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Fall Risk Assessment

To be effective, assessment tools need to be sensitive (correctly identify high risk patients/residents) and specific (correctly identify patients/residents not at risk) and, perhaps most importantly, be easy for nurses to use (embedding the fall risk assessment tool into existing nursing assessments helps with “buy-in” and acceptance of the tool/process).

Purpose of Fall Risk Assessments

Identify patient/resident problems (rational basis for deciding whether risk exists)
Identify those patients/residents most likely to fall
Trigger further fall-related assessments (multidisciplinary)
Identify interventions (guide patient/resident care planning)
Raise staff awareness of fall/injury risk

When to Conduct Fall Risk Assessments

Upon admission
Post-fall
Upon change of health condition (including medication changes)
Daily/every shift (confused patients/residents; patients/residents taking sedatives, recent fall, etc.)

COMPONENTS	FALL RISK FACTORS
Diseases/Conditions	History of falls Impaired vision/hearing Urinary problems (toileting needs) Muscle weakness Gait/balance impairment Dizziness Orthostatic hypotension Mobility impairment (impaired bed, chair and/or toilet transfers) Uses cane/walker
Medications	Polypharmacy (>5 medications) Psychotropics Diuretics Antihypertensives Antiseizure Benzodiazepines Hypoglycemics Sedative/hypnotics
Mental Status	Dementia Depression Delirium Impaired 'safety' judgment Disruptive behaviors Non-English speaking Exhibits unsafe behavior Lacks understanding of mobility limitations
Situational Conditions	New admission Floor-to-floor transfer Post-fall Change of condition and/or starting fall risk medication

Tideiksaar, R. Falls in Older People: Prevention and Management. 4th Edition.
Health Professions Press, Baltimore, MD 2010

Fall Risk Assessment

Purpose of Fall Risk Assessments

When to Conduct Fall Risk Assessments

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