Dont FALL for it
These are 5 medication classes that cause increased risk for falls
Antidepressants, antipsychotics, hypoglycemic agents, narcotics, laxatives, anti-parkinson agents, anticonvulsants, diuretics, anticoagulants, anti-hypertensives, anticholinergics, benzodiazepines
These are 3 initial assessments when you find a patient on the floor
Assess for: injury, ABCs, neuro check, vital signs, range of motion, pain
These are at least 3 positive sepsis findings
Temperature > 100.4, Heart Rate > 90, SBP less than/equal to 90mmHg, Respirations >20/minute, Acute change in Mental Status, WBC > 12,000 or less than or equal to 4000, SHOCK index > 0.8
These are 3 other factors that increase risk for falls
Impaired mobility, impaired vision, frequent toileting, agitation, delirium, orthostatic hypotension, history of falls, vertigo, musculoskeletal weakness
This is who you notify when a patient falls (3)
MD, family, CHS
This is the position I should place my patient if positive for sepsis and BP is adequate
Semi-Fowlers
This is when patient’s fall risk should be assessed
Upon admission, each shift, change in status, transfer to another unit, on discharge
These are 3 types of documentation you complete post-fall
Incident report, nurses’ note, care plan
These are labs that will be ordered if my patient is positive for sepsis
STAT: blood cultures x2, CBC, CMP, ABG, lactate, UA with C&S
This equipment can be used to help prevent falls
Non-slip socks, floor mat, bed rails, yellow fall wristband, call light within reach, fall risk sign, bed/chair alarm
If my patient sustained a bruise during a fall, this is considered a _________ injury
Minor injury
This is how often I should monitor my patient’s vital signs if positive for sepsis
every 15 minutes
These would make a patient’s room considered a safe environment. ( at least 3)
Free of clutter, bed in lowest position, adequate lighting, patient belongings within reach, free of unnecessary equipment, call light within reach
If my patient sustained a head injury during a fall, this is considered a ___________ injury and the patient needs to be sent to ___________
Severe injury, Emergency Department
This type of monitoring should be placed on a patient with positive sepsis findings
Telemetry monitoring