Adult fall risk prevention and management Nursing Education Program Online Test/every 2years Flashcards
Which of the following patient would automatically be highlighted as high risk for falls in the patient medical record:
Choose one answer.
a. Complete paralysis or completely immobilized
b. Pregnant patients above 34 weeks
c. Patient on seizure precautions protocol
d. Patient age 60 and above
c. Patient on seizure precautions protocol
Which of the following is the best action should the nurse do to ensure patient is referred to Rehabilitation (physiotherapy/occupational therapy) Services?
Choose one answer.
a Generate the referral in BESTCare HIS
b. Page the physiotherapist assigned to the unit
c. Inform the physician to refer the patient in BESTCare HIS using the fall risk consultation form
d. Physiotherapy referral is automated based on the risk calculation
Based on standard healthcare practices and the context of ensuring a patient is referred to Rehabilitation Services (physiotherapy/occupational therapy), the best action for a nurse to take from the provided options is:
c. Inform the physician to refer the patient in BESTCare HIS using the fall risk consultation form
Reasoning:
• Standard Workflow: In most hospital settings, including those using electronic health record systems like BESTCare HIS (a hypothetical or specific hospital information system), referrals to specialized services such as physiotherapy or occupational therapy typically require a physician’s order. Nurses often play a key role in identifying the need for a referral and escalating it to the physician, who then formalizes it in the system.
• Fall Risk Context: Since this question follows a discussion about fall risk (e.g., Johns Hopkins Fall Risk Assessment), the “fall risk consultation form” suggests a structured process tied to the patient’s risk assessment. Informing the physician ensures the referral aligns with clinical protocols and is properly documented in BESTCare HIS.
• Nurse’s Scope of Practice: Nurses typically do not have the authority to independently generate referrals to rehabilitation services in many systems; this is a physician-driven action. The nurse’s role is to advocate for the patient and coordinate with the physician.
Why Not the Other Options?
• a. Generate the referral in BESTCare HIS: While efficient, this assumes the nurse has the authority to directly initiate a referral, which is unlikely in most healthcare settings without physician approval. It bypasses the standard chain of command.
• b. Page the physiotherapist assigned to the unit: Paging the physiotherapist directly might expedite communication, but it doesn’t ensure a formal referral is documented in the system. Referrals typically require a physician’s order, not just a verbal request from a nurse.
• d. Physiotherapy referral is automated based on the risk calculation: While some systems might have automated triggers (e.g., based on a high JHFRAT score), this isn’t universally standard. The question implies an active step is needed, and automation isn’t confirmed as operational in this scenario.
Conclusion:
The best action is c, as it ensures the referral process is initiated correctly within the system (BESTCare HIS), leverages the physician’s authority, and ties into the fall risk assessment protocol, making it both practical and compliant with typical healthcare workflows.
A 72 year old male, on insulin and anti-Hypertensive medications, admitted into the surgical unit for Total knee replacement. He walked in unsteady using crutches with no rubl home 3 months ago sustaining minor bruises.
What information in fall risk assessment tool will trigger a referral to the pharmacist?
Choose one answer.
a. Age, fall 5 hours ago and hypertensive
b. Age, medications and fall 3 months ago
c. Age and IHD and total knee replacement
d. Age, total hip replacement and fall 3 months ago
Based on the scenario and the context of a fall risk assessment tool triggering a referral to a pharmacist, the correct answer is:
b. Age, medications, and fall 3 months ago
Scenario Recap:
• Patient: 72-year-old male.
• Medications: Insulin (for diabetes) and anti-hypertensive medications.
• Admission: Surgical unit for total knee replacement.
• History: Walked unsteadily with crutches, fell 3 months ago (minor bruises, no clear residual injury mentioned).
Fall Risk Assessment Tool Context:
Fall risk assessment tools, like the Johns Hopkins Fall Risk Assessment Tool (JHFRAT), evaluate multiple factors to calculate a patient’s risk of falling and may trigger referrals to multidisciplinary team members (e.g., pharmacists) when specific risks, such as medication-related issues, are identified. Pharmacist referrals are typically prompted when medications could contribute to fall risk (e.g., sedatives, antihypertensives, or hypoglycemic agents like insulin that may cause dizziness, hypotension, or hypoglycemia).
Analysis of Options:
• a. Age, fall 5 hours ago, and hypertensive:
◦ The scenario states the fall was 3 months ago, not 5 hours ago, so this is factually incorrect.
◦ Age (72) and hypertension (implied by anti-hypertensive meds) are relevant, but the incorrect fall timing disqualifies this option.
• b. Age, medications, and fall 3 months ago:
◦ Age (72): Advanced age is a risk factor for falls (JHFRAT often assigns points for age >70).
◦ Medications: Insulin and anti-hypertensive drugs are significant. Insulin can cause hypoglycemia (leading to weakness or confusion), and anti-hypertensives can cause orthostatic hypotension—both increase fall risk. These medications often trigger a pharmacist review to assess dosing, interactions, or side effects.
◦ Fall 3 months ago: A history of falls within the past 6 months typically adds points in tools like JHFRAT and indicates a pattern of instability, reinforcing the need for a medication review.
◦ Why this triggers a pharmacist referral: The combination of age-related vulnerability, a recent fall, and high-risk medications (insulin and anti-hypertensives) directly ties to potential pharmacological contributors to falls, warranting a pharmacist’s expertise.
• c. Age and IHD and total knee replacement:
◦ IHD (Ischemic Heart Disease): Not mentioned in the scenario, so this is irrelevant.
◦ Age and total knee replacement are factors, but they are more likely to trigger physiotherapy or surgical team involvement, not a pharmacist, unless medications are explicitly implicated.
• d. Age, total hip replacement, and fall 3 months ago:
◦ The scenario specifies total knee replacement, not hip replacement, making this factually incorrect.
◦ While age and fall history are relevant, the incorrect procedure disqualifies this option.
Conclusion:
b. Age, medications, and fall 3 months ago is the best answer. In a fall risk assessment tool, the patient’s age (72), use of insulin and anti-hypertensive medications (known fall risk contributors), and a fall within the past 3 months would collectively signal a need for a pharmacist to review the medication regimen for potential adjustments or monitoring to reduce fall risk.
Which of the following should be considered mandatory when assessing patients for fall?
Choose one answer.
a. Environmental assessment
b. Surgical history should be included in the assessment
c. Only patient with fall history should be assessed for fall.
d. All patients should be assessed for fall risk factors at admission.
Based on standard healthcare practices and fall prevention protocols, the most accurate answer for what should be considered mandatory when assessing patients for falls is:
d. All patients should be assessed for fall risk factors at admission
Reasoning:
Fall prevention is a critical safety priority in healthcare settings, and evidence-based guidelines (e.g., those from the Joint Commission, CDC, or tools like the Johns Hopkins Fall Risk Assessment Tool) emphasize a proactive, universal approach. Let’s evaluate each option:
• a. Environmental assessment:
◦ Assessing the environment (e.g., wet floors, clutter, poor lighting) is important for fall prevention and often part of a comprehensive strategy. However, it’s not mandatory for every patient’s initial fall risk assessment—it’s a secondary step after identifying individual risk. The patient’s intrinsic factors (e.g., mobility, medications) take precedence in the assessment process.
• b. Surgical history should be included in the assessment:
◦ Surgical history (e.g., recent total knee replacement) can be relevant, as it may affect mobility or recovery, contributing to fall risk. While useful, it’s not mandatory as a standalone requirement—it’s just one piece of a broader assessment. Not all patients with surgical history are at high risk, and not all at-risk patients have surgical history.
• c. Only patients with fall history should be assessed for fall:
◦ Limiting assessments to only those with a fall history is reactive, not preventive. Many patients without prior falls (e.g., due to age, medications, or acute illness) are still at risk. This approach contradicts best practices, which advocate for universal screening to catch risks early.
• d. All patients should be assessed for fall risk factors at admission:
◦ This is the gold standard in healthcare. Universal fall risk screening at admission ensures no patient is overlooked, regardless of history or condition. Tools like JHFRAT or Morse Fall Scale are designed for this purpose, evaluating factors such as age, mobility, medications, and cognition. For example, a 72-year-old on insulin and anti-hypertensives (from your prior scenario) would be assessed even without a recent fall, as would a paralyzed patient or a young patient with acute dizziness. This aligns with hospital accreditation standards and patient safety goals.
Conclusion:
d. All patients should be assessed for fall risk factors at admission is mandatory because it establishes a baseline risk profile for every patient, enabling tailored interventions. It’s a proactive, systematic approach endorsed by clinical guidelines, ensuring safety across diverse patient populations.
Which of the following are the accurate criteria for referral to Rehabilitation Department?
Choose one answer:
a. History of fall within 4 months before admission
b. Having visual or auditory impairment
C. Age above 60 years excluding completely paralyzed or immobilized patient
d. Age above 60 years including completely paralyzed or immobilized patient
a. History of fall within 4 months before admission
Tho Pharmacist department should review patient’s medication for adult patients
Choose one answer
a. within 4 hours of receiving the referral
b. within 12 hours of receiving the referral
c. Within 24 hours of receiving the referral d, within 36 hours of receiving the referral
Based on typical hospital protocols and best practices for patient safety, particularly in the context of medication reviews related to fall risk or other urgent clinical needs, the most appropriate answer is:
c. Within 24 hours of receiving the referral
Reasoning:
• Standard Practice: In most healthcare settings, medication reviews by pharmacists for adult inpatients are prioritized based on urgency. For non-emergent but important referrals (e.g., fall risk due to medications like insulin or antihypertensives), a 24-hour timeframe is a common standard. This allows pharmacists to address potential risks promptly while fitting into workflow realities.
• Patient Safety: The Joint Commission and other regulatory bodies emphasize timely medication reconciliation and review to prevent adverse events like falls. A 24-hour window balances urgency with feasibility, ensuring the patient’s regimen is assessed before significant harm (e.g., a fall due to hypoglycemia or hypotension) occurs.
• Context from Prior Questions: The scenarios (e.g., diabetic/hypertensive patients) suggest chronic conditions with medication-related fall risks. These aren’t immediate emergencies (like a code blue) but still require timely intervention. A 24-hour review aligns with this level of urgency.
Why Not the Other Options?
• a. Within 4 hours: This is more typical for emergent cases (e.g., acute overdose, critical medication errors), not routine referrals for fall risk. It’s overly aggressive for most adult inpatient scenarios unless specified as stat.
• b. Within 12 hours: While faster than 24 hours, this isn’t a universal standard for non-urgent pharmacist reviews. It might apply in high-acuity settings (e.g., ICU), but the question specifies “adult patients” generally, not a specific critical context.
• d. Within 36 hours: This is too delayed for fall risk-related reviews, where medications (e.g., insulin causing hypoglycemia) could lead to harm within a shorter timeframe. It risks patient safety by not addressing potential issues promptly.
Conclusion:
c. Within 24 hours of receiving the referral is the most accurate and widely accepted standard for pharmacists to review medications for adult patients in a hospital setting, ensuring timely intervention while remaining practical for workflow. This aligns with guidelines like those from the American Society of Health-System Pharmacists (ASHP) and hospital accreditation standards.
Which of the following is the purpose of using the fall risk sign?
Choose one answer.
a. To recognize post-fall patients
b. To identify patient’s date of admission
c. To identify patients who had history of fall
d. To make staff aware for those patients at higher risk for falls.
Based on standard healthcare practices and the context of fall prevention protocols, the most accurate answer for the purpose of using a fall risk sign is:
d. To make staff aware for those patients at higher risk for falls
Reasoning:
• Purpose of Fall Risk Signs: In hospitals, fall risk signs (e.g., yellow wristbands, door markers, or bed signs) are part of a visual cue system to alert all staff—nurses, doctors, aides, etc.—to patients identified as having an elevated risk of falling. This prompts staff to implement preventive measures (e.g., closer monitoring, assistance with mobility) as outlined in tools like the Johns Hopkins Fall Risk Assessment Tool (JHFRAT).
• Patient Safety Focus: The primary goal is proactive prevention, not just documentation or historical tracking. By signaling high-risk patients (e.g., those with gait instability, medications, or age-related factors from your prior scenarios), the sign ensures staff take immediate, appropriate action.
Why Not the Other Options?
• a. To recognize post-fall patients:
◦ This suggests the sign is used only after a fall occurs, which is reactive rather than preventive. While post-fall care is important, fall risk signs aim to prevent falls, not just mark patients who’ve already fallen.
• b. To identify patient’s date of admission:
◦ The date of admission is unrelated to fall risk and is tracked elsewhere (e.g., medical records or wristbands with other info). Fall risk signs focus on a specific safety concern, not administrative details.
• c. To identify patients who had history of fall:
◦ While a fall history (e.g., within 3–6 months) contributes to risk scoring, the sign’s purpose isn’t limited to historical falls. It flags all at-risk patients, including those without prior falls but with current risks (e.g., visual impairment, medications), making this too narrow.
Conclusion:
d. To make staff aware for those patients at higher risk for falls is the correct answer. The fall risk sign serves as a real-time, actionable alert to enhance staff vigilance and reduce fall incidents, aligning with hospital safety protocols and the broader context of your fall risk-related questions.
45 years old patient admitted to medical ward a case of uncontrolled DM, complete paralysis due to post motor vehicle accident 4years ago, has HTN on amlodip Based on John Hopkins fall risk assessment tool, what is the probability of patient’s fall risk?
Choose one answer.
a. High fall risk because of complete paralysis
b. High fall risk because on amlodipine tablet
c. Low fall risk because of complete paralysis
d. Moderate fall because the John Hopkins fall risk score is 13
c. Low fall risk because of complete paralysis
A 39 year old G2P1 GA 38wks that recently admitled to antenatal ward as a case of hypertension and dehydration.
What is the time frame to complete the initial fall risk assessment?
Choose one answer
a Sometime before discharge
b. 2 hours after admission to care unit
c. Within 4 hours from admission to care unit
d: Within 24 hours after admission to care unit
Based on standard hospital protocols and best practices for patient safety, particularly in the context of fall risk management, the most accurate answer for the time frame to complete the initial fall risk assessment is:
c. Within 4 hours from admission to care unit
Scenario Recap:
• Patient: 39-year-old female, G2P1 (gravida 2, para 1), gestational age 38 weeks.
• Admission: Antenatal ward for hypertension and dehydration.
Reasoning:
• Standard Practice: Fall risk assessments, such as the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) or similar tools, are typically required to be completed shortly after admission to identify risks early and implement preventive measures. This is especially critical in units like antenatal wards, where patients may have acute conditions (e.g., hypertension, dehydration) affecting stability.
• Patient Safety Guidelines: Organizations like the Joint Commission and hospital accreditation standards mandate timely initial assessments upon admission. For fall risk, this is often specified as within a few hours—commonly 4 hours—to ensure risks like dizziness (from dehydration) or medication effects (e.g., antihypertensives) are addressed promptly.
• Pregnancy Context: At 38 weeks, the patient is near term, and pregnancy-related changes (e.g., shifted center of gravity, possible edema from hypertension) plus dehydration (causing weakness or dizziness) elevate fall risk. A rapid assessment is critical to protect both mother and fetus.
Option Analysis:
• a. Sometime before discharge:
◦ Incorrect. Waiting until discharge defeats the purpose of fall prevention, as the risk needs to be identified and managed during the hospital stay. This is too vague and delayed.
• b. 2 hours after admission to care unit:
◦ While prompt, 2 hours isn’t a standard timeframe in most protocols. It’s slightly faster than typical, and while feasible, it’s not as commonly cited as 4 hours unless the situation is emergent (which this isn’t explicitly).
• c. Within 4 hours from admission to care unit:
◦ Correct. This aligns with many hospital policies and evidence-based guidelines (e.g., within 4–6 hours is common for initial nursing assessments, including fall risk). It allows time for triage and stabilization while ensuring risks are flagged early.
• d. Within 24 hours after admission to care unit:
◦ Too long. A 24-hour delay risks missing early interventions, especially for a pregnant patient with hypertension and dehydration who might deteriorate or require mobility assistance sooner. Most standards aim for much earlier assessment.
Conclusion:
c. Within 4 hours from admission to care unit is the most appropriate timeframe. It reflects a balance between practicality (allowing initial stabilization) and urgency (addressing fall risk promptly), consistent with typical hospital workflows and safety protocols for an antenatal patient with conditions like hypertension and dehydration.
A 46 years old hypogtycemic patient admitted in medical unit. Upon assessment, it was discovered that he had blurry vision and moderate dizziness. The patient had a h As per John Hopkins tool, what fall risk factor is related to this patient?
Choose one answer
a Patent on insulin injection
b. Age more than 40 years old
c. History of fall 4 months before admission
d. Visual or auditory impairment affecting mobility
Based on the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) and the details provided in the scenario, the most relevant fall risk factor for this patient is:
d. Visual or auditory impairment affecting mobility
Scenario Recap:
• Patient: 46-year-old, hypoglycemic, admitted to the medical unit.
• Assessment Findings: Blurry vision, moderate dizziness.
• Additional Note: The sentence cuts off at “The patient had a h” (likely incomplete, possibly intended to say “history” or something else, but no clear fall history is confirmed).
JHFRAT Overview:
The JHFRAT assigns points for fall risk based on factors like age, fall history, medications, mobility, sensory impairments, cognition, and equipment. Let’s evaluate the patient’s risk factors and the options:
Risk Factor Analysis:
1 Age: 46 years
◦ JHFRAT typically assigns points for age >60 or >70 (depending on the version). At 46, no points are scored for age alone.
2 Medications: Hypoglycemic (likely on insulin or oral hypoglycemics, though not specified).
◦ High-risk medications (e.g., insulin) score 2 points due to potential hypoglycemia causing weakness, confusion, or dizziness. This fits the scenario but isn’t explicitly confirmed.
3 Mobility: Moderate dizziness.
◦ Dizziness impairs balance and mobility, scoring points (e.g., 3–5 points depending on severity, typically 3 for “unsteady gait” or “requires assistance”). This is a key risk factor here.
4 Sensory Impairment: Blurry vision.
◦ Visual impairment (e.g., blurry vision) is scored under JHFRAT’s sensory category, often 2–3 points if it affects mobility. Combined with dizziness, this directly impacts the patient’s ability to navigate safely.
5 Fall History: Incomplete info (“had a h”).
◦ If intended to mean a fall 4 months ago (as option c suggests), it would add 3 points (history within 6 months). However, the scenario doesn’t confirm this, so it’s speculative.
6 Cognition/Elimination/Equipment: No info provided.
◦ 0 points assumed.
Estimated Score (Partial):
• Medications (assumed insulin): 2 points
• Mobility (dizziness): 3 points
• Visual impairment: 2 points
• Total: ~7 points (moderate risk, 6–13 range), but the focus is on the specific risk factor.
Option Analysis:
• a. Patient on insulin injection:
◦ Likely true (hypoglycemic suggests insulin or similar), contributing 2 points for high-risk meds. Dizziness could be hypoglycemia-related, but the scenario emphasizes blurry vision and dizziness as findings, not the medication itself as the risk factor.
• b. Age more than 40 years old:
◦ Incorrect. JHFRAT doesn’t score age at 40+; it’s typically 60+ or 70+. At 46, age isn’t a risk factor here.
• c. History of fall 4 months before admission:
◦ Possible if “had a h” meant fall history, scoring 3 points. However, the scenario doesn’t confirm this, making it less directly supported than the explicit findings of blurry vision and dizziness.
• d. Visual or auditory impairment affecting mobility:
◦ Correct. Blurry vision (visual impairment) and moderate dizziness (affecting mobility) are explicitly stated. JHFRAT scores sensory deficits like vision loss (e.g., 2 points) when they impair safe movement, and dizziness amplifies this. This matches the assessment findings most closely.
Conclusion:
d. Visual or auditory impairment affecting mobility is the fall risk factor most directly related to this patient per JHFRAT. The blurry vision and dizziness are highlighted in the assessment, making them the clearest contributors to fall risk, aligning with the tool’s sensory and mobility domains. While insulin (option a) may contribute, the focus on symptoms over medication specifics points to d as the best answer.
A nurse received a post normal delivery patient with a 2nd degree perinea tear and epidural
What is the most appropriate fall-prevention education will the nurse give to this patient?
Choose one answer
a. Mobilize as soon as possible, it will increase sensation in the legs
b. Strict bed rest for 2 days to facilitate healing
c. Do not go to the bathroom alone, call the nurse
d. Let another patient assist her to the bathroom
Based on the scenario and standard fall prevention practices in a postpartum setting, the most appropriate fall-prevention education for the nurse to give this patient is:
c. Do not go to the bathroom alone, call the nurse
Scenario Recap:
• Patient: Post normal delivery with a 2nd degree perineal tear and epidural.
• Context: The nurse is providing fall-prevention education.
Reasoning:
• Epidural Effects: An epidural (regional anesthesia) can cause temporary numbness, weakness, or reduced sensation in the lower body, increasing fall risk during early mobilization. Even after delivery, residual effects may persist for hours, depending on the dose and timing of discontinuation.
• 2nd Degree Perineal Tear: This involves muscle damage (perineal muscles, not the anal sphincter), causing pain and discomfort that can affect mobility and stability. Healing doesn’t require strict bed rest but does warrant caution.
• Fall Prevention: Postpartum patients are at risk for falls due to anesthesia, blood loss, fatigue, and physical changes. Education should focus on safe mobility and leveraging staff support.
Option Analysis:
• a. Mobilize as soon as possible, it will increase sensation in the legs:
◦ Incorrect. While early mobilization is encouraged postpartum to prevent complications (e.g., blood clots), doing so “as soon as possible” ignores the epidural’s lingering effects. Mobilizing too soon without assistance risks a fall, and sensation returns naturally over time, not through forced movement.
• b. Strict bed rest for 2 days to facilitate healing:
◦ Incorrect. Strict bed rest isn’t indicated for a 2nd degree tear or post-epidural unless complications (e.g., hemorrhage) arise. It contradicts postpartum care guidelines promoting gradual activity. It also doesn’t address fall prevention during necessary movement.
• c. Do not go to the bathroom alone, call the nurse:
◦ Correct. This is practical and aligns with fall prevention protocols. The bathroom is a high-risk area for falls (wet floors, standing from sitting). With epidural effects and perineal pain, the patient needs assistance to ambulate safely. Calling the nurse ensures supervised mobility, reducing risk while supporting recovery.
• d. Let another patient assist her to the bathroom:
◦ Incorrect. Another patient isn’t trained or reliable for assistance and may also be compromised postpartum. This violates safety standards—staff (e.g., nurses or aides) should assist, not peers.
Conclusion:
c. Do not go to the bathroom alone, call the nurse is the most appropriate fall-prevention education. It directly addresses the patient’s immediate risks (epidural-related weakness, tear-related discomfort) by ensuring supervised mobility, aligning with hospital safety practices and tools like JHFRAT that emphasize assistance for at-risk patients.
A nurse assigned to an 81 years old patient with a history of un-observed fall eight (8) hours ago due to wet floor. She understood that her patient can be referred to rehabilitation depa
intervention.
Which of the following are the accurate criteria for referral to Rehabilitation Department?
Choose one answer.
a. History of fall within 4 months before admission
b. Having visual or auditory impairment
c. Age above 60 years excluding completely paralyzed or immobilized patient
d. Age above 60 years including completely paralyzed onimmobilized patient
a. History of fall within 4 months before admission
A nurse received a patient who has sutured wound and complaining of muscle strain resulted from fall.
Which of the followings reflects type of patient’s fall injury?
Choose one answer.
a. None
b. Minor Injury
c. Major Injury
d. Moderate Injury
Key Points
• It seems likely that the patient’s fall injury is classified as moderate, given the sutured wound and muscle strain.
• Research suggests that a sutured wound typically indicates a moderate injury, requiring medical treatment beyond first aid.
• The muscle strain, while possibly minor, doesn’t change the classification when combined with a moderate injury.
Direct Answer
Injury Classification
The patient’s fall injury, with a sutured wound and muscle strain, is likely classified as moderate. This is because a sutured wound generally requires medical intervention beyond first aid, fitting the definition of a moderate injury in hospital settings. Muscle strain, depending on severity, is often minor, but the presence of a sutured wound elevates the overall classification.
Supporting Details
• Fall injuries are categorized as none, minor, moderate, or major based on severity and treatment needs. Minor injuries include abrasions or sprains without functional impairment, while moderate injuries involve lacerations needing sutures or strains with functional issues.
• A sutured wound suggests a laceration that needed stitches, which is commonly considered moderate, as seen in guidelines like those from the Agency for Healthcare Research and Quality (AHRQ Toolkit).
• Muscle strain, described as “complaining of,” likely indicates mild pain without significant functional loss, aligning with minor injury, but doesn’t downgrade the overall fall to minor given the sutured wound.
Unexpected Detail
It’s interesting to note that some institutions might classify a small sutured wound as minor, but standard hospital policies, especially for fall reporting, lean toward moderate for any wound requiring closure, highlighting the importance of consistent definitions across settings.
Survey Note: Detailed Analysis of Fall Injury Classification
This section provides a comprehensive analysis of the patient’s fall injury classification, expanding on the direct answer with detailed reasoning and supporting evidence. The patient, received by a nurse, has a sutured wound and is complaining of muscle strain resulting from a fall, and we aim to determine the type of fall injury from the options: none, minor injury, major injury, or moderate injury.
Patient Profile and Injury Description
The patient presents with two specific injuries from the fall:
• A sutured wound, indicating a laceration that required closure with sutures, suggesting medical intervention beyond first aid.
• Muscle strain, with the patient complaining of pain, but no further details on severity (e.g., functional impairment) are provided.
These injuries must be evaluated against standard classifications used in healthcare settings, particularly for fall-related incidents, to determine the appropriate category.
Classification Frameworks and Definitions
Fall injuries are typically categorized into four levels: none, minor, moderate, and major, based on the extent of injury and required treatment. Various sources, including hospital policies and national guidelines, provide definitions, with some variation. Below is a synthesis based on common standards:
Category
Definition
None
No apparent injury from the fall, patient reports fall but no harm.
Minor Injury
Injuries not requiring medical treatment beyond first aid, e.g., abrasions, minor lacerations not needing closure, contusions, sprains/strains without functional impairment.
Moderate Injury
Injuries requiring medical treatment beyond first aid but not life-threatening, e.g., lacerations requiring closure, sprains/strains with functional impairment, minor fractures, minor head injuries without altered mental status.
Major Injury
Life-threatening or significant harm, e.g., fractures (except minor), joint dislocations, head injuries with altered mental status, internal bleeding.
Sources like the Agency for Healthcare Research and Quality (AHRQ Toolkit) and the National Database of Nursing Quality Indicators (NDNQI) align with these categories, though specific thresholds may vary by institution.
Analysis of Patient’s Injuries
1 Sutured Wound:
◦ A wound requiring sutures indicates a laceration that needed closure, which is beyond first aid (e.g., bandaging). Multiple sources, including nursing textbooks and hospital policies, classify lacerations requiring closure as moderate injuries. For instance, the AHRQ toolkit lists such injuries under moderate, as they require medical intervention by a physician or advanced practitioner.
◦ This aligns with the understanding that any injury necessitating sutures is typically moderate, reflecting a level of severity that requires more than basic care.
2 Muscle Strain:
◦ Muscle strains are graded from 1 to 3:
▪ Grade 1: Mild, with minimal pain and no loss of function (minor injury).
▪ Grade 2: Moderate, with pain and some loss of function (could be moderate).
▪ Grade 3: Severe, with significant pain and loss of function (major injury).
◦ The scenario states the patient is “complaining of muscle strain,” without specifying severity. In the absence of details like functional impairment, it’s reasonable to assume a mild strain (Grade 1), which would be classified as a minor injury. However, in fall injury reporting, the overall classification often hinges on the most severe injury.
Determining the Fall Injury Type
In fall injury classification, the event is typically categorized based on the most severe injury resulting from the fall. Given:
• The sutured wound is classified as moderate (laceration requiring closure).
• The muscle strain is likely minor (mild pain, no specified functional loss).
The overall fall injury is determined by the more severe injury, which is the sutured wound, leading to a classification of moderate injury. This is consistent with standard practice, where the presence of a moderate injury (e.g., sutured wound) overrides minor injuries (e.g., muscle strain) for reporting purposes.
Consideration of Alternative Interpretations
Some institutions might define minor injuries to include lacerations requiring closure, especially if small, but this is less common in hospital fall reporting. For example, a study on fall injury classification (Fall Injury Study) notes that lacerations needing sutures are typically moderate, supporting our conclusion. Additionally, the muscle strain, while potentially moderate if severe, is described in a way that suggests it’s not the primary concern, reinforcing the moderate classification based on the wound.
Conclusion
The patient’s fall injury, with a sutured wound and muscle strain, is best classified as moderate injury. This reflects the standard categorization where a laceration requiring sutures is considered moderate, and the muscle strain, likely minor, does not downgrade the overall assessment. This aligns with guidelines from sources like AHRQ and NDNQI, ensuring consistency in patient safety reporting.
Key Citations
• AHRQ Toolkit for Preventing Falls in Hospitals
• Fall Injury Study Classification Standards
A nursing intern is being orientated to the adult fall risk assessment tool. She asks her preceptor for information about the medication category in the tool Which of the following is the incorrect response by the preceptor?
Choose one answer.
a “The BESTCare HIS automatically detects if there was a sedated procedure within past 24 hours*.
b. “Patients on 2 or more high fall risk medications are at higher risk for falls”
c “Medications that increase the risk of falls include opiates, anticonvulsants, anthypertensives, diuretics, hyponotics, laxatives, sedatives, and p
d. “Sedated procedures within the last 24 hours have the highest number of points in the medication category
a “The BESTCare HIS automatically detects if there was a sedated procedure within past 24 hours*.
To prevent patients fall in hospital, patient safety environmental intervention will be performed and documented in BestCare HIS by the nurse:
Choose one answer
a. On admission only
b. Every 4 hours
c. Within 4 hours of each shift
d. Every 24 hours
c. Within 4 hours of each shift
“The fall resulted in pain and bruise, needs cleaning of a wound, application of dressing, limb elevation, and application of topical medication* Which of the followings reflects the correct answer for the fall injury in the statement?
Choose one answer
a. None
b. Major injury
c. Minor Injury
d. Moderate Injury
c. Minor Injury
An Interdisciplinary Plan of Care (IPC), reflecting risk specific interventions, will be initiated for all patients admitted to an inpatient area within:
Choose one answer.
a. 12 hours
b. 6 hours
C. 8 hours
d. 24 hours
b. 6 hours
The nurse discharging patient who is classified as moderate or high fall risk, what education he might need to know about it?
Choose one answer.
a. How to use crutches at home
b. No need as family are around
c. Homewealth care will educate him
d. Home safety and minimizing risk of fall related injury post discharge
d. Home safety and minimizing risk of fall related injury post discharge
A 70 years old diabetic and hypertensive patient admitted as a case of pneumonia, short of breath, fever, Cataract with visual impairment and history of fall at home 4 m no elimination issues. As ordered, patient starts: Oxygen 3L/M nasal cannula, IV 0.9% NACL 1000ml at a rate 80ml/hr, IV antibiotics, oral Fosinopril and Dyazide.
Based on John Hopkin fall risk assessment tool, what is the fall risk of the patient?
Choose one answer.
a. High fall risk because the total fall risk score is >13
b. Low fall risk because the total fall risk score is 6
c. Moderate fall because the risk the total fall risk score is 13
d. High fail risk because the patient has history of fall regardless the scoring
a. High fall risk because the total fall risk score is >13
Which of the following should be considered mandatory when assessing patients for fall?
Choose one answer.
a. Environmental assessment
b. Surgical history should be included in the assessment.
c. Only patient with fall history should be assessed for fall.
d. All patients should be assessed for fall risk factors at admission.
d. All patients should be assessed for fall risk factors at admission
A 41 year old diabetic and hypertensive patient admitted to Labor and Delivery unit for Induction Of Labor. She has had issues of gait stability and she has a history of wears glasses but not had any check in years.
What are the risk factors for falls for this patient?
Choose one answer.
a. High risk for fall medication
b. Mobility and Misual impairment
c. Impairment in cognation status
d. History of fall within the last 3 months
b. Mobility and Misual impairment
The nurse is documenting the fall occurrence, management and interventions in the patient’s electronic clinical record in the BEST Care HIS
Which of the following data should the nurse includes in her documentation?
Choose one answer
•
a. Code status
b. Nurse present, mother name
c. How the patient fell, type of fall, whether the fall was observed or assisted, post fall treatment, level of injury
d. Narrative factual description of how the patient fell
c. How the patient fell, type of fall, whether the fall was observed or assisted, post fall treatment, level of injury
A Nurse was audited by the Quality team and asked about the different types of fall. She answered all correctly she forgets the anticipated physiological fall.
What would be the best answer from the Nurse about anticipated physiological fall?
Choose one answer.
a. Caused by inadequate lighting or wet floor
b. Occur suddenly while a patient having seizure
c. Caused by intrinsic factors such as postural hypotension, impaired gait
d. Refers to a staff attempt topinimize the impact of fall
c. Caused by intrinsic factors such as postural hypotension, impaired gait
Patients who are non-compliant with fall prevention interventions should be referred to:
Choose one answer.
a Social services arla Patient experience
b. Immediate supervisor and Patient experience
c. Immediate supervisor and social services
d. Immediate supervisor and Safety and Security
b. Immediate supervisor and Patient experience
Patient and family education must include: (Choose all that apply)
a. Fall risk status
b. fall prevention interventions
c. Consequences/injury risks from falls
d. The need to call for assistance when mobilizing the patient.
All of the above
