Fall Prevention, Positioning, Bathing/Bedmaking Flashcards
What is the leading cause of injury in elderly?
falls
Standard Fall Precautions
2 bed rails
anti-slip socks
call light w/in reach
water/kleenex/bed pan/personal belongings w/in reach
clear path
night light (when available)
bed in low position, wheels locked
What is the program used at BHS to assess fall risk?
SAFE
CPM Resource Center Fall Risk Assessment Tool
assessment of risk for falling in adults in the acute care inpatient setting
Score Interpretations for CPM (Fall Risk Assessment Tool)
score 4 or greater = at risk for falls, initiate Fall Risk guideline
Recommended Frequency of CPM (Fall Risk Assessment Tool)
complete on admission
re-evaluate every shift and after significant condition change
4 Point Value for CPM (Fall Risk Assessment Tool) (1)
history of fall (within 3 months)
3 Point Value for CPM (Fall Risk Assessment Tool) (3)
poly-pharmacy
CNS/Psychotic meds (ex: sedative/hypnotic, anti-depressant, anti-psychotic/neuroleptic, benzodiazapine)
Cardiovascular meds (ex: diuretic, anti-arrythmic, cardiac glycoside) because decreased heart rate = decreased blood pressure
2 Point Value for CPM (Fall Risk Assessment Tool) (7)
age greater than 65 years
altered elimination (ex: incontinence, urgency, frequency, nocturia, diarrhea)
cognitive deficit (impaired vision, hearing with affect on mobility)
dizziness/vertigo
depression (history of or current diagnosis)
mobility deficit/weakness (unsteady gait, requires assistance/supervision)
1 Point Value for CPM (Fall Assessment Tool (1)
male gender (riskier behaviors, more impulsive, stubborn)
High Risk Interventions for Falls
score greater than 4
gait belt
“safe” band on patient
signage on door
turn alarm on bed
alarm for seated patient
3 bed rails up
communication
How much weight can you lift, pull, or push without help?
35 lbs
Fowler’s
patient in a semi-upright position at an angle between 30 and 90 degress
Semi-Fowler’s
patient on back with a bed angle between 30 and 45 degrees
Orthopneic
“tripod”, upright, pillow on table, lean on pillow/table (allows lung expansion)
Dorsal Recumbent
lies on back with lower extremities moderately flexed and rotated outward
Lateral
side
Sims
lying on left side, left hip and lower extremity straight and right hip and knee bend
Prone
on stomach
Trendelenburg
head lower than feet, increase blood flow to brain
Complete Bed Bath
head to toe
Assist/Set Up (Self-Help)
can bathe, cannot gather supplies
Partial Bath
face, hands, axillae, perineal area, feet and back
most important areas cleaned
Assistive Devices/Safety for Patient Taking Bath
don’t leave alone
may slip
shower chair
call light in shower
shower bench
