A nurse is conducting morning rounds on adult medical-surgical clients. Which clients should the nurse identify as high fall risk requiring intervention? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
High fall risk indicators include orthostatic hypotension (multiple antihypertensives plus dizziness), motor or sensory deficits (stroke with hemiparesis), and altered cognition with tethering devices (delirium plus indwelling catheter). The 32-year-old with a low-impact laparoscopic recovery and the 45-year-old with controlled diabetes ambulating independently are not high risk based on the data given.
Clinical Judgment NCLEX fall risk multipliers: age >65, polypharmacy, orthostasis, prior fall, stroke/hemiparesis, delirium/dementia, tethering devices. Standardized tools: Morse Fall Scale, Hendrich II, STRATIFY. Score above unit cutoff triggers a high-risk care bundle.
Memory Tip Fall risk: Age + Meds + Mobility + Mind + Tubes
KR vs US The Joint Commission and Korean Hospital Accreditation both require a validated fall risk tool on admission and at each shift. Korean tertiary hospitals commonly use Morse Fall Scale, the same tool widely used in the US.
Clinical Practice GuideHigh fall risk care bundle (Joint Commission + AHRQ):- Yellow fall-risk wristband and door sign- Bed in lowest position, side rails up x 2 (not all 4 — counts as restraint)- Bed and chair alarms for cognitively impaired- Non-slip footwear on at all times- Call light within reach; reorient frequently- Hourly purposeful rounding covering pain, position, potty, possessions- Toilet on a schedule for clients with diuretics or urinary urgency- Postural BP and orthostatic safety teaching
CautionIndwelling catheters and IV lines are tethering hazards that increase fall risk. Discontinue at the earliest opportunity. Polypharmacy review (especially benzodiazepines, opioids, antihypertensives) is a high-yield prevention strategy.
Morse Fall Scale — Validated bedside fall risk tool with 6 items: history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, gait, mental status. Score 0-125. Cutoffs vary by institution (commonly low <25, moderate 25-44, high ≥45). Reassessed each shift.
Orthostatic hypotension — Drop in systolic BP ≥20 mmHg or diastolic ≥10 mmHg within 3 minutes of standing. Causes: dehydration, antihypertensives, autonomic dysfunction, prolonged bed rest. Major contributor to falls in older adults. Teach slow position changes and hydration.
Tethering hazard — Any device tethering the client to the bedside (urinary catheter tubing, IV lines, oxygen tubing, telemetry leads, sequential compression devices). Increases fall risk by limiting safe ambulation paths. Remove at earliest clinical opportunity.