A nurse is working on a medical surgical floor and is assigned an elderly, confused patient with a history of falls. The nurse knows that which of the following measures should be implemented to prevent falls in this patient?
Explanation
•Patients are considered a high fall risk if they are confused.
•These patients should be placed on high fall risk precautions and have non-skid socks put on their feet.
•The patient's bed should be in the lowest locked position so that the bed does not roll.
•High fall risk patients who are confused should have the patient room door left open so patient location is readily visible at all times.
Incorrect options:
•Restraint vests should never be used without a specific order from the doctor due to the very high risk of strangulation. Because the least restrictive intervention should always be used, an order for restraints would need to explicitly state why this intervention was required to keep the patient safe.
•Raising all four bed rails is considered a restraint and should not be done. If family members raise the bed rails, always document this in the nursing record.
•Placing the patient in a chair with a bedside table in front of them will not prevent falling as the bedside table rolls and is easily moved. If any obstacle is placed in front of a patient so as to prevent them from moving or getting up, this is considered a restraint.