
Î Consider a rehabilitation therapy consult.
Î Consult the use of a patient observer (family sitter).
4. Post fall management
Î assess for injury and notify physician.
ÎDetermine level of injury. If unable to determine level of injury at the time of fall, do so
with follow up of event.
Î obtain and record sitting/standing vital signs.
Î assess for change In range of motion.
ÎUse the fall risk assessment tool to assess for change in patient's risk of falls.
Î document circumstances in the patients medical record.
Î assess all factors contributing to the fall environment (equipment, medication factors, and
interventions in place at the time of the fall)
- notify all healthcare team members and the patientǯs family of the patient fall
and accomplish the OVAR form and follow the procedure of APP-KSMC-005
(OVAR).
- consider technology (e.g., bed alarms) to prevent a repeat fall.

5. Discharge planning
Î communicate fall risk to physicianǯs clinic and/or home health provider as appropriate.
Î suggest physician consult for outpatient gain program if the patient:
- is demonstrating gait problems.
- has fallen while in the hospital.
- has had a fall within the past 3 months.
- if the patient will live alone after discharge and is at moderate or high risk for falls
involve social services and physical therapy to address fall risk as needed.
Î educate the patient/family at the level of their understanding of the following:
- the purpose of fall prevention measures, when used.
- measures taken to decrease environmental fall risks.
- the need to ask for assistance when exiting bed.
Î for high fall risk patients, include information on exercise, nutrition, home safety, and
make a plan for emergency fall notification.
ÎDocumentation: document the patientǯs fall risk on the fall risk assessment tool. For
moderate and high fall risk patients, document interventions implemented an patient's
response.

c