Medications and side effects
This common family of post op medications can cause dizziness, drowsiness, and slowed reaction time, increasing a patient's risk of falling.
What are Opioids
This is the most important thing a patient should do before getting out of bed or a chair.
What is "call for help".
This common risk factor involves needing help to walk or stand because of weakness, pain, or recent surgery.
What is impaired mobility?
During bedside shift report, this item must always be within the patient's reach to help prevent falls.
What is the call light
As part of hourly safety rounding, staff should check this to ensure the patient can reach items they need without stretching or standing unsafely.
What are personal items or the patient's belongings
Patient's taking this class of medications may experience orthostatic hypotension when standing.
What are Antihypertensives
Nurses should remind patients that these must be worn anytime they are standing or walking to prevent slipping.
A patient who repeatedly tried to get up without calling for help is showing this major behavioral fall risk.
What is impulsiveness
What is the patient's weight-bearing or mobility status?
Hourly safety rounding involves assessing the 5 P's to ensure patient safety. What are they
Pain, Potty, Position, Pumps and Plan of care.
Often used for muscle spasms after orthopedic surgery, this medication family can cause significant sedation and weakness.
What are muscle relaxants.
Patients often don't realize their pain medication can affect this, leading to unsteady walking and falls.
What is their balance or alertness.
The risk factor that occurs when a patient doesn't know where they are, becomes confused, or has moments of disorientation- especially at night.
What is altered mental status or confusion.
This safety device should be checked during report to ensure that it is on, working properly and appropriate for the patient's fall risk level.
What is a bed alarm.
During hourly safety rounds in the environmental sweep of the room, staff should ensure that these items are properly positioned to reduce trips, slips or falls?
What are mobility aids(walker), lines, cords and personal items.
These medications used for sleep can cause confusion, poor coordination, and unsteady gait, especially in older adults.
What are sedative-hypnotics (Ambien)
Education Patients to rise slowly from lying or sitting helps prevent this condition, which can cause dizziness or sudden falls.
What is Orthostatic hypotension.
This cardiovascular-related risk factor causes dizziness or lightheadedness when a patient stands up too quickly.
What is orthostatic hypotension?
During bedside shift report the staff should confirm this with the patient and team to prevent falls related to toileting needs.
What is the patient's toileting schedule/hourly safety rounding.
Hourly safety rfounding is especially important for patients who are high-risk for falls due to this type of post-operative or medication effect that can cause confusion or unsteady gait.
what is sedation, dizziness or delirium?
When combined with opiods, this class of medications greatly increases fall risk due to synergistic sedation and impaired balance.
What are benzodiazepines
Patients must be taught that after anesthesia or nerve blocks, this part of the body may feel weak or numb for hours greatly increasing their fall risk if they try to walk without help.
What is their leg
This high-level risk factor is present when a patient has a recent history of losing balance, slipping, or dropping to the floor-- whether or not they were injured.
What is a history of falls?
During bedside shift report, nurses should perform "this check", ensuring all tubing, lines, mobility aids, and environmental factors are safely arranged-- because many falls are linked to these overlooked hazards.
What is an environmental safety check(itrace, room sweep)
During hourly safety rounding or bedside shift report, reinforcing patient understanding of calling for assistance and safe ambulation is what preventative principle?
What is ongoing patient education or teaching?