Are you a nursing student who wants to learn about how to do fall risk assessment? Or are you a layman trying to understand this concept? Falls are a very common phenomenon among nursing home residents. The fall risk assessment is done by various nursing practitioners to ensure that the adults or any patient have a balanced motion. Although, this cannot be eliminated, but the risk can be minimized by using pre-defined tools and techniques. Some countries have well defined falls risk assessment and management guidelines which are uniformly followed whereas in many of the developing countries hospitals formulate their own fall risk assessment forms and tools. It involves rating patients regarding how likely they are prone to the risk of falling. For example, if a person is undergoing blood pressure medication or depression, then he has a fall risk of 1 point depending on the rules followed by each organization in different places.
Here Are the Generalized Steps That You May Follow to Do A Falls Risk Assessment
• Get Up and Go – Essentially, you need to check gait, strength and balance by making the resident simply getting out of the chair, walk 8 feet and sit back, meanwhile time his performance. Do this every year or whenever you observe change in behavior. If the resident takes more than 10 seconds to complete this task, then he possesses, the risk of fall by fall risk assessment.
• The Five Chair Stand – This is a method to evaluate a resident’s leg strength and determine the risk of a fall. Make the resident sit on a chair and ask him to place both his hands-on chest like a cross and ask him to sit up and down 5 times. If he takes more than 30 seconds to do this or is unable to complete, then he is at the risk of a fall.
• Dual Tasking – It tests the ability to move and think at the same time. Make the resident walk 8 feet and check the time he took. Next, make him walk again but this time he has to count numbers backwards from 100 out loud. If he takes double the time to do the second task as compared to the first, then he is at the risk of fall.
• Standing and Sitting Blood Pressure – Postural hypertension may lead to dizziness that may result in a fall. Take the blood pressure reading of a resident after he has been sitting for at least 5 minutes. Next, make him stand and check blood pressure after 30 seconds of standing and then once more at 3 minutes of standing. If there is a difference of 20+ points in systolic pressure or 10+ points in diastolic pressure, then the resident is at the risk of falling.
• Postprandial Hypotension – It is the term associated with residents dropping blood pressure after eating. Record the resident’s blood pressure in sitting position before eating (a meal of at least calories approx.). Follow up again at 30 minutes and 60 minutes after eating and note down the blood pressure again. A difference of 20+ points in systolic pressure or 10+ points in diastolic pressure indicates risk of falling.
• Vitamin D Deficiency – This causes muscle weakness putting residents at a risk of falling. Ensuring that they get 30 minutes of sunlight will supplement Vitamin D in the body.
• Polypharmacy – The more medication a resident takes, the higher is the risk of falling because medicines can affect blood pressure and balance.
In any of the methods above, if you find out that the resident is at risk then consult the primary care provider and physiotherapist for the evaluation.
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