Assessment
On admission, every shift and significant change of condition.
When to complete fall risk assessment?
What is the point value in assessment tool for male gender?
1 point
Tools are to identify a patient at risk for falls (score of 4 or greater)?
What are Yellow fall risk band, yellow non-skid socks, visual cue on patient's door, fall risk contract
An important intervention to keep patient safe from falling if the patient is a fall risk?
-Staff to toilet; Bed alarm on and to not de-activate; Call for assistance; patient risk factors
What is Family/visitor education
This device should be used for every patient during progressive mobility to aid in mobilization.
What is a gait belt?
All patients admitted to Med-Surg/Telemetry
Who should be assessed for falls?
Assessed on admission to determine patient's functional ability and risk for falls
What is patient's ability to rise from sitting position; walk approximately 10 feet, turn around and walk back to the bed; sit in chair without arms for support.
The standard precautions for all patients.
What are call bell in Reach, bed locked in low position, personal items in reach, clutter free environment?
A Fall or assist to the floor.
What is an unintentional change in position coming to rest on ground, floor, or onto next lower surface (e.g. bed, chair)?
The assessment used to determine risk factors for a fall-related injury? (AGE - over 85, BONES - osteoporosis, previous fracture, prolonged steroid risk, COAGULATION - bleeding disorder, meds that increase bleeding risk, low platelet count), SURGERY - recent surgery, wounds that could dehisce.
What is ABC Risk for Fall with Injury Assessment?
-
The first step toward preventing falls.
What is assessing the patient's functional ability prior to coming to the hospital; history of falls; use of assistive devices; balance screening and use of protective devices.
Type of medications that place patients at higher fall risk in the hospital.
What are CNS/psychotic medications, cardi0vascular medications and poly-pharmacy?
Bed alarm, avasys camera, toileting schedule, assistive devices in room at side of bed, purposeful hourly rounding, call light accessible, patient education, bedside commode if indicated, progressive mobility, hand-off
What is an individualized plan of care based on patient's risk factors and needs?
No Pass Zone
What is the intervention where all hospital staff should not pass a patient room where a call light or alarm is sounding without going in to see what they can do to assist?
Progressive Mobility (GEMS score)
What tool is used to assist the nurses to assign a patient a level of mobility?
Ability to follow directions and cooperate with instructions
What is an indicator of compliance with safety and prevention of falls?
Common risk factors for falls.
What are altered elimination (incontinence, urgency, frequency, nocturia, diarrhea); history of previous falls, poly pharmacy.
An important part of the individualized care plan to prevent falls and injury while in the hospital.
What is patient education?
The Nurse/PCT responsibility when patient is going to/from, and during toileting/dressing to ensure patient safety.
What is Stay Within Arm's Length?
The form that must be completed by the RN/LPN taking care of the patient immediately after a patient.
What is a Fall Scene Investigation (FSI) form?
The score on fall risk assessment that indicates a patient is a risk for fall.
What is a score of 4 or greater?
Patient's knowledge of risk factors and steps to take to prevent falls.
What is assessment to determine what the patient knows about safety?
A safety practice that addresses the 4 P's (pain, potty, position, possessions) and is an expectation of all bedside staff.
What is Purposeful hourly rounding & Bedside Hand?
Avasys
What is the telesitter with camera program called?
The intervention that should be initiated if patient is at risk for falls and needs assistance to toilet, is incontinent, taking medication to cause diuresis, having diarrhea?
What is scheduled toileting plan?