Chapter 12: Post Fall Care and Nursing Scenarios

A set of 21 vocabulary flashcards covering post-fall clinical care, universal precautions, prevention levels, and targeted nursing scenarios.

Immediate Post-Fall Assessment

The immediate evaluation of a patient's physical and neurologic status, possible head injury or fracture, and vital stability following a fall.

Post-Fall Huddle

A collaborative process used to reconstruct the event, identify causes, and revise the prevention plan after a fall occurs.

Universal Hospital Fall Precautions

Standard safety measures applied to hospital patients, consisting of a low bed, a clear walking path, and an accessible call light.

Additional Universal Fall Precautions

Supplementary safety practices that include non-skid footwear, adequate lighting, and safe access to the commode.

Purposeful Rounding

A proactive nursing practice used for the assessment of needs and reduction of unassisted unsafe mobility.

Bed or Chair Exit Alarms

Safety devices used for alerting staff when a high-risk patient attempts to get up.

Fall TIPS

A patient-centered fall prevention program where the plan is individualized and kept visible to the patient at the bedside.

Medication Reconciliation (Fall Prevention)

A review process that supports fall prevention by identifying potentially avoidable sedating or hypotensive medications.

HELP (Hospital Elder Life Program) Interventions

A set of structured interventions that include cognitive stimulation, early mobility, hydration, sleep support, and sensory aids.

Nurse's Overarching Fall-Prevention Responsibility

The duty to assess risk, implement tailored interventions, and reevaluate their effectiveness.

Fall Risk Patient and Family Education

Educational guidance provided to support safer behavior and environments across care transitions.

Quality of Life Preservation

The broader objective supported by fall prevention through preserving mobility, function, independence, and confidence.

Intrinsic and Extrinsic Risks

The interacting patient-related (intrinsic) and environmental (extrinsic) factors from which falls arise.

Acute Underlying Illness Indicator

A clinical consideration when a patient falls unexpectedly and appears confused, indicating that the presentation is not merely normal aging.

Secondary Prevention

The level of prevention emphasized when a resident has fallen recently (e.g., twice recently), focused on preventing another fall.

Primary Prevention

The level of prevention indicated when a resident has not fallen but presents with environmental and balance risks, targeting both hazards and balance.

Tandem Stance Inability (< 10 seconds)

A clinical balance test outcome indicating elevated fall risk, requiring the examiner to stop the test and plan appropriate interventions.

Non-Restraint Safety Measures

Individualized safety strategies that serve as the appropriate first-line alternative to physical restraints when a confused patient repeatedly climbs out of bed.

Priority Head Strike Protocol

The immediate clinical and neurological assessment required as the first step when a patient falls and may have hit their head.

Sedative and Unsteady Gait Protocol

The prioritized nursing response consisting of medication review and targeted mobility/fall precautions.

Individualized Prevention Interventions

Tailored interventions developed by translating risk assessment findings into practice, as a fall risk score alone is not sufficient.