跌倒所有的高危因素
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Agitation/Delirium- infection, toxic/metabolic, cardiopulmonary change, CNS, dehydration/ blood loss, sleep disturbance
Meds (dose/timing)-psychotropics, CV agents (digoxin especially), anticoagulants(increased risk of injury), anticholinergic, bowel prep Orthostatic hypotension, autonomic failure Frequent toileting Impaired mobility
Impaired vision, inappropriate use of assistive device/footwear
History of Falls (CV/light headed-dizzy, Dysequilibrium- loss of balance with no abnormal motion sensation, Vestibular/Vertigo, Weakness-Musculoskeletal/give way, combination, other)
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Psychotropics, digoxin, type 1a antiarrhythmic, diuretic (thiazides>loop diuretics) Antihistamines/benzodiazipines- withdrawal has shown decrease in falls risk, assess for sleep disorder, avoid routine PRN orders-try non-pharmacological approaches including quiet sleep protocols on units
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Antidepressants- Tricyclics higher risk than SSRI, but SSRI's have risk as well, high level of phenytoin; low dos amitriptyline affects gate; gabapentin 10-25% ADR Cardiac drugs/antihypertensives- if orthostatic (drop in sys>20 mm in 3 min) and symptom atic
Anticoagulants - subdural hematomas are rare; avoid only if very unstable gait or balance, concurrent use of alcohol, or other drugs that interact and increase bleeding, or non-compliant with regimen or lab follow up
∙ Drugs treating nocturia (consider tamsulosin due to lower risk of orthostasis)
Nursing fall risk assessment, diagnoses and interventions are based on use of the Morse Fall Scale (MFS) (Morse, 1997). The MFS is used widely in acute care settings, both in hospital and long term care inpatient settings. The MFS requires systematic, reliable assessment of a patient's fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. MFS subscales include assessment of:
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Hazardous activities Time of day External lighting Clutter Spoils
Loose electrical cords
Intrinsic Factors:
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Muscle and strength weakness Gait and balance disorders Visual disturbances
Cognitive impairment/Mental status alterations Dizziness/Vertigo Postural hypotension Incontinence Polypharmacy Age
∙ Chronic disease
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Assess patient's fall risk upon admission, change in status, transfer to another unit and discharge.
Assign the patient to a bed that enables the patient to exit toward his/her stronger side whenever possible.
Assess the patient's coordination and balance before assisting with transfer and mobility activities.
Implement bowel and bladder programs to decrease urgency and incontinence. Use treaded socks for all patients.
All Staff:
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Approach patient towards unaffected side to maximize participation in care. Transfer patient towards stronger side.
Education:
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Actively engage patient and family in all aspects of Fall Prevention Program. Instruct patient in all activities prior to initiating assistive devices. Teach patient use of grab bars.
∙ Instruct patient in medication time/dose, side effects, and interactions with food/medications.
Equipment:
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Lock all moveable equipment before transferring patients. Individualize equipment specific to patient needs.
Environment:
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Place patient care articles within reach.
Provide physically safe environment (eliminate spills, clutter, electrical cords, and unnecessary equipment). Provide adequate lighting.
Medical Staff:
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Evaluate and treat gait changes, postural instability, spasticity. Initiate treatment for impaired vision, hearing. Evaluate medication profile for fall risk. Evaluate and treat pain.
Evaluate and treat orthostatic hypotension.
Assess and treat impaired central processing (dementia, delirium, stroke, perception)
∙ Consider use of: technology for fall prevention. (See section), non-skid floor mat, raised edge mattress.
Environment:
∙ Clear patient environment of all hazards
Medical Staff:
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Review medications for fall risk and adjust as indicated
CV agents - if orthostatic (drop in systolic > 20 mm in 3 minutes) and symptomatic
o Discontinue HCTZ, liberalize sodium in diet
o If ACE inhibitor appropriate, use agent with less renal metabolism (fosinopril) o If Calcium channel blocker - NOT nifedipine
o If ß blocker - not cardioselective / not metoprolol / atenolol; use pindolol /
propranolol
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Consider referral to services such as physical medicine and rehabilitation, audiology, ophthalmology, cardiology.
Optimize treatm
ent of underlying medical conditions. Evaluate and treat for pain.
Evaluate circumstances surrounding fall for extrinsic and intrinsic contributing factors.
Education:
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Exercise Nutrition Home safety
Plan for emergency fall notification procedure.
1. Assess for injuries (e.g. abrasion, contusion, laceration, fracture, head injury) and
determine Level of Injury (0, 1, 2, 3). (See ) 2. Obtain and record sitting/standing vital signs. 3. Assess for change in range of motion. 4. Alert Physician.
5. Follow organizational policies for patient monitoring. 6. Document circumstances in medical record. 7. Complete incident report.
8. Assess intrinsic and extrinsic factors. 9. Notify all team members of patient fall.
10. Consider technology to prevent repeat fall (see ). Medical
1. Assess and treat any injury.
2. Initiate diagnostic and treatment interventions for contributing causes.
3. Determine probable cause of fall (history, physical factors, medications, laboratory
values).
4. Consult appropriate services. 5.
Evaluate and treat for pain.
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Increased knowledge about falls
Increased strength, balance, and mobility
Increased ability to compensate for sensory, balance loss
Increased functional independence with use of exercises and assistive/adaptive devices
Increased confidence in abilities Reduced severity of fall-related injuries Proper hydration Proper nutrition
Program Outcomes
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Interdisciplinary approach to fall prevention and management Increased availability of experts in fall prevention and management Systematic program deployment and evaluation
∙ Document circumstances in patient medical record.
o Patient appearance at time of discovery o Patient response to event o Evidence of injury o Location
o Medical provider notification o Medical/nursing actions
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Complete incident report
Notify Nurse Manager or designee
Definitions
Fall
Loss of upright position that results in landing on the floor, ground or an object or furniture or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or
stair.
Fall Response Team
Fall Response Teams are comprised of interdisciplinary team members that are activated following a fall to evaluate circumstances surrounding a fall with the goal of reducing risk factors and preventing a repeat fall. This team examines the environment, equipment, fall program elements, and resources including staffing, surveillance, communications, and knowledge of risk factors that may have
contributed to the event. The Team makes immediate recommendations to reduce fall risks for an individual patient.
Level of Injury
0 = None
1 = Minor Injury (abrasion, bruise, minor laceration) 2 = Major Injury (hip fracture, head trauma, arm fracture) 3 = Death
Post Admission Fall Occurrence
A fall that occurs after a patient is admitted to an inpatient setting.
Slip
Loss of balance as a result of slippery surface that does not result in a fall.
Stumble
Loss of balance due to knees giving way or other reasons but does not result in a fall.
Trip
Loss of balance due to a specific obstacle that does not result in a fall.
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Bed and/or chair alarms. Alarms at exits.
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Nurse call systems and communication systems. Low beds for patients at risk for falls. Video camera surveillance.
Falls and Bedrails
Fall prevention programs emphasize bedrail reduction. Bedrails contribute to patient fall risk by creating barriers to patient transfer in and out of beds. Use of bedrails must be assessed specific to individual patient needs. When possible, use alternative pillows and positioning devices to avoid the use of bedrails.
References
Department of Veterans Affairs. (1996, June). Clinical practice guidelines: The prevention and management of patient falls. Tampa, Fl: Author.
Hendrich, A, Nyhuis, A, Kippenbrock, T, et al, (1995). Hospital falls: Development of a predictive model of clinical practice. Applied Nursing Research , 8. 129-139.
Hoskin A.F. (1998). Fatal Falls: Trends and Characteristics. Statistical Bulletin, Apr-Jun, 10-15. Maki, B.E. (1997). Gait changes in older adults: Predictors of falls or indicators of fear? Journal of American Geriatrics Society, 45 , 313_20.
Morse J. (1997). Preventing patient falls . Thousand Oaks, CA: Sage. . 1999. Report on Injuries in America . Itasca, IL.
Rawsky, E. (1998). Review of the literature on falls among the elderly. Image , 30(1), 47-2. Steven, J, & Olson, S (1999, October). Check for safety. A home fall prevention checklist for older adults. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Tideiksaar, R (1997). Falling in old age. Its prevention and management . (2nd ed). New York: Spinger Publishing.
(NCPS). (2000).
VISN 8 Patient Safety Center. (January 2001). Proceedings: Promoting Patient Freedom and Safety: Preventing Falls. VISN 8 Patient Safety Center of Inquiry: St. Pete Beach, FL.
VISN 8 Patient Safety center of Inquiry.(1998).
For suggestions to improve or broaden this algorithm, please contact Dr. Pat Quigley, Associate Director, Clinical Division, VISN 8 Patient Safety Center of Inquiry, Tampa, Florida. E-mail:
∙ Consider use of: technology for fall prevention. (See section), non-skid floor mat, raised edge mattress.
Environment:
∙ Clear patient environment of all hazards
Medical Staff:
∙ ∙
Review medications for fall risk and adjust as indicated
CV agents - if orthostatic (drop in systolic > 20 mm in 3 minutes) and symptomatic
o Discontinue HCTZ, liberalize sodium in diet
o If ACE inhibitor appropriate, use agent with less renal metabolism (fosinopril) o If Calcium channel blocker - NOT nifedipine
o If ß blocker - not cardioselective / not metoprolol / atenolol; use pindolol /
propranolol
∙ ∙ ∙ ∙
Consider referral to services such as physical medicine and rehabilitation, audiology, ophthalmology, cardiology.
Optimize treatment of underlying medical conditions. Evaluate and treat for pain.
Evaluate circumstances surrounding fall for extrinsic and intrinsic contributing factors.
Education:
∙ ∙ ∙ ∙
Exercise Nutrition Home safety
Plan for emergency fall notification procedure.