跌倒所有的高危因素倒所有的高危因素.docVIP

If any of these medical factors are present, go to Standard Fall Prevention Interventions: Agitation/Delirium- infection, toxic/metabolic, cardiopulmonary change, CNS, dehydration/ blood loss, sleep disturbance Meds (dose/timing)-psychotropics, CV agents (digoxin especially), anticoagulants(increased risk of injury), anticholinergic, bowel prep Orthostatic hypotension, autonomic failure Frequent toileting Impaired mobility Impaired vision, inappropriate use of assistive device/footwear History of Falls (CV/light headed-dizzy, Dysequilibrium- loss of balance with no abnormal motion sensation, Vestibular/Vertigo, Weakness-Musculoskeletal/give way, combination, other) Psychotropics, digoxin, type 1a antiarrhythmic, diuretic (thiazidesloop diuretics) Antihistamines/benzodiazipines- withdrawal has shown decrease in falls risk, assess for sleep disorder, avoid routine PRN orders-try non-pharmacological approaches including quiet sleep protocols on units Antidepressants- Tricyclics higher risk than SSRI, but SSRIs have risk as well, high level of phenytoin; low dos amitriptyline affects gate; gabapentin 10-25% ADR Cardiac drugs/antihypertensives- if orthostatic (drop in sys20 mm in 3 min) and symptomatic Anticoagulants - subdural hematomas are rare; avoid only if very unstable gait or balance, concurrent use of alcohol, or other drugs that interact and increase bleeding, or non-compliant with regimen or lab follow up Drugs treating nocturia (consider tamsulosin due to lower risk of orthostasis) Nursing fall risk assessment, diagnoses and interventions are based on use of the Morse Fall Scale (MFS) (Morse, 1997). The MFS is used widely in acute care settings, both in hospital and long term care inpatient settings. The MFS requires systematic, reliable assessment of a patients fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. MFS subscales include assessment of: 1. History of falling; immediate or within 3 mon