How to prevent falls

RainMom · Nov 8, 2014

Hmmm, we don't have too many falls when staff is assisting; falls are mostly when pts get up on their own.

Are these pts being ambulated too far of a distance, causing some fatigue in the joint & resulting in the knee buckling? We use a commode for anyone that c/o of buckling in the knee or seems a little wobbly rather than ambulating to the bathroom.

Karolyte · Nov 8, 2014

Hmmm, we don't have too many falls when staff is assisting; falls are mostly when pts get up on their own.
Are these pts being ambulated too far of a distance, causing some fatigue in the joint & resulting in the knee buckling? We use a commode for anyone that c/o of buckling in the knee or seems a little wobbly rather than ambulating to the bathroom.

We also use commode versus bathroom, knees with femoral block are the ones falling most of the time. Do you have 2 persons to assist the patient? Do they get up with knee immobilizers?

RN403, BSN, RN · Nov 8, 2014

We also use commode versus bathroom, knees with femoral block are the ones falling most of the time. Do you have 2 persons to assist the patient? Do they get up with knee immobilizers?

Usually, the day of surgery and post op day 1, I utilize 2 assistance with ambulating/moving patients. After that, I use my own nursing judgment based on how PT says the pt is doing with movement and what I see. We also utilize walkers when ambulating patients, even if it is just a short trip to the bedside commode.

If a knee immobilizer is ordered then, yes, I have them wear it with ambulation.

I agree with the PP that most falls occur when patients try to get up and move on their own. Also, if patients are not properly educated on how to ambulate after surgery they are at risk for falls. Make sure you educate your patient on how to properly get up from bed, use their assistive devices, and talk them through aloud what their next steps/moves should be. Patients may not realize their limitations and may try to move to quickly/suddenly/how they used to and could fall and injure themselves.

If a patient is truly non-compliant/unsafe I bring 2 others in with me and make it a 3 assist. If a patient starts to go down/starts to feel unsteady it is nice to have an extra pair of hands.

Also, patients may fall if they start to feel dizzy/lightheaded. Make sure you teach patients to dangle before getting up, then have them stand, and ask how they are feeling. Be specific. "Mr so and so do you feel dizzy or lightheaded?" If yes, immediately sit them down and try again later.

It's all about safety.

RainMom · Nov 8, 2014

We also use commode versus bathroom, knees with femoral block are the ones falling most of the time. Do you have 2 persons to assist the patient? Do they get up with knee immobilizers?

We use two assist initially & with anyone that still has significant numbness after a block. Otherwise, it's a judgment call.

We don't use immobilizers at all for routine TKR. Often a fall with assistance on my floor is d/t dizziness/syncope; or someone just misjudged the amt of assist needed (or couldn't find a helping hand).

poppycat, ADN, BSN · Nov 11, 2014

When I had knee replacement last February, I had the femoral block. I was kept in an immobilizer the whole time I was in the hospital. Unfortunately, one morning the CNA was walking me to the bathroom & I fell because my knee buckled. Neither of us had realized the immobilizer had slipped down to where it wasn't supporting my knee. I felt totally stupid & the look on her face was sheer horror.

Therefore, my advice is to check the immobilizer before getting knee replacement patients out of bed.

mmc51264, BSN, MSN, RN · Nov 13, 2014

PT assess first. Bed alarms for all pts. NO knee immobilizers to get up. 2 people if there is any question. When PT is ambulating, they follow with a w/c. Agreed that most falls are pts that try to get up on their own. Education and be alarms, frequent rounding. These have all helped us. I think all ortho units have to contend with this.

amoLucia · Nov 15, 2014

PT assess first. Bed alarms for all pts. NO knee immobilizers to get up. 2 people if there is any question. When PT is ambulating, they follow with a w/c. Agreed that most falls are pts that try to get up on their own. Education and be alarms, frequent rounding. These have all helped us. I think all ortho units have to contend with this.

I am facing bilateral knees surgery in the not to distant future. I would be terribly mortified and insulted if you tried to put a bed alarm on me!!!! I understand your concern. But I will REFUSE an alarm!

A question - is there some window of dys-opportunity that the falls seem to be occurring? I realize the idea behind surgery is for the pt to walk again unassisted, but would using a tri-tip cane for say 72 hours be unreasonable - a very short designated period??? Just until that critically vulnerable period passes?

poppycat, ADN, BSN · Nov 15, 2014

I would not have allowed a bed alarm, either. When I fell after having my knee replacement, I was using a walker. However, when your knee buckles there's really nothing you can do to save yourself from falling. Fortunately, nothing got hurt but my pride!

Also, why "no immobilizers"? When you're given a femoral block before surgery & get up walking within a few hours, you have to have that for support.

Anonymous865 · Nov 16, 2014

I am facing bilateral knees surgery in the not to distant future. I would be terribly mortified and insulted if you tried to put a bed alarm on me!!!! I understand your concern. But I will REFUSE an alarm!
A question - is there some window of dys-opportunity that the falls seem to be occurring? I realize the idea behind surgery is for the pt to walk again unassisted, but would using a tri-tip cane for say 72 hours be unreasonable - a very short designated period??? Just until that critically vulnerable period passes?

Good luck refusing the bed alarm. I had a hysterectomy last year, and they put a bed alarm on me. I was AOx3. I told them I wanted the alarm removed. They refused to disable it. I told them that as a competent adult that I had the legal right to refuse any drug, test, procedure, or intervention and that I was refusing the bed alarm. They refused to disable it. I told them that by using an alarm against my wishes they were committing medical battery and false imprisonment. They refused to disable it. After 2 hours of arguing I gave up.

If I were you, I would work out the bed alarm issue BEFORE being admitted to the hospital.

The bed alarms are more than just a dignity issue.

Bed alarms operate at a dB level that is damaging to hearing. All the ones that I have found documentation on operate between 90 and 120 dB. A rock concert is about 110 dB and a jet engine is about 130 dB (source CDC). At 120 dB hearing damage occurs in about 15 secs.

Noise negatively affects bp and hr. Here is a reference:

Associations of exposure to noise with physiological and psychological outcomes among postâ€cardiac surgery patients in ICUs

My experience was that the bed alarm went off every time I tried to change position in the bed. If I was uncomfortable on my back and tried to roll to my side a deafening alarm would go off and continue going off until someone came into my room to reset it. Same thing if I wanted to sit on the side of the bed. The alarm also went off when I tried to lay down from a sitting position.

I've always used repositioning for pain before asking for pain med, but I couldn't with the bed alarm. I've had surgeries that were much more painful than this surgery and never took any pain meds, but with this surgery I was asking for the max dosage as frequently as I could get them because I couldn't use other pain management techniques. The noise also raised my anxiety level which made the pain seem worse.

Every time the bed alarm went off my heart would race (> 180 bpm) and bp would go up. Not surprisingly I developed a large hematoma which had to be surgically drained.

My sleep was disturbed and my anxiety level was raised each time another patient's alarm went off, and they went off all night long.

I didn't mean to derail this thread, but I did want you and poppycat to know that it's not as easy as just refusing the alarm.

amoLucia · Nov 17, 2014

To Anonymous865 - Thank you for your info. I will work on it.

mmc51264, BSN, MSN, RN · Nov 17, 2014

Seriously? No bed alarms? That one pt that thinks they will be all right is the one that falls. Or the one that wakes up in the middle of the night, slightly disoriented because they are not at home, and forget for a second that they have had surgery? You are on narcotic pain medication. All of these factors contribute to falls and the bed alarm is a reminder. If you are not cleared by PT to get up unassisted, sorry-you get a bed alarm. That is our policy.

As far as the immobilizer, it is very difficult to lift your leg and get out of the bed with it on w/o help. Again, with the pain medications, patients are not 100%. I just can't imagine why anyone would want to take the chance of falling. We are not doing it to be mean. We want everyone to be safe.

We have a 30 bed unit and have about 40 joint replacements a week; average 20 hip fx d/t outside falls/month. Our fall rate is very low because of the precautions we take.