Week 3: Safety In Mobility: Fall Risk Management (IYM)

List the 6 It's Your Move checkpoints

1. Three for the top

2. Three for the bottom

3. Elbows tucked in

4. Safe effective grip

5. Comfort zone

6. Weight transfer

Explain the It's Your Move checkpoint: Three for the top

Ears, shoulders, and hips should all be aligned

Explain the It's Your Move checkpoint: Three for the bottom

-Tighten the stomach

-Push butt back

-Body weight over heels

-Move your truck forward bending at the hips

Explain the It's Your Move checkpoint: Elbows tucked in

Tuck elbows in at your side

Explain the It's Your Move checkpoint: Safe effective grip

Palms up maintaining a neutral wrist

Explain the It's Your Move checkpoint: Comfort zone

Stand with elbows bent and tucked to the side then move your hands from your shoulders to your hips

Explain the It's Your Move checkpoint: Weight transfer

Shifting your body weight from the front leg to the back leg or from side to side

Should the height of the working surface be raised to the comfort zone of the taller or shorter person?

Taller person

1 multiple choice option

True or False: Using passive terms (E.g. Slide or roll) can reinforce the side to side and front to back weight transfers?

True

1 multiple choice option

______________+ ______________ + ______________ = No unsafe lift

Minimal physical effort, maximum equipment use, client participation

List the four categories of hazards

-Physical hazards

-Chemical hazards

-Biological hazards

-Psychological hazards

List the barriers that affect our ability to identify and act on hazards?

-Complacency

-Workload

-Resources

-Perceived expectations

What are the three areas of assessment?

-Self

-Environment

-Client

What components are involved in self assessment?

-Physical status

-Emotional status

-Training/experience

-Communication

-Workload

What components are involved in environmental assessment?

-Room/area

-Color/lighting

-Noise/distractions

-Working surfaces

-Equipment

What components are involved in client assessment?

-Communication

-Cognitive

-Emotional/behavioural

-Medical

-Functional assessment

What is the in transition functional logo?

In transition logos are logos used when the clients abilities change/fluctuate rapidly or if the client was admitted less than 24 hours. These logos reflect the client's needs at the time of the move

What is a functional assessment algorithm?

A tool that guides the assessment, organized in a sequential manner to help determine the minimum level of assistance required for the patient based on their functional abilities

Who can complete a functional assessment record (FAR)?

A regulated health professional upon patient admission and is repeated any time there is a significant change. All records are located in the chart

When is the best time to conduct a functional assessment record (FAR)?

At a time when the patient is at their best. If possible avoid times when the patient is in pain, uncooperative, tired, or feeling unwell

What are the exceptions to performing a functional assessment?

When the patient is:

-Physically unable

-Cognitively unable

Define patient safety

The pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes

How can the nurse keep themselves safe during patient transfers?

Practice ergonomics to avoid injuries, such as maintaining proper body alignment, movements, and posture

How can the nurse keep the patients safe during patient transfers?

Consider the patient's alignment, movements, and posture to ensure they are not at risk for injury

Define posture alignment

The relationship between one body part and another along a horizontal or vertical line, and involves positioning where there is no excessive strain on any muscle, joint etc.

Define balance

Achieved when the center of gravity is balanced over a stable base of support and is enhanced by using proper posture

Define gait

The manner or style of walking and includes rhythm, cadence and speed

What can gait be affected by?

Gait can be affected by diseases, injury, age, etc

How can you use balance to maintain proper body alignment and posture?

By widening your base of support, and bringing the center of gravity to the base of support

Define a fall

An event that results in a person coming to rest inadvertently on the ground or floor or other lower level, with or without injury

How is a fall described?

Described as a complex multifactorial phenomenon, syndrome, and an indication of an emerging or worsening health condition

According to Healthcare Excellence Canada what can falls be classified as?

-Anticipatory

-Unanticipated

-Accidental

How can anticipatory falls be prevented?

Through screening, communication, and implementation of targeted prevention strategies

How can fall injuries affect quality of life

Falls decrease independence, and may also require alternative housing arrangements. For example after a fall a patient may become anxious, less confident, and afraid of falling again. This in turn may result in them engaging in less physical activities resulting in deconditioning, muscle weakness and greater risk of falling

How many fall risk factors have been identified?

Over 400

Fall risks may be _______ or _______

Modifiable, non modifiable

Are scatter rugs, nutrition, clear walkways a modifiable or non-modifiable risk factor?

Modifiable

1 multiple choice option

Is age a modifiable or non-modifiable risk factor?

Non-modifiable

1 multiple choice option

List the AHS falls risk management policy PS-58 elements

-Prevention

-Screening and assessment

-Intervention

-Data collection and measurement

-Evaluation

-Practice improvement

What are universal fall precaution?

Precautions that are automatically applied for all people whether or not they are deemed a fall risk

Of all types of injuries, which one is the leading cause of injury deaths, hospitalizations, permanent total or partial disabilities?

Falls

According to RNAO best practice guidelines on falls, who should be screened for fall risks?

All adults

List the types of fall risk assessment tools

-Functional Gait Assessment (FGA)

-Hendrich ii Fall Risk Model

-St. Thomas Assessment Tool (Stratify)

-Schmid Falls Assessment Tool

What is the Schmid Falls Assessment Tool?

A screening tool used in healthcare settings to evaluate the fall risk of patients aged 65 and older

List the categories of the Schmid Falls Assessment Tool

-Mobility

-Mentation

-Elimination

-Prior fall history

-Current medications

What schmid fall assessment score indicates that a patient is at potential risk for falls, and that strategies should be implemented?

A score of 3+

Outline the mobility category of the Schmid Falls Assessment Tool

-(0) no gait disturbance and unable to ambulate

-(1) Ambulates/transfers with assistive devices and unsteady gain no assistance

Outline the mentation category of the Schmid Falls Assessment Tool

-(0) alert, oriented x3 and comatose at all times

-(1) periodic confusion or confusion at all times

Outline the elimination category of the Schmid Falls Assessment Tool

-(0) independent

-(1) independent with frequency or diarrhea, needs assistance with toileting, incontinent

Outline the prior fall history category of the Schmid Falls Assessment Tool

-(0) No prior history

-(1) Yes before admission or unknown

-(2) yes during admission (If a person has had a period fall they are at higher risk for another)

Outline the current medications category of the Schmid Falls Assessment Tool

(1) anticonvulsants/tranquilizers/psychotropics/hypnotics

What steps should be taken if a patient falls

-Assess for injuries; provide treatment

-Monitor for injuries that may not be immediately apparent

-Determine factors that contributed to the fall (post fall assessment)

-Conduct further assessments; determine appropriate interventions

-Modify or add to care plan such (E.g Referral for physical rehabilitation, support psychological well- being)