Introduction to Medical-Surgical Nursing, 6th ed.
20
Lesson Plans for
Falls
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 20.1:
2. Give the incidence of falls.
4. Discuss the relationship between restraint use and falls, types of restraints, and regulations for
5. Describe fall prevention techniques.
7. Explain what is meant by “least restrictive” interventions for fall prevention.
CHAPTER TEACHING FOCUS
• In this chapter, students will be introduced to the definition of falls, their incidence, and nursing
interventions. The chapter includes information on the greater incidence of falls among older adults,
particularly those in long-term care and hospital settings. In addition, students will have the opportunity
to learn about factors that place patients at greater risk of falling, as well as interventions designed to
prevent falls. Finally, students will have the opportunity to learn about the use of restraints, the
Omnibus Reconciliation Act (OBRA) regulations, and alternative methods of ensuring patient safety.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Care Competencies
• Concept: Safety
• Exemplar: Fall Prevention, p. 318
• Figure 20-1: The National Aeronautics and Space Administration (NASA) has developed a secure
ambulation mode (SAM) that allows patients to ambulate safely and securely as the regain the
ability to walk after a traumatic injury or receive physical therapy for a degenerative disease, p. 318
• Table 20-1: Intrinsic Risk Factors for Falling and Possible Interventions, p. 319
2 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) An example of an extrinsic factor that makes a patient more prone to falls is __________.
a) poor vision
b) poor lighting c) osteoporosis
d) fear of falling
2) In the majority of falls, __________.
a) no injury occurs
b) fractures occur c) lacerations occur
d) stroke occurs
3) Holding a patient in a bed when a stroke occurs could be considered
a) a restraint
b) a nuisance c) a comfort measure
d) an obstacle
4) When the bed rails are raised, the patient __________.
a) cannot fall because he cannot get out of bed
b) is at risk for falls
c) feels helpless
d) rings the call bell more often
5) Restraint application can be justified in which of the following situations?
a) The patient is a hazard to others.
b) The patient is confused.
c) The patient is using obscenities.
d) The patient is refusing to take his medications.
6) A mitt prevents the patient from carrying out which of the following actions?
a) Pulling out an IV
b) Wandering c) Losing balance
d) Climbing over the bed rail
7) The rules of restraint application include which of the following?
a) Restraints are removed only when the patient becomes compliant.
b) Restraints are removed every 2 hours.
c) Restraints are removed every 24 hours.
d) Restraints are removed when visitors come to see the patient.
8) After finding a patient on the floor near his bed, the nurse should __________.
a) call 911
b) assess the patient and circumstances of the fall as soon as possible
c) inspect the room for loose rugs or furniture the patient could have tripped over
d) administer O2 by nasal cannula
9) The immediate assessment of a patient who fell includes __________.
a) the patient’s ability to move all extremities without pain
b) the patient’s O2 saturation
c) memory assessment
d) a review of all the medications the patient is taking
10) The patient’s risk of falling should be determined __________.
a) on admission
b) after the patient has fallen
c) before restraint application
d) while helping the patient with ambulation
_________________________________________________________________________ Chapter 20 Falls 3
Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: A patient’s relative says: “I am afraid my dad will not be able to call for help when he needs it.
He is confused and forgets how to use the call light. But he does need help to go to the bathroom,
especially now that he is on Lasix and has urinary urgency.” How can the nurse ensure the patient’s
safety?
Answer: This patient is at high risk for falls. He is confused, and he has urinary urgency due to the
diuretic he is taking. There are several ways for the nurse to promote patient safety. The nurse should
Question: A patient’s visitors ask the nurse to temporarily release the patient’s restraints. The nurse says
that the patient has a nasogastric tube and an intravenous line, which he can pull out because he is
somewhat confused. The visitors assure the nurse that they “will watch the patient” and seek help if he
attempts to do any of the above. The nurse agrees to release the restraints. Five minutes later the call
light goes on, and the nurse enters the room and sees that the patient has pulled out his nasogastric
tube. The visitors are surprised it happened so fast. How can the nurse prevent this situation from
happening?
Answer: The nurse should have spent time educating the visitors about the purpose of the restraints.
4 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
Instructor Preparation
Textbook Objectives Covered
1. Define falls.
3. Describe factors that increase the risk of falls.
4. Discuss the relationship between restraint use and falls, types of restraints, and regulations for
restraint use.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speakers: registered nurse, or nursing home or hospital administrator
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying falls, including:
• The relative incidence of falls among different segments of the elderly population and the
likelihood that a fall will result in injury
• The intrinsic and extrinsic factors that increase the risk of falling, and the interventions that
Materials and Supplies
• copies of a restraint protocol
and documentation
Key Terms
• intrinsic factors (p. 315)
_________________________________________________________________________ Chapter 20 Falls 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (p. 315)
2
READ – Textbook (pp. 315-316)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1, 2 (p. 323)
ANSWER – Study Guide
• Part IIG: 1-7 (p. 119)
3
• Part III I: 1-3 (p. 120)
READ – Textbook (pp. 315-316)
REVIEW
• Figure 20-1: The National Aeronautics and Space Administration (p. 318)
• Table 20-1: Intrinsic Risk Factors for Falling and Possible Interventions (p. 319)
ANSWER – Text
• Review Questions for the NCLEX Examination: 5, 9, 10 (pp. 323-324)
ANSWER – Study Guide
• Part IB: 1, 2 (p. 117)
• Part ID: 1-12 (p. 118)
4
• Part IIIH: 1 (p. 120)
READ – Textbook (pp. 316-318)
REVIEW
• Box 20-1: Alternatives to Fall Restraints (p. 318)
ANSWER – Text
• Review Questions for the NCLEX Examination: 3, 4, 6, 8 (pp. 323–324)
ANSWER – Study Guide
• Part IA: 1-6 (p. 117)
• Part IC: 1 (p. 118)
• Part IE: 1 (p. 118)
6 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
50-Minute Lesson Plan
Lecture Outline 20 minutes
Slide 1
Chapter 20
Falls
1
Slide 2
Definition
• Definitions vary from “unexpected displacement” to “unintentional change in position” to
“inadvertent events in which the subject comes to rest unintentionally on the ground”
TALKING POINTS:
• Although falls do not necessarily result in serious physical injuries or death, many older
people who have fallen become less confident in their ability to function independently.
• Why do people who have fallen restrict their activity?
2
Slide 3
Incidence and Risk Factors
• The risk of injury is highest in people older than age 65
• Falls are the most frequent cause of accidental injury and death among older adults
• Older adults constitute only 12% to 13% of the total U.S. population, but account for 72%
of total deaths from falls
TALKING POINTS:
• At what age are people at highest risk for falls?
• Older women residing in community and long-term care facilities appear to be at higher
risk of falling than older men.
• Potentially avoidable environmental factors cause 40% to 50% of fatal falls.
• According to the Public Health Service, adequate medical evaluation and treatment for
underlying medical conditions could probably prevent most of the remaining 50% to 60%
of fatal falls.
3
Slide 4
Incidence and Risk Factors (cont.)
• Intrinsic factors
• Factors related to the functioning of the individual, such as the aging process or
physical illness
• Extrinsic factors
_________________________________________________________________________ Chapter 20 Falls 7
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
Slide 5
Intrinsic Factors
• Reduced vision and hearing
• Age-related changes in posture and gait
• Confusion or depression
• Lack of exercise leads to weakness and decline in physical vigor
• Multiple medications related to the increased incidence of chronic illness in older adults
TALKING POINTS:
• Discuss specific education the nurse can give elderly patients to decrease their risk of
falls at home.
Slide 6
Extrinsic Factors
• Home environment
• Low-lying and poorly visible tables
• Trailing electrical wires
• Pets
• Steep and unlit stairs
• Loose carpeting
• Unsafe walking aids
TALKING POINTS:
• When do institutional falls often occur?
• Falls may result from imposed immobility.
Slide 7
• Deep tissue damage or concussion occurs in about 5%
• 1% to 5% of falls result in fractures
Incidence and Risk Factors
• Injury-causing falls are more likely to occur in long-term care facilities than in the
community
• Among community-dwelling older adults, 30% fall every year, compared with 50% of
those living in residential care facilities
8 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
Slide 8
Incidence and Risk Factors (cont.)
• Factors known to increase the risk of falling
• A history of previous falls
• Osteoporosis
• Hemiparesis
• Sensory impairment
4
Slide 9
Restraints
• Physical restraints
• Chemical restraints
Slide 10
Physical Restraints
• Anything that restricts movement
• If patient able to apply or release a safety device, it is not considered a restraint
• Geriatric chairs, side rails, vest, waist, wrist, or ankle ties
• Common reasons
TALKING POINTS:
• Restraints are often used to prevent falls.
• Wrist and ankle restraints may be made of soft material or leather.
• What are the most common incidents precipitating the use of restraints?
Slide 11
Physical Restraints (cont.)
• May actually cause or worsen problems
• Patients often able to untie their restraints and wriggle out of them, resulting in falls from
TALKING POINTS:
• Do restraints eliminate the risk of injury?
• The Food and Drug Administration reports at least 100 restraint-related deaths each year.
_________________________________________________________________________ Chapter 20 Falls 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
Slide 12
Physical Restraints (cont.)
• May have damaging psychological effects on older patients
• Patients may experience anger, discomfort, resistance, and fear of physical restraint
• Poor self-image, growing dependency, increased confusion and disorientation, regressive
TALKING POINTS:
• What does the OBRA law specify about restraints?
Slide 13
Physical Restraints (cont.)
• Physician’s order for restraint use; must specify duration and circumstances under which
restraint may be used
Slide 14
Physical Restraints (cont.)
• According to OBRA regulations, the only people who are considered restrainable are
those who
• Have a history of severe falls or are at extremely high risk of taking a fall that is life–
threatening
TALKING POINTS:
• What are some complications of restraints that can occur?
• How does that limit their use?
Slide 15
Physical Restraints (cont.)
• The least restrictive device is best
• Check patient frequently, at least every 15 to 30 minutes
• Agitated or combative patient: monitored continually
• Make sure that the patient’s condition is good and that the restraint is used properly and is
TALKING POINTS:
• What are some alternatives to physical restraints?
• Patients, family members, or both should be involved in the decision to use or not to use
physical restraint.
10 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
Slide 16
Alternatives
• Physical therapy
• Sitting and talking with patients for short periods
• Asking staff to be responsible for wanderers in small blocks of time
TALKING POINTS:
• Why do you think it is so vital to use alternatives before placing a patient in restraints?
Chemical Restraints
Slide 18
Chemical Restraints (cont.)
• Commonly prescribed psychotropic drugs
• Antidepressants
• Sedatives/hypnotics
• Antipsychotic drugs
• Adverse effects
TALKING POINTS:
• What drugs may increase the risk of falls due to orthostatic hypotension?
• Avoid the use of psychotropic drugs if at all possible.
Slide 19
Question 1
• Older adults account for _______ of total deaths due to falls.
A. 52%
B. 62%
C. 72%
D. 82%
TALKING POINTS:
_________________________________________________________________________ Chapter 20 Falls 11
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
Slide 20
Question 2
• Which of the following is NOT true about injuries and falls?
A. The risk of injury from falls is highest in people over age 65, and falls are the most
frequent cause of accidental injury and death among older adults.
B. The U.S. Public Health Service estimates that two-thirds of the deaths due to falls are
preventable.
C. Falls occur in older adults only because of intrinsic factors, or factors related to the
functioning of the individual, such as the aging process or physical illness.
D. People who are at least risk for falls and injury are those who have fallen before and
those who have multiple intrinsic risk factors
TALKING POINTS:
Activities
Classroom Choose from below to make 30 minutes
Online
1
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Invite an RN or nursing home administrator
to class to discuss the incidence of falls in
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class.
12 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
2
DISCUSS
• Discuss differences in the incidence of
falling within various subpopulations
including those older than age 65, male and
female residents of long-term care facilities,
persons older than 75, and males and
females in a hospital setting.
• Divide the class into small groups. Present
the following scenarios and have them
discuss each scenario and rank each
according to the patient’s risk level for a fall.
Next, have the students rank which
individual is most likely to be injured by a
fall.
• An 85-year-old woman with osteoporosis
POST AND COMMENT
• Post the following discussion topic online
and have students comment. What do you
feel are the most important strategies to
implement to prevent falls in the older adult?
Explain.
3
DISCUSS
• Discuss the differences between intrinsic
and extrinsic factors that contribute to the
risk of falling in older adults.
• Discuss the Nursing Care Plan. Examine the
ways in which each of the suggested
interventions addresses intrinsic and
extrinsic risk factors.
• Discuss the chief risk factors for falling in
older adults.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe five
risk factors for falls in the older adult. Create
a teaching plan to prevent falls in older
adults.
_________________________________________________________________________ Chapter 20 Falls 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.1
4
DISCUSS
• Discuss the differences between physical
and chemical restraints and the situations in
which each is likely to be used.
• Discuss the OBRA regulations for use of
restraints.
• Divide the class into two groups. Have one
group define and provide examples of
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe the
physical and psychological effects that may
result from the use of physical restraints.
Critical Thinking Question
The nurse notices that a patient is becoming confused and restless. He is pulling on his
oxygen tubing and attempting to get out of bed every 10 minutes. His medical history
includes a diagnosis of chronic obstructive pulmonary disease (COPD), and at present his
lips appear slightly cyanotic; he is pursing his lips to take a breath. His respiration rate is 26
breaths per minute. Before considering the application of restraints, what should the nurse’s
first action be?
Discussion Guidelines: Before considering restraint application, the nurse should rule out
Instructor Notes/Student Feedback
14 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.2
• Assemble materials and supplies needed for each lesson as indicated below.
Textbook Objectives Covered
6. Describe nursing interventions to use when a fall occurs.
7. Explain what is meant by “least restrictive” interventions for fall prevention.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speakers: physical therapist
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying falls, including:
• The relative incidence of falls among different segments of the elderly population and the
likelihood that a fall will result in injury
Materials and Supplies
Key Terms
• intrinsic factors (p. 315)
• Omnibus Reconciliation Act
(OBRA) (p. 316)
Student Preparation
Assignments 2 hours
5
READ – Textbook (pp. 318-321)
ANSWER – Study Guide
• Part IF: 1-3 (pp. 118-119)
• Part IIIH: 2-5 (p. 120)
6
• Nursing Care Plan 20-1: Patient with a History of Falling (p. 317)
READ – Textbook (pp. 321-322)
REVIEW
7
READ – Textbook (pp. 317-318)
ANSWER – Text
• Review Questions for the NCLEX Examination: 7 (p. 323)
_________________________________________________________________________ Chapter 20 Falls 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.2
50-Minute Lesson Plan
Lecture Outline 20 minutes
7
Slide 21
Physical Restraints (cont.)
• The least restrictive device is best
• Monitored continually
• Place patient in room near nurses station
• If physical restraints are necessary they should be removed every 2 hours for 10 minutes
TALKING POINTS:
• What are some alternatives to physical restraints?
5
Slide 22
Fall Prevention
• Most important intervention for falls: prevention
• Best prevention: education of patients and caregivers
• Prevention aimed toward minimizing intrinsic and the extrinsic factors causing falls and
the potential for injury
TALKING POINTS:
• What are some possible intrinsic risk factors for falling?
• Effective interventions need to be individualized to consider the specific factors that create
a fall risk for the individual patient.
6
Slide 23
Reducing Fall-Related Injuries
• Hip protectors
• Aim to decrease the severity of fall-related injuries
• Individuals at risk for falling also can be taught to rotate forward or backward to avoid
TALKING POINTS:
• Health care providers accept an increased number of falls as an inevitable risk that is
outweighed by the benefits of physical activity and rehabilitation.
• Why do some patients decline to wear hip protectors?
Slide 24
When a Fall Occurs
• Hospital or long-term care facility
• Determine circumstances of fall and any injuries
• Document the fall according to agency protocol
• Note what the patient was doing at the time, the mental and emotional status, and
16 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.2
Slide 25
When a Fall Occurs (cont.)
• Home
• Requires cooperation of the person who is at risk, the family, and possibly neighbors
• Plan of action should include information about getting up and seeking help
TALKING POINTS:
• What methods can be taught to assist patients to get up after a fall in the home?
Activities
Classroom Choose from below to make 30 minutes
Online
5
DISCUSS
• Discuss the intrinsic risk factors for falling
outlined in Table 20-1 and the interventions
that will help the patient avoid falling.
• Divide the class into several small groups.
Have each group discuss specific types of
restraints, or the need for further
assessment, in the following situations.
Have students answer the question: Should
the patient be restrained or should a
different intervention be used?
• A patient with Alzheimer’s disease
attempting to leave the unit
• An intoxicated patient newly admitted to
the unit and threatening to kill his family,
who signed him in
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Briefly
describe the fall prevention guidelines
provided in Health Promotion Considerations
and Box 20-3 and the importance of
incorporating these into the nursing care
plans of elderly patients.
_________________________________________________________________________ Chapter 20 Falls 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.2
6
exercises are done to increase their strength
DISCUSS
• Discuss methods that may safely be used by
the older patient to get up after a fall, as
outlined in Patient Teaching.
• Discuss recommended interventions for
patients who are likely to be unable to rise
from falls without assistance. Review the
ask the speaker questions.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. List the top
three nursing diagnoses you would use after
a patient has had a fall. What interventions
would you implement for each of those
diagnoses? State your rationale.
7
DISCUSS
• Discuss why you feel it is important to use
the least restrictive restraint devices.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Create a table
Critical Thinking Question
One of the patients on the geriatric unit wanders frequently. When confronted and asked to
return to his room, he often becomes combative. He has an order for haloperidol as needed.
Several nurses who take care of him administer it regularly. During change-of-shift report, a
discussion ensues about oversedating the patient. Some nurses believe that the patient
should not be administered haloperidol as often as he has been receiving it. Others say that
it keeps him safe because they’re short of staff. Who is right?
Discussion Guidelines: Staff shortage cannot be used as an excuse for applying chemical
restraints to the patient more often than is necessary. The staff needs to explore better options to
18 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 20.2
Instructor Notes/Student Feedback
_________________________________________________________________________ Chapter 20 Falls 19
Introduction to Medical-Surgical Nursing, 6th ed.
20
Assessments for
Falls
CHAPTER OBJECTIVES
Lesson 20.1:
2. Give the incidence of falls.
4. Discuss the relationship between restraint use and falls, types of restraints, and regulations for
restraint use.
Lesson 20.2:
5. Describe fall prevention techniques.
7. Explain what is meant by “least restrictive” interventions for fall prevention.
Assessments by Lesson & Objective
Lesson 20.1
1
Evolve Instructor Resources
• Test Bank: 14
2
Study Guide
• Part IIG: 1-7 (p. 119)
Evolve Instructor Resources
Evolve Student Resources
• NCLEX Review: 1
3
Study Guide
• Part IB: 1, 2 (p. 117)
• Part ID: 1-12 (p. 118)
Evolve Instructor Resources
• Test Bank: 9, 11, 17, 22, 23, 26, 29
Evolve Student Resources
• NCLEX Review: 8
20 Chapter 20 Falls _________________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
4
Study Guide
• Part IA: 1-6 (p. 117)
• Part IC: 1 (p. 118)
Evolve Instructor Resources
• Test Bank: 7, 8, 11, 12, 16
Evolve Student Resources
• NCLEX Review: 2-7, 9, 10
Lesson 20.2
5
Study Guide
Evolve Instructor Resources
• Test Bank: 1, 3, 5, 6, 18-20, 30, 32
Evolve Student Resources
• Prioritization: 1-3
6
Evolve Instructor Resources
• Test Bank: 2, 13, 24, 25, 27
Evolve Student Resources
7
Evolve Instructor Resources
• Test Bank: 28
Instructor’s Notes/Student Feedback