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week 3

read the outline and attached pdf’s

FALL PRECAUTIONS CARE PLAN INTERVENTIONS

· Post the “Fall Precautions” sign

on the patient’s room door
.

· Place a

yellow
 identification band on the patient’s wrist.

· Instruct the patient/parent (using appropriate communication tools and/or interpreters) to call when they need assistance getting out of bed, moving from the chair, etc.

Note: Ask the patient to repeat these instructions and demonstrate their ability to use the call light/portable call bell.

· Apply a positioning belt, as applicable to the patient’s condition and level of fall risk, when up in the chair (see also text box in Attachment 3).

· Place the call light/portable call bell within the patient’s reach.

Note: Ask the patient to demonstrate their ability to use the call light/portable call bell.

· Utilize side rails appropriately

· Assure that three (3) bed rails are up at all times

Note: If four (4) bed rails are required, see “Restraints and Seclusion Use” policy #PFF00004 as 4 bed rails are considered a patient restraint.

Exception: Pediatrics can use all side rails up for safety precautions

· Place all side-rails up on gurneys/stretchers for transportation.

· Place bed in low position.

· Turn the bed alarm on (if applicable).

· Place urinal within reach if appropriate.

· Keep the bathroom light on when rooms are dark and at night.

· Make frequent rounds to assure the patient’s needs are met and needs/desires to get out of bed (OOB) without assistance are minimized.

· Provide positive feedback to the patient when he or she calls for assistance (e.g. “I’m glad you called me to help you.”)

· Utilize approaches as appropriate to assist in orienting the patient to person, place, and time, such as:

· Verbal orientation

· Visible clock and/or calendar

· Writing information on the communication board in the patient’s room, such as the hospital, day, date, why he or she is here, who the doctor and nurse are, etc.

· Television programming

· Frequent visitation by family/significant other. Encourage family attendance.

· Educate the patient and family regarding the “Fall Precautions” plan of care (actions in place to prevent fall utilizing the patient and family written handout.

· Order a PT Evaluation (per Fall Precautions Protocol) if:

· Patient is clinically appropriate and not on bedrest.

· Morse scale is
> 45.


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