According to the Morse Fall Scale, which factor indicates the highest risk? Show A) Having short term memory loss. B) History of falls within the last 3 months. C) Having chronic illness. D) Walking with a cane. B) History of falls within the last 3 months. Patient with history of falls within the last 3 months will be awarded 25 points in Morse Fall Scale, which compares with other factors: Chronic
disease - 15 points * highest risk also: Patient ambulates clutching onto the furniture for support. A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the client will benefit the most from A) installing fluorescent lighting throughout the house. B) becoming oriented to the position of the furniture and stairways. C) maintaining complete bed rest in a hospital bed with side rails. D) applying physical restraints. B) becoming oriented to the position of the furniture and stairways. -Orienting the client to the position of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision. a. Attempts should be made to reduce glare. Light bulb wattage can be increased to help improve visibility. The best intervention to prevent falls is first to orient the client to the surroundings. c. Maintaining complete bed rest is not the best option. Complete bed rest can cause other health problems because of a lack of mobility. d. The client should not be restrained for poor vision. Attempts should be made to help compensate for the decreased vision to prevent falls. Orienting the client to the position of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision. The nurse assesses that the client may need a restraint and recognizes that A) an order for a restraint may be implemented indefinitely until it is no longer required by the client C) no order or consent is necessary for restraints in long-term care facilities. D) restraints are to be periodically removed to have the client re-evaluated. D) restraints are to be periodically removed to have the client re-evaluated. Restraints must be periodically removed, and the nurse must assess the client to determine if the restraints continue to be needed. A 72 year old female was admitted to the general medical unit with a diagnosis of COPD, IDDM, and HTN. Per protocol the Morse Fall Scale was completed on admission. The patient has a history of falls, ambulates with a walker, IV is infusing at 50 ml/hr, has difficulty rising after sitting in the chair or lying in the bed, and patient is forgetful - keeps getting out of bed without calling for assistance with frequent reminders. The Morse Fall score is A) 0 B) 110. C) 125. D) 85. B) 110. - Has a history of falls - 25 Diagnosis of COPD, IDDM, and HTN - 15 Ambulatory aids (Walker) - 15 IV is infusing at 50 ml/hr - 20 Gait/Transferring (Impaired -has difficulty rising after sitting in the chair or lying in the bed) - 20 Mental status (patient is forgetful) - 15 Total- 110 Which one of the following is NOT an extrinsic factor to the cause of fall? A) Slippery floor. B) Poor illumination (LIGHTING) conditions. C) Poor safety awareness. D) Cluttered rooms. C) Poor safety awareness. Cluttered rooms, slippery floor and poor illumination conditions are considered as extrinsic factors. Restraints can be used only when a client A) is an inconvenience to staff. B) at risk of harm to self and/or others. C) has fracture and is on fall risk precaution. D) is shouting and screaming. B) is at risk of harm to self and/or others. - There are many alternatives to the use of restraints. Use these alternatives before applying restraints. Physical restraints on a patient must be prescribed or clinically approved by the physician when all other alternatives or less restrictive measures are deemed not effective ro prevent physical injuries to self and/or others and damage to property. A 1-year-old child is scheduled to receive an intravenous (IV) line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n) A) mummy restraint. (MITTEN) B) wrist restraint. C) elbow restraint. D) jacket restraint. A) mummy restraint. A mummy restraint is used in the short-term for a small child or infant for examination or treatment involving the head and neck. This would be the most appropriate type of restraint to use for a 1-year-old who is going to receive an IV line. The wrist restraint maintains immobility of an extremity to prevent the client from removing a therapeutic device, such as an IV tube. It would not be the best choice for starting an IV on a 1-year-old. The jacket restraint is often used to prevent a client from getting up and falling. It is not the best choice for starting an IV line. An elbow restraint is commonly used with infants and children to prevent elbow flexion, such as after an IV line is in place. A 79-year-old resident in a long-term care facility is known to "wander at night" and has fallen in the past. Which of the following is the most appropriate nursing intervention? A) An abdominal restraint should be placed on the client during sleeping hours. B) The client should be checked frequently during the night. C) A radio should be left playing at the bedside to assist in reality orientation. D) The client should be placed in a room away from the activity of the nursing station. B) The client should be checked frequently during the night. - Alternatives to restraints should be attempted first (A physician's order is required for restraints to be applied). The most appropriate intervention is to check on the client frequently. a. Alternatives to
restraints should be attempted first. Each client who is admitted because of a fall, and / or who has a history of falls, should have a fall risk assessment complete within A) 24 hours. B) whenever the nurse has time to do it. C) 72 hours. D) 48 hours. A) 24 hours. All patients admitted to hospitals or long term care institutions should undergo falls risk assessment at the point of admission, within 24 hours, to identify those at higher risk of falls. Cognitive (MENTAL) impairment should be assessed in an effort to reduce risk of falls. True OR False True - Cognitive impairment results in agitation, poor judgement, and poor awareness of risk and safety. A nurse can reduce the risk of falls by taking time to show the elderly patients around and how things work. False OR True True - Knowledge of location and surrounding and use of call bell are essential to patient safety. Fear of falling has no impact of actual falls. True OR False False - If someone has a fear of falling, then they are five times more likely to fall. Having older people engage in exercise increases their risk of falls. True OR False False - Exercise is an important intervention for preventing falls in older people. Because of the age of the residents, most falls in senior care environments are unavoidable. True OR False False - Many slips, trips, and falls in care environments are preventable. All restrained patients must have an order prior to placement or immediately after if it is an emergency situation. True OR False False - The written order from the doctor for using physical restraint must be within 1 hour of application if it is not done earlier. In order to reduce the risk of falling, how would you educate the patient and family on the use of call bell system? - Explain and demonstrate how to turn call bell on and off at bedside and bathroom. - Have patient perform return demonstration. - Explain to patient and family when and why to use call system. - Secure call bell reachable location How would you use the side rails to reduce the risk of falling for a dependant and independent patient respectively? Dependent, Independently Describe the nursing care for a patient who is on physical restraints. - Monitor patient hourly. - Ensure patient safety and that restraints are properly secured and not too tight. - Check respiratory status; peripheral circulation of restrained limbs for warmth, sensation, distal pulses, colour; skin condition for pressure related injuries i.e. redness, bruises, abrasions or oedema. - Ensure range of movement is not restricted. - Check body alignment and movement. Do 2 hourly turning to prevent pressure-related injury. - Evaluating patient's behaviour for discontinuation of physical restraint(s). List the nursing interventions for patients at higher risk of falling. - Monitor and assist patients in daily schedules. - Initiate elimination schedule, using bedside commode when appropriate. - Stay with patient during toileting. - Place patients in geri chair or wheelchair with wedge cushion. - Activate bed alarm for patient. - Prioritize call bell response to patient at high risk, using a team approach - Ensure trousers above ankle during ambulation. - Regular nursing round and prompt toileting - Advise on effect of medication that would increase risk of fall. State the environmental interventions to reduce the risk of falling. - Remove excess equipment, supplies and furniture from rooms and halls. - Keep floors clutter and obstacle free, particularly path to bathroom. - Clean all spills promptly. Put the 'wet floor" signage. Remove sign when floor is dry. - Ensure adequate glare-free lighting. Use night-light at night. - Have ambulatory aid located on exit side of bed.(e.g., walker, cane, bedside commodes) - Arrange necessary items within patient's reach. (e.g., water jug, eyeglasses, dentures, telephone) - Secure locks on beds and wheelchairs. Types of physical restraints 1) Bed Rails 2) full body/ waist vest 3) hand mittens 4) Seat belt or chest
boards/trays 5) Limb restraint What are some interventions to help prevent patient falls?Have sturdy handrails in patient bathrooms, room, and hallway. Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. Keep hospital bed brakes locked. Keep wheelchair wheel locks in "locked" position when stationary.
How can you reduce the risk of patient harm resulting from falls?What can you do to reduce your risk for falling?. Follow your mobility plan. ... . Call for help when you need to get up or go to the bathroom.. Keep what you need within reach, especially your call button.. Get out of bed slowly in three steps. ... . Use your assistive device when you get up.. Turn on the lights.. What are 5 nursing interventions used to address a client with a risk for falls?Interventions to Prevent Falls. Familiarize the patient with the environment.. Have the patient demonstrate call light use.. Maintain the call light within reach. ... . Keep the patient's personal possessions within safe reach.. Have sturdy handrails in patient bathrooms, rooms, and hallways.. How do you assist a patient with toileting?The following things can make it easier to use the toilet:. Allow plenty of time so the person doesn't feel rushed. ... . Place a chair halfway if it's a long walk to the toilet so they can have a rest.. Keep the floor free from clutter so they don't trip.. Keep a light on to help them safely reach the toilet during the night.. |
Which intervention will reduce the risk of falling in a patient who needs to go to the bathroom at night?
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