References and Resources
Prevention a Possible Fall
Primary prevention:
This means taking measures to prevent falls in
people who have not fallen. Examples
include:
 Increasing exercise and physical activity
 Reviewing medication
 Changing adverse environmental factors
 Improving management of any medical
conditions
Secondary prevention:
This means taking measures to prevent
further falls in those who have had a previous
fall. Those who have already had a fall are at
much higher risk of further falls.
Remember:
 Many clients fall when attempting to get out
of bed to use the toilet. So, try to schedule
their elimination.
 Be aware of any illnesses and physical
conditions can affect your client’s strength
and balance as well as your own.
 Make sure client has grab bars put in their
bathtub, shower and toilet area.
 Minimize the chance of wet surfaces
(especially bathroom)
 Use proper interventions if your client has a
sensory problem.
Nursing Skills On – Line: Module 07, Safety
(Lesson 1 – Safety Equipment and Fall
Prevention)
Potter & Perry
Pages: 775-780, 1190, 1201
Articles:
(2005). Improving patient and health care
provider safety: task force develops
recommendations on patient handling. PT:
Magazine of Physical Therapy, 13(4), 48.
Retrieved from CINAHL database.
Sadowski, A. (2003). Training staff in
resident transfers. Nursing Homes: Long
Term Care Management, 52(8), 44-45.
Retrieved from CINAHL database.
Rapp, K., Lamb, S., Büchele, G., Lall, R.,
Lindemann, U., & Becker, C. (2008). Transferring a Client with One
Prevention of falls in nursing homes:
subgroup analyses of a randomized fall Sided Weakness
prevention trial. Journal of the American And
Geriatrics Society, 56(6), 1092-1097. Retrieved How to Prevent a Possible Fall
from CINAHL database.
Sjösten, N., Vahlberg, T., & Kivelä, S. (2008).
The effects of multifactorial fall prevention
on depressive symptoms among the aged at It is better to be safe than sorry.
increased risk of falling. International Journal
of Geriatric Psychiatry, 23(5), 504-510. By: Hashim Ali Jaffery
Retrieved from CINAHL database.
Ryerson, Centennial, George Brown,
Collaborative Nursing Degree Program
Websites:
http://www.patient.co.uk/doctor/Preventio Centennial Site
n-of-Falls-in-the-Elderly.htm
 Transferring a Client with One
Sided Weakness
Before moving and / or positioning a client in
bed, identify what the nurse should first assess
for.
 Muscle strength (legs and upper arms)
 Joint mobility and contracture formation
 Paralysis or paresis (spastic or flaccid)
 Orthostatic hypotension
 Activity tolerance
 Presence of pain
 Vital signs
Keep in mind when transferring a client with
one sided weakness:
 Inspect and identify any sources of pain at any
of the joints.
 Having more than one nurse while moving the
client would be ideal.
 Use good body mechanics during the transfer to
prevent injury.
Don'ts
 Don't let the patient wear slippers or shoes
without nonslip soles.
 Don't leave the wheelchair's footrests down
because they'll interfere with the transfer.
 Don't change the patient's position quickly
because his cardiovascular system may not have
time to adjust to postural changes.
 Don't stretch your back at any time during the
transfer.
Transferring a Client with One Prevention a Possible Fall
Sided Weakness
Use the proper equipment.
 Use of a transfer belt (called a gait belt when
used for walking with a client) helps prevent
caregiver back injuries and aids in the safe
transfer of the client. The belt encircles the
client's waist and has handles attached for the
nurse to hold. It is applied over the client's
clothing, never over bare skin.
Assessment of someone who falls
 Use mechanical or hydraulic lift to transfer the
client when necessary. Make sure the equipment The following should apply to all clients who fall.
is functioning properly and being of how to This should incorporate a good history of exactly
correctly use it. what happened (If possible get collaboration
from a witness).
After any transfer:
 Was it tripping over something or loss of
 With each transfer, evaluate the client’s balance?
tolerance and level of fatigue and comfort.  Was there loss of consciousness?
 After each transfer, evaluate the client’s body  Is there a history of any previous falls?
alignment.  As always in the elderly, note drug history.
 Praise the client’s progress, effort, and  Past medical history is important in assessing
performance. risk of falls and injury.
 Home assessment can be very instructive in
Clients with severe one sided weakness: diagnosis, risk assessment and falls
prevention. It can identify environmental
 Remember to compensate for that weaker side factors.
when lifting and transferring.
 Place a wheelchair on the patient's unaffected With the answers to these questions
side. Instruct the patient to pivot and bear as prevention of a fall is greatly improved, by
much weight as possible on the unaffected side. using appropriate interventions.
Support the affected side because the patient
will tend to lean to this side. Use pillows to
support the hemiplegic patient's affected side to
prevent slumping in the wheelchair.
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