Show:
Post Fall Huddle
Fall Risk
Interventions
Assessment
Fall Prevention
100
A period of debriefing that should always include the patient to determine causes of a fall, and to identify ways to prevent fall reoccurrence.
What is purpose of Post-Fall Huddle?
100
Asked on admission, and should include information about the circumstances, history and any injuries the patient was treated for.
What is determining fall risk history?
100
Placed under the bed sheet at the edge of the bed to prevent patient from rolling out of bed; commonly used for increased sedation.
What is a noodle?
100
Potty, Pain, and Position
What are the Three P's?
100
These are supplied on admission and should be worn whenever out of bed.
What is non-skid footwear or socks?
200
Occurs immediately following a fall or within one hour of the fall, no later than shift change.
When should Post Fall Huddle occur?
200
Anti-Psychotics Benzodiazepines Opioid Agonists Beta-Blockers Anti-epileptics
What are medications that increase the risk of falls?
200
Orientation to unit and surroundings, patient education, non-slip footwear, lighting, cleanliness without clutter, bathroom assistance, patient monitoring, medication evaluation
What are level one interventions?
200
Completed and documented by the RN when a patient falls and hits their head or when a fall is un-witnessed.
What are Post Fall Neuro Checks?
200
Orientation to surroundings When to notify staff for assistance Medication side effects notification How to get out of bed/chair
What are critical elements of patient teaching to prevent falls?
300
The RN, house supervisor, assistant manager, PC's, the person who witnessed the fall and any other staff on the unit at the time.
Who Participates in the post fall huddle?
300
Patients experiencing this are high fall risk on admission, and remain a high fall risk due to narcotic replacement medications.
What are patients experiencing detoxification?
300
Ambulation assistance, patient observation, arm band, falling star, assistive devices.
What are level 2 interventions?
300
An individual unintentionally coming to rest on the floor or other surface lower than the patient; including patients who are found on the floor or intentionally eased to the floor by staff members.
What is a fall?
300
Most often given to patients who have used this at home, require education with return demonstration, and must have a MD order.
What is a patient wheelchair?
400
SBAR, the format of the post fall huddle
What is Situation, Background, Assessment, and Recommendations?
400
Confusion Agitation Hallucinations Tremors Stupor Seizures
What are symptoms of delirium tremens (DTs)?
400
This occurs when a patient has been determined as a high risk for falls at night due to non-compliance with calling for assistance or disorientation. This does not require an MD order and can be initiated by the Nurse or PC.
What is increased level of observation?
400
1. Assist patient to lie down flat for 5 minutes 2. Obtain BP and Pulse while in lying position 3. Slowly assist the patient to standing position 4. Have them stand for 3 minutes 5. Obtain BP and Pulse while in standing position
What are Orthostatic Blood Pressures?
400
Two of the highest risk patients for fall, and need special care by staff.
What are COs and 1:1 patients?
500
After the nurse has assessed the patient post fall, the fall is documented in the medical record under post fall event, any notations for injury, Updates to the patients care plan and an SIR
What is required documentation in addition to the post fall huddle form?
500
Patients at risk have yellow arm band, falling star located on the patients chart and patients doorway.
How are high fall risk patients identified?
500
Assess PERRLA, muscle strength/tone, LOC, speech, gait, vomiting, pain, tingling, numbness and obtain vitals.
What are Neuro Checks?
500
Walking with blankets wrapped around them, sleeping in chairs, post blood draws, unsteady gait, pushing/pulling furniture, change in medications, first dose anti-psychotics, not educated to assistive devices, and non-structured activities.
What are high fall risks?
500
1. Can identify high risk patients when done on admission Done after a fall 2. Involves monitoring a patient in various positions 3. A drop in Blood Pressure of ≥20 mm Hg, or in Diastolic Blood Pressure of ≥10 mm Hg
What are orthostatic vital signs?