Safety and Documentation Study Notes

Scoring Thresholds: * Moderate Fall Risk: $6-13$ total points. * High Fall Risk: $> 13$ total points.
Key Assessment Categories: * Age: Points awarded for age $\geq 60$ (highest points for $\geq 80$ ). * Fall History: One fall within $6$ months before admission ( $5$ points). * Elimination: Points for incontinence, urgency, or frequency. * Medications: High-risk drugs include PCA/opiates, anticonvulsants, anti-hypertensives, diuretics, hypnotics, laxatives, sedatives, and psychotropics. * Sedated Procedures: Within the past $24$ hours ( $7$ points). * Equipment: Any equipment tethering the patient (e.g., IV infusion, chest tube, indwelling catheter, SCDs). * Mobility: Assessment of assistance needs, unsteady gait, and sensory impairments. * Cognition: Assessment of impulsivity, physical awareness, and understanding of limitations.

Restraint Protocols: * Used only when alternatives are ineffective; requires a doctor's order and monitoring $Q15min$ . * Types: Soft wrist restraints, mitten restraints, bed rails $x4$ , enclosure beds, and FREEDOM SPLINTS. * Chemical Restraints: Drugs like Ativan, Geodon, and Haldol used to control behavior.
Safety Alternatives: * Bed alarms, frequent toileting, diversional activities, moving the patient closer to the nurses' station, and family involvement.
Aggressive Patients: Call for help if threatened; always partner with another staff member for assessments.

Sepsis Definition: An overwhelming systemic response to infection leading to vasodilation, shock, and organ failure.
SIRS Criteria (Positive if $\geq 2$ plus infection): * Temp $< 36^{\circ}\text{C}$ or $> 38^{\circ}\text{C}$ . * $RR > 20$ * $HR > 90$ . * $WBC > 12000$ or $< 4000$ .
1 Hour Sepsis Bundle: * Measure Lactate Level (sign of organ failure if $> 2.0\,mmol/L$ ). * Obtain blood cultures before administering antibiotics. * Administer ordered antibiotics. * Begin $30\,ml/kg$ normal saline IV bolus. * Administer vasopressors if the patient remains hypotensive.

General Rules: * "If it isn't charted… it didn't happen!" * Use military time (e.g., $1530$ ) and document objectively (e.g., "BP is $120/80$ "). * Document the intervention followed by the patient response. * Never document an intervention before it is completed.
Paper Documentation: Use black ink, draw a single line through errors (label as "Error" and initial), and never leave blank lines.
Physician Orders: * Nurses must "read back" verbal or telephone orders. * Student Policy: Per SJSU and hospital policy, students do not receive orders from physicians.
DAR Format for Nursing Notes: * Data: Patient assessments. * Action: Nursing interventions. * Response: Patient outcome and future plan.