Module 4 – Safety and Security: Protective Restraints and Fall Prevention
Who is most at risk for falling?
patient with a history of falling is a great risk to fall again
What measures are used in assessing patients for risk of falling?
Hendrich Fall Risk Assessment (we assess the individual, the environment, and the specific risk
How does the Hendrich II Fall Model Risk Assessment tool assist in assessing patient for falls?
It quickly rates the patient's likelihood of falling with eight independent risk factors.
What are examples of home safety measures that should be utilized to prevent falls and injury.
Inform the patient of the major causes of falls in the home. (include slippery surfaces, poor lighting,
clutter, and improperly fitting clothing or slippers. Common traffic pathways in the home, the
bathroom, and access areas to and from the home are hazardous areas for older adults.) Measures
as simple as installing hand rails in bathrooms and on stairs, ensuring good lighting, and discarding or
repairing broken equipment around the home help prevent accidents.
What interventions are appropriate for use in healthcare facilities in prevention of falls?
Use of the Hendrich II Fall Model to assess the patients likelihood of falling. Orient to new
surroundings, Keep two side rails up (depending on policy), Keep call light, bedside table, water,
glasses, etc. within easy reach, Use a night light, Keep bed in low position, Make sure patient has
non-skid footwear, Ambulate only with assistance when appropriate, Locate patient close to the
nurses station, Upon exiting the room, always ask the 4P’s – pain, possessions, positioning and
What are purposes of using a restraining device?
Sometimes the Patient’s safety is still at risk so restraints are a necessity for Medical Care.
Prevent the patient from falling and sustaining injury
Patients who are hypotensive, have lost a lot of blood, receiving narcotics, etc.
Position and protect patient during treatments and to maintain ongoing care
Prevent pulling on catheter, nasogastric tube, stitches