Policy says...
This is used to screen adult patients in the inpatient setting for falls risk.
What is fall predictive scoring or EPIC predictive scoring?
This should be updated at least once per shift and include the patient.
What is plan of care?
This medication class can cause dizziness, drowsiness, and increased fall risk.
What are sedatives or antihypertensives?
This should always be within the patient's reach before leaving the room.
What is the call light?
This belt is used to assist all high fall risk patients with ambulation.
What is a gait belt?
This should be reported off at bedside hand off.
What is fall risk score and/or any falls that have occurred?
This should be reassessed before ambulation because both the symptom itself and its treatment can result in increased fall risk.
What is pain?
Patients with this neuro condition may have weakness, neglect, of balance deficits that increase fall risk.
What is a stroke?
These should be locked before transferring a patient.
What is wheelchair or bed brakes?
This device alerts staff when a patient attempts to get up.
What is a bed alarm?
This occurs after a fall and includes team members.
What is a post-fall huddle?
Leaving these on the other side of the room may increase fall risk.
What are possessions or personal items?
This can cause patients to rush to the bathroom and frequently puts patients at higher risk for falls.
What is urinary urgency or incontinence?
Patients should wear these when ambulating.
What is non-skid socks or non-skid footwear?
This piece of equipment should be kept locked and in its lowest position when not providing care.
What is the bed?
These two things must be done after a fall.
What is document the fall in the post-fall flowsheet AND complete a pulse report of the safety event?
This "P" of purposeful rounding includes offering assistance to the bathroom or bedside commode.
What is personal needs?
This common age-related change can contribute to falls.
What is decreased balance or muscle strength?
Before assisting with ambulation, a nurse should assess these.
What are the ability to bear weight, maintain balance, and follow directions?
This transfer device should be used for patients who are able to sit up, can follow directions, and can bear weight through at least one leg.
What is the Sara Stedy?
These are times/events when a nurse must acknowledge the fall risk score.
What is once per shift, on admission, transfer, after a falls event, and with any significant change?
Addressing pain, position, personal needs, and the plan of care during rounding helps reduce falls, call light usage, and this common patient complaint.
What is poor communication or unmet needs?
A patient has a bed alarm, yellow armband, and recent history of falls. During toileting assistance, you should do this until the patient is safely finished AND back in bed.
What is remain with the patient?
This intervention is recommended when a patient is impulsive and repeatedly attempts to get up alone.
What is a sitter or increased rounding/ observation?
For a patient who becomes short of breath or is unsteady when walking, this equipment may be safer than attempting a trip to the bathroom.
What is a bedside commode?