FALL RISK
Name one intrinsic fall-risk factor
What is:
Weakness
Age
Dizziness
Cognitive impairment
Normal adult RR
What is: 12-20
What tool is used to assess consciousness?
What is: Glasgow Coma Scale (GCS)
What is the most effective way to prevent infection?
What is: Hand hygiene
What does SBAR stand for?
What is:
Situation
Background
Assessment
Recommendations
What is a common extrinsic fall-risk factor?
What is:
Clutter
Poor lighting
Slippery floors
Bed height
Which VS changes FIRST with early deterioration?
What is: Respirations
Name two components of a neuro check
What are:
LOC
Orientation
Pupils
Limb strength
Sensation
What position prevents aspiration during oral care?
What is:
Side-lying/Head turned
Semi/High-fowlers
Give an example of an appropriate 'Situation' statement
What is:
'I'm calling about Mr. Lee's increasing SOB'
A patient scores 'High Risk' on the fall-risk assessment scale. Name one 'High Risk' intervention
What is:
Bed alarm
Close observation
Assist for toileting
Keep call bell in reach
Define orthostatic hypotension
What is: A drop in BP when standing, with symptoms
What does perfusion mean in a peripheral vascular assessment?
What is: Adequate blood flow to extremities
How often should a patient be repositioned to prevent pressure injuries?
What is: Every 2 hours
Which part of SBAR includes objective data like vitals?
What is: Assessment
What is the FIRST action after finding a patient on the floor?
What is:
Assess VS
Assess ABCs
Assess for injury
What does a pulse oximeter measure?
What is: SpO2 and pulse rate
Define 'adventitious lung sounds'
What is: Abnormal sounds, such as crackles or wheezes
Name a safety step before giving a bed bath
What is:
Appropriate bed height
Lower railings on working side
Check water temperature
What should the nurse ALWAYS have ready before calling the provider?
What is:
Chart
Vitals (recent)
Relevant labs
Allergies
Current meds
Name three components of a fall prevention plan for a confused patient
What are:
Bed alarm
Frequent rounds
Sitter/Close monitoring
Non-slip footwear
Clear environment
Two reasons a pulse ox reading may be inaccurate
What are:
Cold extremities
Nail polish
Movement
Poor perfusion
List the correct HTT sequence
What is:
Neuro
Resp
CV
GI
GU
MSK
Skin
List three pressure-injury risk areas
What are:
Heels
Sacrum/Coccyx
Elbows
Hips
Occiput
Reword this into a proper recommendation - "I don't know... maybe check on him?"
What is:
I was hoping you could come assess him and his breathing
Would you like to order a CXR and inhalers?