Introduction Show
Aim Definition of Terms Maintaining a safe environment for all patients Educating families and carers Risk assessment Management Considerations for discahrge Companion documents Links
Evidence table IntroductionFalls are the most common cause of paediatric injury leading to emergency department visits. It is widely acknowledged that children are at risk of falls, with many education programs supporting prevention, it is
important that this education is reflected in the hospital environment. Children fall as they grow, develop coordination and new skills; often unaware of their limitations. RCH incident data suggest those at the highest risk of falls are those in the toddler age group (1-2 years) and the adolescent group (10-17 years). AimThe intention of this guideline is to raise awareness and educate nursing staff
and the multidisciplinary team of the importance of maintaining a safe environment for all patients; assist with identifying patients who are at high risk of falls; provide the tools to educate families and carers of the potential risk of falls and outline strategies to develop management plans of care to reduce risk for high risk patients. Definition of TermsFall - A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Anticipated falls - may occur when a patient whose score on a falls risk tool indicates she or he is at risk of falls. Unanticipated falls - occur when the cause of the fall is not reflected in the patient's risk factor for falls, conditions exist which cause the fall, yet these are not predictable (e.g., the patient faints suddenly). Near miss fall – when a fall was likely but did not occur, but was averted due to action by patient, carers or staff. Accidental falls - occur when a patient falls unintentionally, usually as a result of tripping or slipping, as a result of equipment failure or other environmental factors. Patients cannot be identified as being at risk for falls prior to this type of fall. Risk assessment tool - a conceptual framework that organises knowledge on the aetiology of predicting falls. Maintaining a safe environment for all patientsAll paediatric patients are considered at risk of falling and simple prevention strategies should be put in place to ensure the risk of injury is minimized. A safe environment should be maintained for all patients within the Royal Children's Hospital
(RCH). Standard safety measures should be put in place for all patients regardless of identified risk, these include:
Educating families and carersHalf of falls incidents within the RCH occur when a parent or carer is present. Whilst most parents are aware of maintaining a safe environment for their children in the home environment, many are unaware of the environmental risks when in hospital due to being in an unfamiliar environment accompanied with increased levels of anxiety related to hospital admission. The hospitalisation of children provides an opportunity to reinforce parent/carer information and education concerning normal psychological and motor development of small children, which is related to falls risks and other hazards both inside and outside hospital. Parents/carers should be encouraged to:
Risk AssessmentAll patients have a falls risk assessment completed using the Little Schmidy Falls Risk Assessment Tool completed at the following stages:
The falls risk assessment score is documented in the Primary Assessment flow sheet in the EMR. The falls risk assessment tool does not replace clinical judgment, if a patient does not present with a high risk score but is thought to be high risk by medical or nursing staff, allied health, parents or carers extra precautions to protect such patients should be documented and actioned Factors influencing risk include: Factors influencing risk include:
See Clinical Guideline (Nursing): Nursing Assessment for more detailed assessment information. ManagementStandard safety measures should be put in place for all patients regardless of the risk identified.
Falls score equal to or greater than 3 necessitates the implementation of a Falls High Risk Management Planwhich is located in the Primary Assessment flowsheet within the EMR. Falls score equal to or greater than 3 necessitates the implementation of a Falls High Risk Management Plan which is located in the Primary Assessment flowsheet within the EMR. For all patients identified as high risk, i.e., those with a falls risk score of 3 or greater; a Falls High Risk Management Plan must be commenced. The plan will be developed in collaboration with the child's parent or carer and will be specific to the patient's individual needs. The plan will remain in use until the patients falls risk score changes. If the falls risk score alters a new plan will be implemented as the patients needs may have changed. Patient risk should continue to be assessed daily, once the patient's risk score is less than 3 and the patient's risk of falling is reduced, a management plan is no longer required; however it is important that a safe environment is always maintained. A referral may be needed to a physiotherapist or an occupational therapist if there has been a change to a patients mobility or function during an admission. A physiotherapist can advise as to how to safely support the patient during positioning, transfers, standing, walking and use of mobility aids. An occupational therapist can ensure safe setup of the ward bedroom, bathroom and toilet to minimise falls risks and recommend management techniques/assistive equipment for self care tasks. In the event of the occurrence of a fall:
Documentation of a Falls event
Considerations for dischargeSome patients may have a high risk score at the time of discharge. For this patient group the following should be considered:
High risk patients may be eligible for Post Acute Care (PAC). To make a referral contact the RCH Complex Care Hub. Companion DocumentsLittle Schmidy Falls Risk Assessment Tool Paediatric Fall and Entrapment Prevention and Management Guideline Appendix B: Paediatric Cot and Bed Allocation Guide (attached below) Links
Evidence TableClick here to view the evidence table. Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Sarah Sly, Improvement Manager, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2022. Which client is most at risk for foot difficulties quizlet?People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk but an active older adult is less at risk.
Which assessment will the nurse perform to determine a patient's ability to perform foot care select all that apply one some or all responses may be correct?The nurse will assess a patient's balance, visual acuity, muscle strength, flexibility, orientation, and cognitive function to determine the patient's ability to safely and effectively perform foot care.
Which condition is observed in a patient who has gingivitis?Bacterial buildup around the teeth is the most common cause of gingivitis. The main symptom of gingivitis is red, puffy gums that may bleed when a person brushes their teeth. Gingivitis often resolves with good oral hygiene, such as longer and more frequent brushing, and regular flossing.
Which interventions might the nurse implement in order to prevent pressure ulcers?Prevention includes identifying at-risk persons and implementing specific prevention measures, such as following a patient repositioning schedule; keeping the head of the bed at the lowest safe elevation to prevent shear; using pressure-reducing surfaces; and assessing nutrition and providing supplementation, if needed ...
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