Question

Ebony is an independent 86-year-old female who has been admitted to the hospital for dizziness and syncopal episodes that have resulted in falls at home. She has not sustained any injury from her falls. She is being evaluated for a cardiac cause to her syncopal episode. She has a history of diabetes mellitus that is diet controlled. She has no other significant medical or surgical history. She started using a cane to walk due to dizziness and syncope. Ebony is alert and oriented with a normal gait. Intravenous fluids are infusing. Nursing staff oriented her to the use of the call bell and educated her to ring when she wanted to get out of bed. Non-skid slipper socks were put in her bedside stand to use when she got out of bed. Ebony rang the bell during the night to ask for assistance to use the toilet. She waited for ten minutes but there was no response so she decided she would go to the bathroom on her own. When the staff responded, Ebony was found on the floor, bleeding from her head.

You (the nurse) leading a post-fall huddle. you will only need to answer the question below on a post-fall huddle and the post-fall huddle should be between 5 – 7 minutes.

1 Use a validated tool to include all information in the post-fall huddle

-Identify yourself and your role on the floor as well as the other health care team members who are expected to be present for the post-fall huddle

-You need to include the patient’s fall risk by using the Morse Fall Scale?

Answer 1

NURSES ROLE DURING FALL IN FLOOR :

When a patient falls, don't assume that no injury occur. Before the patient ask him what he thinks caused the fall and assess any associated symptoms. Then conduct a comprehensive assessment including ----------

• Check vital sign, and the apical and radial pulse.
• Check the cranial nerve.
• Check the skin for pallor, trauma, sensation and bruising.
• Assess level of consciousness.
• Look for cognitive changes.
• Check pupils reaction.
• Note any pain.

MORES FALLS SCALE :

A patient who scores less than 25 considered low risk of falling, 25to 45 moderate and above 45 considered high risk of falling.

In more fall scale 6 items there -----'

1. History of fall:immediately or within 3 months

Score : No - 0 , Yes - 25

2. Secondary diagnosis

No - 0 , Yes - 15

3. Ambulatory aid

Bedrest/nurse assist - 0

Canes /crutches - 15

Furniture - 30

4. IV /heparin lock

No- 0 , Yes- 25

5. Gait

Normal/bed rest - 0

Weak - 10

Impaired - 20

6. Mental status

Orientd to own ability - 0

Forget limitations - 15

According to mores fall scale with patients history, fall risk scoring is ---'''

1. History of fall present (at home )-- 25

2. Secondary diagnosis present ( diabetes mellitus )-- 15

3. Ambulatory aid use ( cane)-- 15

4. IV/heparin lock present - 25

5. Gait is normal - 0

6. Mental status -- oriented to own ability - 0

Total score is 80.

Patient under high risk (above 45 ) of falling.