ON ADMISSION:Fall risk assessment is usually done on admission. It is used to find out if patient has low ,moderate or high risk for fall.If patient do, the nurse will implement measures in place to prevent patient from falling and to minimize injury if patient fell.
ASSESSMENT AND REASSESSMENT:Patient is assessed and reassessed every shift for fall.
CHANGE IN CONDITION:Patient is reassessed when there is a change in patient conditions. For example your patient return from surgery and is no longer making sense you have to reassess change in patient condition. You( Registered nurse) gave the patient morphine sulfate 4mg IV as ordered and 20minutes later the patient asked why are the rats and elephants in my room?. And the rat are chasing the elephant, you know that the patient is now confused due to the morphine sulfate because there is no elephants or rats in patient room.This patient is at a high risk for fall due to change in condition. So this findings should be documented and monitored.
WHAT WILL YOU(REGISTERED NURSE ) DO?.
(1) Reorient patient and call bell/ call light within patient reach.
(2)Place a fall risk sign. Wear patient the yellow gown,yellow fall star on the patient door ,yellow armband on patient.
(3) Bed in low position for safety.
(4) Reorient, reorient and reorient.
(5) Leave the light on at night.
(6) Use arm chair when sitting patient up or sit patient up in bed. Sometimes for patient safety restraint might be an option. And doctor orders will be needed if indicated.
CATEGORIES FOR FALL RISK.
Score of less than 3 :Will be low risk.
Score of 3 to 6 :Moderate risk.
Score of 7 and higher will be high risk. For example you ask patient his name ,he looked at you and starting talking to himself. He is not making sense,his gaits are unsteady, you can smell alcohol in his breath.
(1)Hourly rounds is very important to minimize fall.During hourly round the nurse applies the 4 Ps(Pain, Position, Potty,Possession).
(2) Fall risk must be initiated on patient admission, assess while inpatient, every shift ,reassessed and assess during change in patient condition.
(3)Call light should be answered by the primary nurse and any person close to patient room promptly. Any staff can answer the call lights because the most important thing is prompt response.
(4) Education:Patient teaching, orientation and reorientation. Assessment and reassessment of patient.
(5) Documentation, documentation if it is not documented, then the assumption is that it is not done.