ANTI - HYPERTENSIVES , DIURETICS , HYPNOTICS , LAXATIVES , SEDATIVES , AND PSYCHOTROPICS ( SINGLE - SELECT ) ● On 1 high fall risk drug (3 point) ● On 2 or more high fall risk drugs (5 points) ● Sedated procedure within past 24 hours (7 points) P ATIENT CARE EQUIPMENT : A NY EQUIPMENT THAT TETHERS PATIENT , E . G ., IV INFUSION , CHEST TUBE , INDWELLING CATHETERS , SCD S , ETC ) ( SINGLE - SELECT ) ● One present (1 point) ● Two present (2 points) ● 3 or more present (3 points) 3 M OBILITY ( MULTI - SELECT , CHOOSE ALL THAT APPLY AND ADD POINTS TOGETHER ) ● Requires assistance or supervision for mobility, transfer, or ambulation (2 points) ● Unsteady gait (2 points) ● Visual or auditory impairment affecting mobility (2 points) 2 2 C OGNITION ( MULTI - SELECT , CHOOSE ALL THAT APPLY AND ADD POINTS TOGETHER ) ● Altered awareness of immediate physical environment (1 point) ● Impulsive (2 points) ● Lack of understanding of one’s physical and cognitive limitations (4 points) 2 *Moderate risk = 6-13 Total Points, High risk > 13 Total Points Total Points 14 The Johns Hopkins Hospital © 2006 The patient’s fall risk of 14 means that patient is at moderate risk. He has multiple tubes/wires connected to him at all times. He has been educated to call whenever she needs to move around or needs something. Patient is monitored very closely to reduce risk of falls. References
Violet Pola-Kanuha NURS157 DATE OF CARE: 2/28/28 CN 89M 219A Garber, Jeannie Scruggs., Monty Gross, and Anthony D. Slonim. Avoiding common nursing errors . Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2010.
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- Summer '19
- Subdural hematoma, BIPAP, CN 89M 219A