Falls
What is the definition of a fall?
A sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can).
1. When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall.
2. If a patient who is attempting to stand or sit, falls back onto a bed, chair, or commode, that is only counted as a fall if the patient is injured.
3. Developmental falls are defined as: Falls experienced as a part of normal growth and development by infants, toddlers and preschoolers learning to walk, run and pivot. The focus of this fall type is not to prevent the fall but to prevent injury by providing a safe environment for the toddler that promotes development of normal skills.
4. “Falls during play” are falls that occur during normal play activities in such areas (gyms or other designated play areas for patients) and are reportable only when they result in injury.
In what situations would the application Violent/Self-Destructive restraints be justified?
To manage violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others and significant damage to the environment.
When should a central line dressing be changed?
Every 7 days, or immediately if soiled, wet/bloody, or not intact.
What are 2 assessment findings of the SIRS Criteria?
Temperature >101 F (38.3 c) or <96.8 F (36 c)
HR >90
RR >20
WBC >12k or <4k, or >10% Bands
If you are wearing gloves, you do not need to wash your hands after removing them...
Incorrect, wearing gloves is NOT a substitute for cleaning your hands
What are fall prevention interventions for high fall risk patients?
Initiate all green (low risk), and yellow (moderate risk) interventions, plus:
Red Chiklet or Roomlink icon
Verbally state at unit shift huddle all patients scored as red fall risk
Assess for enrollment in structured toileting program
Consider unit specific interventions protective devices (low beds, etc.)
One-One Observation or Tele Sitter
Staying with the patient while toileting or showering
List the restraints that can be used for Violent/Self-destructive behavior.
• Soft Quick Release Restraints
• Lockable restraints
• Restraint Chair (BH only)
• Seclusion (BH only)
***THE USE OF ANY VIOLENT RESTRAINT REQUIRES A 1:1 SITTER***
What is the CDC definition of a CLABSI infection?
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site.
What are 2 indications of organ dysfunction?
SBP <90 or MAP <65, or SBP decrease >40 from baseline
Creatinine >2 mg/dl
Urine output <0.5 ml/kg/hr. for >2 hrs.
Lactate >2 mmol//L
INR >1.5 or a PTT >60 secs
Platelets <100k
Bilirubin >2 mg/dl
When is hand hygiene required?
Hand hygiene is performed when entering and exiting a patient room (area) along with the World Health Organization’s (WHO) five moments of hand hygiene. The five moments are:
• Before touching a patient
• Before clean/aseptic procedure
• After body fluid exposure risk
• After touching a patient
• After touching patient surroundings
What is a structured toileting program and what are the benefits?
Structured toileting involves taking the patient to the restroom at pre-determined times of the day. Structured toileting works well for patients who are not capable of independent toileting.
A structured toileting program can improve the patient’s quality of life, and increase patient mobility, while decreasing falls and skin breakdown related to incontinence.
Prior to the application of restraints, the following must have been done and documented...
1. Complete a comprehensive physical assessment to identify medical problems that may cause behavior changes in the patient (for example – temperature elevation, hypoxia, hypoglycemia electrolyte imbalance, drug interactions)
2. Confirm that all least restrictive interventions and alternatives have been exhausted including, but not limited to:
a) Therapeutic de-escalation
b) Redirection
C) Distraction
E) Companionship/supervision
If blood return is absent when you assess the patency of a central line, what is the next step you should take?
Notify the MD and document
How is severe sepsis defined?
1. Presence of/presumed infection
2. SIRS Criteria (2 or more)
3. Any evidence of organ dysfunction (Not considered to be chronic conditions)
A Healthcare Associated Infection (HAI) is an infection that occurs on or after day _____ of admission.
On or after day 3 of admission
(exception-C-diff/MRSA Bacteremia and surgical site infection)
Who should be considered for the structured toileting program?
Patients who:
Are determined to be a high fall-risk
Are taking high-risk medication (Diuretics, sedatives, laxatives)
Are incontinent, have urinary frequency/urgency, or frequent stools
Are cognitively impaired (memory problems, impulsivity)
Consider other impairments (ambulatory dysfunction, visual impairment, tethers such as IV fluids/poles or chest tubes)
Any patient can be enrolled based on the nursing assessment
When are bed rails considered a restraint?
The determination of whether side rails are considered a restraint is based on “intent.” If bedrails or side-rails are raised that restrict the patient’s freedom to exit the bed, but the patient is not physically able to get out of bed, then bedrails or side-rails are not considered a restraint. If in the case of four segmented side rails, and all but one side rail is raised to allow the patient to freely exit the bed, the side rails would not be considered a restraint. Stretcher side-rails and seat belts applied during transport because they are a prudent safety intervention, are not considered a restraint. Side rails raised as a seizure precaution are not a restraint.
What treatment is used to prevent the occurrence of a CLABSI infection?
Daily Chlorhexadine (CHG) treatment
Septic shock "Time Zero" is the earliest time one of ___________(What Criteria) is met?
The time that the patient is identified as having severe sepsis or septic shock.
When is Chlorhexadine (CHG) treatments indicated to reduce the risk of infection?
Pre-op
All patients admitted to ICU
Patients who have a central line or indwelling urinary catheter
What fall risk assessments are used at Inspira besides the Morse Fall Scale?
Kinder-1 (ED)
Graf-Pif-Pediatric
"No Falling Star"-Newborn
Can staff discontinue restraints as a trial and then re-start it under the same order?
No, a new order must be obtained.
Note: A temporary, directly supervised release for the purpose of caring for a patient’s needs (e.g., toileting, range of motion) is not considered a discontinuation of restraint as long as a staff member is continuously present.
What are the set of interventions in Inspira's CLABSI Prevention Bundle?
1. Proper hand hygiene
2. Maximum barrier precautions
3. Chlorhexidine antimicrobial skin prep
4. Optimal catheter site selection
5. Daily review of the necessity for the central line
What interventions are included in the 3-hour bundle and 6-hour bundle?
3-Hour Bundle:
Lactic Acid
Blood cultures (PRIOR to antibiotic administration)
Antibiotics
IV fluid bolus (30 ml/kg crystalloid) for hypotension or lactic acid > or = to 4mmol/L
Repeat Lactic Acid level if initial was >2
6-Hour Bundle:
Vasopressors if hypotension is persistent within 60 minutes after fluid bolus, or 2 consecutive MAP <65 or SBP <90
Reassessment exam (performed and documented by Physician/APN/PA-C)
What is the process for transporting a patient with isolation precautions in place?
Prior to leaving the room, the patient should be changed into a clean gown and asked to wash their hands.
Contact-cover all draining wounds or skin lesions
Droplet, Airborne, Enhanced Respiratory Isolation-the patient wears a standard surgical mask when leaving the room
The Transporter should not wear a mask
PPE should not be worn in the hallways
Notify the receiving deparment