Fall Risk Assessment Tool
These patients should be assessed for Fall risk.
What is all patients?
This should be done for every patient upon admission or transfer to a unit to assist in fall prevention.
What is orient patient and family to room and surroundings?
The color of socks a patient should wear if high risk for falls.
What is yellow?
This is an internal characteristic or condition that increases their likelihood of falling.
What is an intrinsic fall risk factor?
Name of the Fall Risk Assessment Tool used for Adults in EHMC.
What is the Hendrich II Fall Risk Assessment Tool?
What is the call bell?
A _________ occurs when a patient is found on the floor and neither the patient nor staff know what happened.
What is an unwitnessed Fall?
A factor related to the environment or a patient's interaction with the environment that increases the likelihood of falling.
What is an extrinsic fall risk factor?
What is 5 or greater?
What is a Posey Chair Alarm?
Name a person who should be notified after a patient falls.
Who is the LIP?
Who is patient's family?
Who is the nursing supervisor/manager/anm?
A patient has arthritis and has trouble ambulating long distances. This is considered a __________fall risk factor.
What is intrinsic?
This should also be considered when assessing a patient's risk for falls in addition to the Hendrich II Fall Risk Assessment.
What is patient's history of falling?
A patient was admitted with a diagnosis of a GI Bleed. Patient's fall risk assessment score is a 3. This should be done for this patient to help prevent falls.
What is a staff member should assist patient with ambulation?
This is the first thing a nurse should do if a patient falls.
A patient has a rolling walker that is not tall enough. This is considered a __________ risk factor.
What is an extrinsic risk factor?
Name one of the categories assessed in the Hendrich II Fall Risk Assessment tool.
What is confusion/disorientation/impulsivity?
What is symptomatic depression?
What is altered elimination?
What is dizziness/vertigo?
What is gender?
What is antiepiletics or benzodiazepines administered?
What is the get up and go test?
This should occur when a patient who is at high risk for falls is assisted to the bathroom.
What is remaining with the patient?
A patient with developmental delay puts herself on the floor in her room due to a disagreement with staff. This is considered an ______________.
What is an Intentional Fall?
What is extrinsic?