Fall Prevention
True or False. All residents are assessed for Fall Risk on admission and with any significant change.
What is TRUE.
True or False. If a resident is a high risk for falls, it needs to be careplanned.
What is TRUE. Interventions need to be careplanned for a consistent approach. Careplans must be shared with all team members and family/visitors of the resident.
Examples of risk factors for ulcer development
What are immobility, dehydration, incontinence, excessive moisture, poor circulation, ill fitting incontinence products, certain medical diagnoses
Examples of information included in a wound careplan.
What are: frequency of turns, moisturize skin, increase hydration (if appropriate), use of a turning sheet, any specialized equipment (i.e. air mattress, special cushion, etc.)
What is the frequency of post fall assessment for witnessed vs unwitnessed falls (or with head involvement).
What is
24 for witnessed and 48 for unwitnessed (or with head involvement)
Examples of common risk factors related to falls.
What are: unsteady gait, poor vision, cluttered areas, inappropriate footwear, risk taking behavior, polypharmacy, poor lighting, slippery floors, cognitive deficit.
If a resident falls and is unable to get up independently, which lift is the most appropriate to use?
What is a FULL mechanical lift.
Examples if information/education shared with patients and families.
What are:
skin care products used, review or copy of careplan, any consultations, purchasing of specialized equipment (mattresses, cushions, special shoes, booties, slings, turning sheets, etc.), status of the wound, what our interventions have been.
True or False. Every resident is assessed for pressure ulcer risk upon move in.
What is TRUE. Every new resident is assessed as soon as possible after move-in (within 24 hours or no less than 7 days)
What are some universal fall precautions that everyone can use to minimize incidents of falls.
What are: uncluttered areas, well lit rooms, regular toileting, pain management, call bell and personal items within reach.
What assessment is required immediately following a fall?
Examples of tasks you do to help prevent the development of ulcers
What are: complete daily skin observation assessments and tools in POC, moisturize dry skin, ensure proper fitting incontinent products, good hygiene, report any skin changes, regular toileting, consult dietician or OT as appropriate.
How we share concerns from wound rounds with the interdisciplinary team.
What are: at report, adjustments of the careplan, progress notes, minutes, consultations sent to OT/dietary/ISFL consult, physician's book, pictures in PCC.
This is the standardized assessment tool used in LTC) for pressure ulcer risk assesment.
What is PURS (pressure ulcer risk scale
Name the 4Ps
What are:
Pain
Positioning
Placement
Personal Needs
Examples of signs and symptoms or a hip fracture
What are:
pain at the hips
unable to bear weight
limited ROM
affected side may be shortened, adducted or externally rotated
brusing and swelling
Tools we use to monitor wounds
What are: skin observation record, wound flow sheet, BWAT, pictures of wounds in PCC, measurement of wounds, wound rounds, pain assessments, ISFL consults.
This is the standardized assessment tool used in SL) for pressure ulcer risk assesment.
What is Bates Jensen wound assessment tool
Do we have a policy on falls that help guide our actions?
What is YES. We have a Falls Prevention and Risk Management polic, a Falls Prevention and Risk Management Algorithm and Post Falls Algorithm,
When are you allowed to move the resident following a fall?
What is once the nurse has done their full assessment and has deemed that the person is safe to be moved.
True or False. Wounds need to be careplanned.
What is TRUE. wounds need to be careplanned.