ROLE OF NURSES IN Ministry of Health Malaysia
MODULE NO. 2
FALLS MANAGEMENT
(IN-PATIENT)
Participant handouts
MODULE DEVELOPED BY : MODULE DEVELOPED BY :
SLIDE NO.
SLIDE NO.
NATIONAL FALL PREVENTION AND NATIONAL FALL PREVENTION AND
1
1
INTERVENTION STEERING COMMITTEE INTERVENTION STEERING COMMITTEE
MinistryMINISTRY OF HEALTH
of Health Malaysia MALAYSIA MINISTRY OF HEALTH MALAYSIA
DEFINITION
•A fall is defined as an •A stumble event or •When patient is
UN-WITNESSED FALL
NEAR FALLS
FALLS
event which results loss of balance that found on the floor
in a person coming to would result in a fall neither the resident
rest inadvertently on if sufficient recovery nor anyone else
the ground or floor or mechanisms were knows how he or she
other lower level. not activated. At least got there.
(WHO) two of the following
compensatory
mechanism should
be activated to be
determined as a near
fall.
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
2
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
INTRODUCTION
COMPONENTS OF FALLS PREVENTION AND INTERVENTION PROGRAMME
Pa�ent Falls
Falls risk Falls risk
registra�on / preven�on
assessment stra�fica�on Discharge
admission measures
Post-fall
Pa�ent fall interven�on
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
3
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
Ministry of Health Malaysia
2
MODULE NO.
ROLE OF NURSES
MODULE DEVELOPED BY : MODULE DEVELOPED BY :
SLIDE NO.
SLIDE NO.
NATIONAL FALL PREVENTION AND NATIONAL FALL PREVENTION AND
4
4
INTERVENTION STEERING COMMITTEE INTERVENTION STEERING COMMITTEE
MinistryMINISTRY OF HEALTH
of Health Malaysia MALAYSIA MINISTRY OF HEALTH MALAYSIA
RESPONSIBILITIES
Identify who is at risk of falls
Assess using Morse Falls Scale
Tag patient
Handover
Prevention measure
(eg; orientation, lighting, flooring etc.)
Intervention (if fallen)
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
5
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
IDENTIFY PATIENT WITH
HIGH RISK OF FALLS
SIMPLE BED SIDE ASSESSMENT
INTRINSIC FACTORS
Such as :
• POSTURAL HYPOTENSION – how to measure and management
• VISUAL ACUITY – can refer to ophthalmologist
• ELECTROCARDIOGRAPHY (ECG) – for any symptoms such as:
giddiness/ presyncope/ palpitations/ chest pain/ dyspnea
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
6
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
EXTRINSIC RISK FACTORS FOR FALLS
NON ENVIRONMENTAL :
Gait – attire, footwear
Restraint - railings
ENVIRONMENTAL :
Toilet : floor, curb
Bedside : unreachable belongings like locker, food, visual aid
Hallway : lighting, obstacles and tripping hazards (e.g IV drip stand, urine
catheter)
Chair : type of chair
Lighting
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
7
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
SAFE ENVIRONMENT IN HOSPITAL
Call nurse/ Get assistance to help Place patient in most appropriate place on the
in ADL/ transferring Avoid restraining ward as she/he needs
confuse patient
Keep railing bed up if Use visual/ hearing
needed & lowered the bed Make sure pathway to
aids if needed
toilet is clear
Prepare best
Keep patient’s belongings lighting for
Use only unmoving Avoid wet floor
within reach includes patient’s patient
walking aid objects to help in
steady gait Use grab bar in the
toilet
Remove obstacles on Lock bed/ wheelchair during
floor transferring patient
Use proper footwear &
Medications review
suitable walking aid
when ambulating
Provide falls education brochure to patient/ family,
MODULE DEVELOPED BY :
SLIDE NO.
Refer to OT/PT for safe
engage them in care plan NATIONAL FALL PREVENTION AND
ambulation & walking aid
8
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
EDUCATION
1. PRECAUTION OF FALLS FOR STAFF
• educating new staff
• CNE ward
• bedside teaching
• falls workshop
2. ADVICE FOR PATIENT AND FAMILY IN PREVENTING FALLS
– flip chart, pamphlet, poster
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
9
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
POST FALL
INTERVENTIONS
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
10
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
POST-FALL INTERVENTION
FLOWCHART
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
11
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
12
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
What to
Include in Who to
Report?? inform??
WHO?
WHEN?
WHERE?
HOW?
WHY?
VITAL SIGN
• Doctor
• Ward sister
INJURY?
• Staff nurse next shift
INTERVENTION - ACTION TAKEN • Other allied health
• Family members
PREVENTION
MODULE DEVELOPED BY :
SLIDE NO.
NATIONAL FALL PREVENTION AND
13
INTERVENTION STEERING COMMITTEE
Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA