KINDER 1 (AutoRecovered)
KINDER 1 (AutoRecovered)
KINDER 1 (AutoRecovered)
ADULT FALL RISK INTERVENTION TABLE PEDIATRIC FALL RISK INTERVENTION TABLE
UNIVERSAL FALL PRECAUTION / UNIVERSAL FALL PRECAUTION /
LOW RISK PATIENT IMPLEMENT INTERVENTION 1 TO 7 LOW RISK PATIENT IMPLEMENT INTERVENTION 1 TO 10
1. 2. Ensure that the call bell is in working condition and 1. Assess elimination needs, assist as needed
within reach. 2. Call light is within reach, educate the patient/family on its functionality.
3. Place bed in the lowest position with brakes locked. 3. Environment clear of unused equipment, furniture’s in place, clear of hazards
(If appropriate) 4. Orientation to room
4. Ensure that the upper side rails are raised at all times. 5. Place bed in the lowest position with brakes locked.
5. Educate the patient / watcher on the usage of call bell. (If appropriate)
6. Educate the patient / watcher concerning fall risk. 6. Side rails up, assess large gaps, such that a patient could get extremity or
7. Advise the patient on postural hypotension and its other body part entrapped, use additional safety precautions.
effects. 7. Use of appropriate size clothing to prevent risk of tripping
8. Advise on the effects of medication / sedation / 8. Assess for adequate lighting, leave nightlights “ON”
anesthesia. 9. Patient and family education available to the parents and patients
10. Document fall prevention teaching and include in the plan of care
HIGH-RISK PATIENT IMPLEMENT INTERVENTION 1 TO 15 HIGH-RISK PATIENT IMPLEMENT INTERVENTION 1 TO 21
9. 11. Evaluate the frequency of medication administration.
10. Place a Fall Risk signage and educate patient / watcher.
12. Remove all unused equipment out of room
11. Assist the patient with transfer / ambulation.
13. Protective barriers to close off spaces, gaps in the bed
12. Ensure that the patient has yellow wrist tag.
14. Keep the door open at all times unless specified isolation precaution are in
13. Remain with the patient while the patient is in the toilet.
use
14. Ensure that all side rails are raised when the patient is in
15. Move the patient closer to nurses’ station
bed.
16. Ensure that the patient has yellow wrist tag.
15. Advise the relative to inform the nurse if he / she is
17. Place a Fall Risk signage “Humpy Dumpty Poster” in beds and educate
leaving the room.
patient / watcher.
16. Conduct nursing rounds
18. At a minimum time, check the patient hourly if unattended
(4P’s: Potting, Positioning, Proximity of possession,
19. Assist the patient with transfer / ambulation.
Pain.) at least twice in a shift.
20. Document fall prevention teaching and include in the plan of care
17. Apply physical restraints if necessary.
21. For neonates, implement appropriate fall preventive strategies
DISCLAIMER: This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors
which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to
each individual presentation.
OSPITAL NG MAKATI
Sampaguita corner Gumamela Sts., Pembo,
Makati City, Philippines
Tel. +632 882 6316 to 36
PhilHealth Accredited
DISCLAIMER: This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors
which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to
each individual presentation.