Case 2 Fall Risk Assessment

Question 1

What are the cut off scores on the AM-PAC “6 clicks” for needing/not needing more than one visit

Answer 1

• Score <18.5 need more than one visit (more likely to go home)
• Score >18.5 don’t need more than one visit (more likely to go to rehab facility/need ongoing care)

Question 2

What scores on the AM-PAC provide good accuracy for predicting d/c destination

Answer 2

• Score ≤42.9 for basic mobility to d/c to post-acute rehab facility
• Score ≤39.4 for daily activity to d/c to post-acute rehab facility (often scored by OT)

Question 3

Nursing assessment for fall risk

Answer 3

• Morse fall scale
• Bedside Mobility Assessment Tool
• MOVES (move often, very early, & safely)
• BMAT

Question 4

What are the cut-off scores for fall risk for the Berg Balance Scale

Answer 4

• Hx of falls w/BBS score <51 = predictive of falls
• No Hx of falls w/BBS score <42 = predictive of falls
• BBS score <40 associated w/almost 100% fall risk
• Older adults in nursing home w/BBS score <47 = fall risk

Question 5

Evidence supported cut-off scores for BBS, TUG, and 5TSTS

Answer 5

• BBS: ≤50
• TUG: ≥12 sec
• 5TSTS: ≥12 sec

Question 6

What are the PADIS guidelines for the cardiovascular system to stop PT

Answer 6

• HR decreased below 60 or increase above 130
• Systolic BP decrease below 90or increase above 180
• MAP decrease below 60 or increase above 100

Question 7

What are the PADIS guidelines for the respiratory system to stop PT

Answer 7

• RR decrease below 5 or increase above 40
• SpO2 decrease below 88%
• Concerns regarding adequate securement of airways

Question 8

Describe the scoring for the RASS (Richmond Agitation Sedation Scale

Answer 8

• Combative +4: overtly violent, immediate danger to staff
• Very agitated +3: pulls on/removes tube(s), aggressive behavior towards staff
• Agitated +2: frequent non purposeful movement
• Restless +1: anxious or apprehensive but movements not aggressive or vigorous
• Alert & calm 0
• Drowsy -1: not fully alert but has sustained awakening (>10 secs)
• Light sedation -2: briefly awakens (<10 secs) with eye contact to voice
• Moderate sedation -3: Any movement but no eye contact to voice
• Deep sedation -4: No response to voice but any movement to physical stimulation
• Unarousable -5: no response to voice or physical stimulation

Question 9

What is the American academy of critical care nursing (AACN) 4 level mobility protocol

Answer 9

• Level 1: elevated supine
• Level 2: Seated EOB
• Level 3: Seated in chair
• Level 4: Walking