The nurse is caring for a 79-year-old male who has a non–weight-bearing cast on the left lower extremity. The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance
Which response by the nurse is most likely to keep the patient from falling? a. Apply a vest restraint and offer frequent toileting.
b. Plan fall prevention with patient, family, and healthcare provider.
c. Inform family that the patient needs phys-ical restraints.
d. Document that the patient has a high po-tential for falling.
B
Planning an individualized fall prevention program with the help of the patient, family, and healthcare provider is more likely to reduce the patient's risk of falls because he gains some con-trol over the plan of care and still benefits from the input of the provider, family, and nurse and the fall prevention program. A combination of interventions is more useful in preventing falls. Including the patient in planning also gives him ownership of the plan, making it less likely that he will disregard a plan he helped to design. Vest restraints are associated with serious injuries and are not recommended for use. Documenting the patient's risk is important because it com-municates the information and records the nurse's acknowledgment of the risk, but it is not as effective as engaging the patient in planning care as a prevention technique because it is indirect. Alternative methods of engaging the patient in a care plan that minimizes risks should be ex-hausted before resorting to restraints.
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