Falls Assessment
To help ensure nurses accurately and appropriately assess a patient’s potential risk for falls, our current Fall scale utilized?
What is Hester Davis Fall scale (HD Fall).
Medication that increases urination
What is diuretic?
Risk factor assessment for every patient.
What is falls screening?
Goes on the floor near patient to decrease fall related injuries.
What is fall mat?
When should the fall scale be updated?
What is upon admission, daily, shift handoffs & transfers, after a fall, change in patient’s condition or plan of care?
A high fall risk patient is assigned to a room farthest from the nurses station, what's your is next step?
What is ESCALATE to move the patient closer to the nurses station
When a high fall risk patient is assisted to the restroom, the patient requests to be left alone. The appropriate response
What is stay with the patient. State" for your safety, I must remain close by".
Placed on bed or chair to alert staff of fall risk patient attempting to ambulate without assistance.
What is Posey Alarm?
The Posey alarm in your patient's room is malfunctioning, what is your next action?
What is ESCALATE to the charge nurse for repair or replacement?
Medications given during procedure that alters their perception
What is sedation?
Safe bed position
What is bed in low and locked?
An assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help with walking around. It is secured around the waist to allow a caregiver to grasp while assisting in lifting or moving a person.
What is gait belt?
A NUMBER calculated from a falls risk assessment tool to determine a patient's likelihood of falling
What is a falls score?
Diagnosis that can result in paralysis of one side.
What is stroke?
Name the 5 P's addressed during intentional hourly rounding
What is
PAIN: “How is your pain?”
POSITION: “Are you comfortable?”
POTTY: “Do you have bathroom needs?”
PERIPHERY: “Do you need me to move the phone, call light, trash can, water cup, or over-bed table?”
PUMP: Check the IV pump.
Patients encouraged to push this device when requesting assistance from staff with needs and transfers.
What are call light?
What do nurses review with patients about NEW medications?
What is medication side effects education?
If a patient has been in ICU for several days they are likely to present with a change in thought process known as what?
What is delirium?
At the beginning of each shift, the charge nurse leads this gathering of co-workers to discuss those at risk for falls
What is staff safety huddle?
Fall prevention items implemented on all patients that score 15 and above or at the nurses request on the Hester Davis fall scale.
What is non-skid socks, yellow gown, yellow armband, signage outside door, bed/chair alarm, call light within reach, moved closer to desk, fall mat, low bed, encourage family to stay and assist?