Mobility & Fall-Risk Assessment and Prevention

Concept of Mobility

• Mobility ≈ motion / movement used for Activities of Daily Living (ADLs): self-care, driving, cooking, exercise, etc.
• Adequate mobility → improved health outcomes, quality of life, ↓ risk of falls.
• Determinants of mobility & balance
  • Posture & body alignment → create stable center of gravity.
  • Balance: integrates musculoskeletal strength + neurologic, vestibular & visual input.
  • Physical exercise preserves / restores these components.

Nursing Responsibilities Related to Mobility

• Assess, preserve, maintain &/or restore a client’s mobility status.
• Evaluate general health + specific fall‐related risk factors.
• Populations at risk: all ages & settings → hospital, rehabilitation, long-term care, home, community.
• Mandate: complete fall-risk assessment at admission, on transfer of care, and at regular intervals (per policy / change in status).

Fall-Risk Assessment

• Purpose: Early identification → prompt, individualized interventions.
• Standardized, evidence-based tools → consistency & comparability.

Timed Up & Go (TUG) Test (review from Engage Fundamentals mobility lesson)

• Procedure
  • Client sits in chair → on command stands, ambulates 10 ft (≈3 m), turns, returns, sits.
  • Nurse observes balance, stride, posture, gait.
• Interpretation
  • Older adult needing >12\text{ s} to finish = ↑ risk for falls.
• Documentation: exact seconds, gait deviations, need for assistive devices, client tolerance.

Additional Assessment Components

• Orthostatic BP: note drop when supine → sitting → standing.
• Sensory deficits: vision, hearing, proprioception.
• Cognitive status: orientation, judgment, impulsivity.
• Medication review (see pharmacology section).

Individualized Plan of Care Based on Risk Findings

• Match interventions to specific etiology
  • e.g., Orthostatic hypotension → educate: change positions slowly, ‘dangle’ legs at bedside before standing; assure assistance with first ambulation.
• Continuous reassessment & modification as client condition evolves.

Environmental & Home-Safety Modifications (esp. Home-Health Scenario)

• Remove trip hazards: throw rugs, loose carpets.
• Manage cords: against wall / behind furniture; avoid across pathways.
• Bathroom adaptations
  • Grab bars by toilet & inside tub/shower.
  • Raised toilet seat.
  • Non-skid mats + shower chair.
• Lighting: adequate inside & outside; night-lights in hallways.
• Exterior: steps & sidewalks in good repair.
• Oxygen safety: no frayed cords, avoid tripping over tubing.

Special Focus: Older Adult

• Age-related changes ↑ fall risk
  • ↓ strength & endurance.
  • Impaired mobility & balance.
  • Improper use of aids; unsafe clothing (loose hems, slippery shoes).
  • ↓ sensory perception (vision, vestibular, proprioceptive).
  • Postural changes (kyphosis), slowed reflexes, ↓ joint mobility, ↓ muscle mass.
  • Generalized deconditioning & functional decline.

System-Specific Complications of Immobility & Related Nursing Actions

• Musculoskeletal
  • Disuse osteoporosis, sarcopenia, foot-drop.
  • Interventions: active/passive ROM, assist with ambulation, PT referral, support devices.
• Cardiovascular
  • Orthostatic hypotension, Deep Vein Thrombosis (DVT).
  • Interventions: gradual position change, anti-embolism stockings, hydration, mobilize when safe, fall precautions.
• Respiratory
  • Atelectasis, pneumonia.
  • Interventions: incentive spirometer, repositioning, secure lines/tubing to avoid tripping, monitor {\text{SpO}_2}.
• Gastrointestinal & Genitourinary
  • Constipation, urinary stasis.
  • Interventions: hydration, fiber, toileting schedule, keep pathways to bathroom clear, ensure assistive devices within reach.

Universal/Nursing-Unit Fall-Prevention Measures

• Respond promptly to call lights; encourage use.
• Identify fall risk visually: color-coded wristbands, door signs.
• Room placement: highest-risk clients nearest nurses’ station.
• Bed safety
  • Lowest height; wheels locked.
  • Side rails up for sedated/unconscious as appropriate (avoid entrapment & restraint issues).
• Environment
  • Adequate lighting.
  • Floor free of clutter → no scatter rugs, cords, furniture obstacles.
• Assistive items
  • Keep glasses, hearing aids, walkers, canes, transfer devices within easy reach after verifying safe use.
  • Provide non-skid footwear; non-skid bath mats.
  • Utilize gait belts, mechanical lifts as needed → protects client & nurse ergonomics.
• Scheduled rounds
  • Regular toileting, hydration, pain control, orientation for confused clients.
• Technology
  • Chair/bed alarms or weight sensors for clients who attempt unassisted exits.
• Education
  • Client & family informed of risks & plan → fosters cooperation.
• Dizziness protocol
  • Instruct to report dizziness, weakness, dyspnea immediately; pause ambulation until resolved.

Post-Fall or Unexpected Outcome Management

• If client becomes dizzy during ambulation → stop, help to chair or floor in controlled manner.
• If fall occurs
  1. Lower gently to ground protecting head/neck.
  2. Assess: ABCs, vital signs, obvious injury, neuro check if head impact suspected.
  3. Safe positioning (supine with alignment unless contraindicated).
  4. Call for help; notify charge nurse/supervisor & provider.
  5. Incident report: objective details, no blame language, do NOT chart that form completed in EMR.

Scenario Recap (Client found on floor)

• Interventions mirrored above: assess, safeguard, notify, document.

Pharmacology & Fall Risk

• Newly prescribed medications → unknown individual reaction.
• Cardiovascular / pulmonary
  • Beta blockers, ACE inhibitors, vasodilators → \downarrow BP → orthostatic hypotension.
• Central nervous system
  • Opioids, sedatives, hypnotics, antiepileptics, antipsychotics → dizziness, sedation, impaired judgment.
• Polypharmacy & drug interactions amplify risk.
• Nursing actions: medication reconciliation, monitoring side effects, timing dosing around activity, client education.

Special Populations & Additional Safety Tips

• Assignment considerations
  • When delegating to float / agency nurse, include current fall-risk status & specific precautions in hand-off.
• Newborn
  • Teach parents: never leave infant unattended on elevated surfaces (couch, bed, table) → newborns can scoot to edge & fall.
• Dementia Clients
  • Cognitive deficits impair ability to remember or follow safety instructions.
  • Educate & involve family/caregivers in prevention plan; environmental cues (signage, contrasting colors) may help.

Ethical, Professional & Real-World Implications

• Fall prevention aligns with non-maleficence (do no harm) & beneficence.
• Regulatory & accreditation bodies (e.g., CMS, The Joint Commission) view falls as Never Events when associated with serious injury.
• Incident data drive Quality Improvement (QI) projects; nurses’ accurate reporting essential.
• Financial impact: unreimbursed costs, extended length of stay, liability claims.

Key Takeaways / “Exam Flags”

• Complete fall-risk assessment on admission, transfer, & status change.
• >12\text{ s} on TUG = red flag.
• Orthostatic hypotension protocol: sit → stand in stages.
• Secure environment: clear paths, locked wheels, low bed, adequate lighting.
• Multisystem complications of immobility demand proactive interventions.
• Educate clients & families; informed participants call for assistance.
• Post-fall: lower, assess, secure, notify, document.
• Medication classes to memorize for fall risk: cardio (beta blockers, ACE-I), CNS (opioids, sedatives), polypharmacy.
• Special populations (older adults, newborns, dementia) require tailored strategies.
• Fall prevention is a continuous, interdisciplinary process integral to patient safety culture.