week 10: Falls & Assessment Flashcards
what is functional assessment? what 6 things do we measure?
measures a person’s ability in the areas of physical health
-Activities of Daily Living (ADLs) = ambulation, bathing, toileting, transfers, dressing, & eating
what tool do we use to assess Functional status and what do the results tell us?
-Katz’ Index
-0: patient is very dependent
-independent vs dependent
fall definitions: patient safety
the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery
fall definitions: adverse event
an injury caused by care delivered that delays discharge and/or results in disability
what are the intrinsic contributing factors for patient falls?
-history of a previous fall
-vision loss
-postural hypotension or syncope→dizziness
-conditions affecting gait and balance
-alterations in bladder function→urge continence, rushing, & falling
-cognitive impairment
-adverse medication reactions
-slowed reaction times
-deconditioning
what are the extrinsic contributing factors for patient falls? (outside of patient)
-environmental hazards
-inappropriate footwear→must be broad based shoes
-unfamiliar environment
-improper use of assistive devices
what tool can we used to assess fall risk?
-Hendrich II Model
what elements are used to assess for fall risk?
-confusion
-symptomatic depression
-altered elimination
-dizziness/vertigo
-gender (male)
-any administered antiepileptics (anticonvulsants)
-any administered benzodiazepines
-Get up and go test “rising front the chair”
Hendrich II Model Score meaning
A SCORE OF 5 OR HIGHER: HIGH RISK
fall prevention protocol
-fall risk ID bracelet
-fall risk sign on door and walls
-give info to the patient and family about fall risk
-nursing interventions: hourly rounds, low safety bed, fall risk gown, & call light
-safety equipment when moving pt
-remove excess furniture & equipment
-rubber soles on shoes & slippers
4 steps to take in response to a fall
-assessment
-notification & communication
-monitoring & reassessment
-documentation
response to fall: assessment, what do you do?
-ask: are you okay & does anything hurt?
-before moving a patient who has fallen, assess for injury
-focus assessment for injury for any positive S/Sx of injury (EX: external rotation & shortened leg)
-vital signs
what is fallophobia? what can it lead to?
the fear of falling after a fall & can lead to seclusion and depression
before moving a patient after a fall what should we base our movements on?
help them get up or use a lift in order to prevent a second fall or worsening an injury
Post Fall Assessment: SPLATT acronym
-Symptom experienced at time of fall, during fall, & after fall
-Previous number of falls or near falls that year
-Location of the fall (where did you fall)
-Activity engaged in at time of fall, how got help afterwards (what were you doing when you fell)
-Time (hour of the day) of the fall and length of time on ground
-Trauma or injury (physical, psychological) associated with fall
Give an example of how to assess each component of the acronym: SPLATT
S: “how were you feeling when you fell, during it and after?
P: “have you had any other falls within the last yea?”
L: “where did you fall?”
A: “what were you doing when you fell?”
T: “around what time did your fall occur at? How long were you on the floor after your fall?”
T: “did you experience any trauma or injury due to the fall? It can be either physical or psychological”
Who should we notify regarding the patient falling? Why?
-know facility policy & procedure
-physician or nurse practitioner (admitting/ordering provider)→always notify when pt fell
-family member
-risk manager or safety officer
-staff
why: to prevent further fall
what do we do after we move the patient after a fall? what kinds of assessments?
after a fall, we monitor and reassess the patient
-we do a neurological assessment (LOC, motor function, pupillary light reflex)
-vital signs
what are the important elements we need to document after a patient fall?
-know facility policy & procedure for documenting a fall
-assessment data
-notifications: who
-interventions: as a result
-evaluation
-incident report: internal document, do not chart it
fractured hip signs
external rotation & shortened leg
