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1跌倒的定义Definition of fall凡是发生在任何场所、任何情况下,不论有无造成身体伤害之非预期性地跌坐或滑坐于地面,包括因肢体无力或扶持不住而不得不缓缓坐于地上Any unexpectedfalling orsliding on the groundat anyplace andunder anycircumstances,regardless ofcausing bodyinjury ornot,including sittingontheground slowlydue toweakness oflimbs orfailure tohold somethingfor support.2伤害程度分级Grading ofinjury degree
2.1无伤害No injury
2.2I级伤害只需稍微治疗与观察的伤害,如挫伤、擦伤、不需缝合的皮肤小裂伤Grade IinjuryThe injury requires onlyminor treatmentand observation,such ascontusion,abrasion andskin cracksthat sutureis notrequired.
2.3II级伤害需冰敷、包扎、缝合或夹板等医疗或护理处置与观察的伤害,如扭伤、大而深的撕裂伤或挫伤等Grade IIinjury:Those requiremedical treatment,nursing orobservation,e.g.ice bagdressing,bandage,suture orsplint,such assprain,large anddeep tearor contusion.
2.4III级伤害需医疗处置及会诊的严重组织或功能伤害,如骨折、意识丧失、精神状态改变等此伤害会严重影响病人疗程及延长住院天数Grade III injury:those serioustissue injuryor functionalinjuryrequiremedical treatmentand consultation,such asbone fracture,loss ofconsciousness,change ofmental state.Such injuriesmay influencecourse oftreatment significantlyand extenddays ofhospitalization.3跌倒的高危因素High riskfactors of fall住院病人跌倒/坠床预防流程图Flow chartof preventionof fall/drop frombed of inpatients门急诊患者跌倒/坠床危险因子评估表(儿童)陪伴者口无口家属□保姆□其他评估项目勾选6周岁以下□主诉头晕、眩晕□步态不稳□特殊药物24小时内使用药物如镇静安眠、利尿剂、降压药、麻醉止痛剂、泻□药、散瞳剂中任何一种药物符合者在口内打勾,勾选1个及以上项目表示为局危跌倒/坠床患者评估者签名时间年月日时分Outpatientsemergency patientsfall/drop frombed riskfactors assessmentform forchildren CompanionDNo nfamily member□nurse Dothers items tickUnder6years old□complaintdizzy,vertigo□Unstable gait□Special drugs:within24h,use one of thefollowing:sedatives,hypnotics,diuretics,antihypertensives,anesthetics,analgesics,□laxatives,pupil dilateddrug Tick in□,more than1item indicatespatient with high riskof fall/drop frombed Signature of assessortime:Y MD IIM陪伴者口无口家属□保姆□其他评估项目勾选年龄》65周岁□主诉头晕、眩晕□意识障碍□尿频、夜尿多、常下床□虚弱、无力、活动障碍□视力模糊□步态不稳□最近一年内有跌倒史□特殊药物24小时内使用药物如镇静安眠、利尿剂、降压药、麻醉止痛剂、泻□药、散瞳剂中任何一种药物符合者在口内打勾,勾选3个及以上项目表示为高危跌倒/坠床患者评估者签名时间年月日时分Outpatientsemergency patientsfall/drop frombed riskfactors assessmentform foradults CompanionDNo Dfamily member DnurseDothersitemstick age^65years old□complaintsdizzy,vertigo□conscious disorder□Frequent micturition,more nocturia,often leavingbed□weak,lassitude,motion disturbance□Blurred vision□unstable gait□Fall historywithin ayear□Special drugs:within24h,use oneof thefollowing:sedatives,hypnotics,diuretics,antihypertensives,anesthetics,analgesics,□laxatives orpupil dilateddrug.Tickin□,more than3items indicatepatient with high risks of fall/drop frombed Signature of assessortime:Y MD HM无锡市第五人民医院住院病人跌倒/坠床评估与护理措施计划表科室______床号______姓名____________性别年龄住院号_______诊断:年龄N65岁;曾有分跌值倒标史准;步态不稳、平衡障碍或肢体功能障碍日;期贫时血间或体位性低血压;低血项目/内容填表对象糖;颈0椎分病;有使用易致1跌分倒药物的病人;营养不良、虚弱、头晕;意识障碍(失去定向感、躁
1.主诉眩晕或有虚动混乱等);睡眠障碍;视力障碍;肢体功能障碍;孕妇否是填弱感
(1)新入院或转科病人;
(2)病人意识状态或病,情转变时;
(3)手术或特殊检查治疗后;
2.在家评或估住时院间有跌
(4)使用易导致跌倒的药物
(5)低危险者每周评估2次(周
一、周四)直至0分;高危险者每表无有倒病史天评估,直至V4分说评明★危险程度零危险分;低危险1・3分;高危险>4分
3.意识状态清醒或深昏迷有意识障碍估★易致跌倒药物稳利定尿自剂主、或止痛完剂全、行缓走泻时剂需、要镇帮静助安(眠人药、心血管药物、抑郁药、肌肉松弛剂、抗癫痫药等
4.行动能力内护理措施填写说明无责法任移护动士根据患者或的工具具体)情况选择对应措施容
5.睡眠形态正常睡眠形态紊乱
6.有体位性低血压无有
7.★使用易导致跌无有倒之药物
8.排泄需他人协助不需需总分★危险程度教导使用呼叫铃(床边或卫生间)安全环境(使用床栏、维持地面干燥、适当照明)护药物宣教(导致跌倒的药物使用注意点)理指导患者穿防滑鞋和舒适衣裤措腕带上贴黄标点,床头挂防跌标识施指导病人转变体位或上下床时的注意点家属陪伴巡视根据医嘱使用保护性约束其他(填写具体措施)患者家属签名护理人员签名责任组长/护士长签名Wuxi No.5Hospital inpatientsfall/drop frombed assessmentand nursingplan formdept.bed namesex ageadmission diagnosisNo.No.scores Datetime item/contents
011.complain ofdizzy No Yes orweak co
2.fall historyat homent No Yes orin hospitalen tsConscious ordeep Withconscious
3.consciousness comadisorder Stable,Walk withaid
4.movement abilityautonomous orperson ortool unableof moving
5.sleep normalDisturbed sleepNoYes
6.postural hypotension
7.★use drugs apt toNoYesfall NoYes
8.excretion needsaid Totalscore★risk degreeTeach how to usecall bellbedside ortoilet.Safe surroundingsuse bedguard rail,keep floordry,proper lighting.nu Medicationeducation pointsfor attentionusing drugsresulting inrsi fall.ng Guidepatients towear anti-slip shoescomfortable clothes.m Stickyellow signon wristband,hang fallprevention markon eabedside.su Guidepatients tochange posture,go tobedleave bed.re sEscort byfamily members.patrol Useprotective restraintas perorder othersfill inconcrete measuresSignature offamily memberSignatureofnurseSignatureofresponsible teamleader/head nurseage^65years old;with historyof fall;unstable gait,balance disorderor limb function disorder;anemia orpostural hypotension;low blood glucose;cervical spondylosis;using drugsapt tofall;targets malnutrition,weak,dizzy;conscious disturbanceloss oforientation,restless etc.;sleep disturbance;vision disturbance;limbfunctiondisturbance;pregnant woman.1newly admittedor transferredpatient;2consciousness orconditions changed;3after operationTime ofassessment orspecial examination or treatment;4using drugsapt tofall.5twice a week forpatient with low riskMon.Thu.until0;once every day forpatient with high riskuntil
4.★risk degree0risk0;low risk1-3;high risk★drugsaptto Diuretics,analgesics,slow laxatives,sedativeshypnotics,cardiovascular fallagents,antidepression drug,muscle relaxant,antiepileptics etc.Remarks offilling Responsiblenurse shallselect measuresbased onconditions of the patient.nursing measures获经批准Approved by院长Hospital director_____________日期Date______________
3.1年龄包括N65周岁的老年患者、儿童及孕妇;Age includingold patients,65years old,children andpregnant women;
3.2既往有跌倒/坠床史;Past historyof fall/drop frombed;
3.3步态不稳、平衡障碍或肢体功能障碍;Unstable gait,balance disorderor limbfunction disorder;
3.4意识障碍或睡眠障碍;Consciousness disorderor sleepdisorder;
3.5视觉损伤;Vision injury;
3.6贫血、营养不良、虚弱;Anemia,malnutrition,weakness;
3.7体位性低血压或低血糖;Postural hypotensionor lowbloodglucose;
3.8颈椎病或眩晕症;Cervical spondylosisor vertigo;
3.9手术、麻醉后;After operationor anesthesia;
3.10使用过影响意识或活动的药物,包括利尿剂、止痛药、缓泻剂、镇静药、降压药、降糖药等Use drugsthat mightaffect consciousnessor movement,including diuretics,analgesics,slow laxatives,sedatives,anti hypertensivesand hypoglycemics.4门急诊跌倒的高危场所及情境High riskplaces andsituations of fall inOPD andemergency room
4.1感染科、结核科Department ofInfectious,Tuberculosis
4.2呼吸内科、心内科、内分泌科、神经内科、儿科、ICU、普外科Department ofRespiratory,Cardiology,Endocrinology,Neurology,Pediatrics,ICU,Department ofGeneral Surgery
4.3B超室、内镜室、理疗科B-Ultrasound Room,Endoscopy Room,Physiotherapy Dept.
4.4急诊室Emergency Room
4.5卫生间、楼梯、扶梯Toilet,Staircase,Escalator
4.6救护车、轮椅、推车、检查床间转移Transfer to ambulance,wheelchair,trolley oranother bed5跌倒风险评估Assess fall risks
5.1门诊跌倒风险评估Assess fall risks atOPD
5.
1.1各专科分诊护士负责门诊患者跌倒风险的评估The nursesorting the patients shall be responsiblefor assessmentof fall risks ofoutpatients.
5.
1.2分诊护士根据目测、简单询问病史及用药史,对有跌倒高危因素的患者进行评估The sortingnurse shallevaluate patients withhigh fall risksthrough visualinspection,asking briefcase historyand historyof medication.
5.
1.3根据《门急诊患者跌倒/坠床危险因子评估表》进行评估Assess based on“Outpatients andemergency patientsfall/drop frombed riskfactor evaluationform”.
5.
1.4如评估为高危跌倒患者,在患者身上明显部位粘贴“小心跌倒”标识,并采取跌倒/坠床预防措施When apatient isidentified asone withhigh fallrisk,stick amark“Be carefulof falling”on eye-catching partof hisher bodyand take preventive measures for fall/drop frombed.
5.2急诊跌倒风险评估Assess fallrisks ofemergency patients
5.
2.1急诊预检分诊护士负责急诊患者跌倒风险评估The sortingnurse shallbe responsiblefor evaluationof fallrisks ofemergency patients.
5.
2.2根据《门急诊患者跌倒/坠床危险因子评估表》进行评估u AssessbasedonOutpatients andemergency patientsfall/drop frombed riskfactor evaluationform^.
5.
2.3如评估为高危跌倒患者,在患者身上明显部位粘贴“小心跌倒”标识,并采取跌倒/坠床预防措施When apatient isidentified asone withhigh riskof fall,stick amark“Be carefulof fallingon eye-catching partof hisher bodyand take preventive measuresfor fall/drop frombed.
5.3血透患者Patients of hemodialysis血透患者均作为高危跌倒患者处理,无需进行跌倒/坠床风险评估,直接采取跌倒/坠床预防措施All patientsofhemodialysisare regardedas oneswithhighfallrisk,risk evaluationof fall/drop frombed is not necessary,takepreventivemeasures straightaway.
5.4住院患者跌倒风险评估Assessment of fallrisksofinpatients
5.
4.1患者入院后,由责任护士在本班内完成住院患者的跌倒/坠床风险初筛After apatient isadmitted,the responsiblenurse shall carry outpreliminary screeningon risksof fall/drop frombed duringher shift.
5.
4.2所有住院患者均要进行跌倒/坠床风险初筛All inpatientsshall undergopreliminary screeningon risksoffall/drop frombed.
5.
4.3如入院护理评估单中跌倒/坠床危险评估初筛为有危险者,则启用《住院病人跌倒/坠床评估与护理措施计划表》进行评估0分为相对零危险,1-3分者为低危险,N4分为高危险低危险者至少每周评估2次周
一、周四直至0分;高危险者每天评估,直至<4分《住院病人跌倒/坠床评估与护理措施计划表》应存放在病历中;零危险患者,无须填写When apatient isidentified asone withrisksoffall/drop frombed inpreliminary screeningby the nurse,start assessmentwith Evaluationof risksoffall/drop frombed ofinpatients andnursing measuresform”.Score0means0risk,1~3means lowrisk,34means highrisk.Assess thosewithlowrisks atleast twicea weekMon.Thu.until0;assess thosewithhighrisks everyday until
4.Put theform incase history,it isunnecessary tofill infor patients with0risk.
5.
4.4评估有跌倒危险的患者,应在其床尾悬挂“防跌倒”标识,在腕带上粘贴“黄色”警示标识,并采取跌倒/坠床预防措施u Hanga Preventfall”label onbed of the patientwith fallrisks,stick a“yellow”warning signon hisher wristband,takepreventivemeasuresforfall/drop frombed.
5.5持续评估Continuous assessment
5.
5.1初次评估低危险患者每周评估2次周
一、周四直至0分;Assess twiceaweekMon.Thu.on thosepatients withlow fallrisks inpreliminary assessmentuntil0;
5.
5.2初次评估为高危险患者,应每日对其进行一次评估,直至评分4分Assess onceeverydayon thosepatientswithhighfallrisks inpreliminary assessmentuntil
4.
5.6再评估Reassessment
5.
6.1患者病情、治疗发生变化时,如特殊检查后、手术后,使用或调整镇静剂、利尿剂、降压药、泻药、降血糖药后以及出现意识障碍等应对患者进行再评估When conditionsor treatmentis changed,for example,after specialexaminationoroperation,after usingor adjustingsedatives,diuretics,antihypertensive drugs,laxatives andhypoglycemics,conscious disorderappeared,thepatientshallbereassessed.
5.
6.2患者面临新的治疗环境,如转科等,应对患者进行再评估When apatient comestoanew treatmentsurrounding,such astransfer toanother ward,reassessment isrequired.6跌倒预防措施Preventive measureson fall根据风险因素,对病人和家属进行针对性宣教,采取预防跌倒和坠床的安全措施并记录,并加强床边交接班,督促强化各项预防措施的落实Educate thepatients andfamily membersaccording tofallrisks,take measuresto prevent fall/drop frombed,record themeasures,hand overat bedside,supervise implementationofthemeasures.
6.1保持医疗区域、公共区域光线充足Keep medicaland publicareas bright.
6.2地面干燥不潮湿,拖地或地面潮湿时及时放置警示标识Keep floordry,put awarning signafter moppingthe floor.
6.3通道无障碍物,病房通道内设置扶手,楼梯上设置“小心台阶”警示标识Keep passagefree,set handrailsin corridorof wardsand putwarning signsWatch yoursteps”on staircase.
6.4增加全院各处警示标识的张贴,尤其在卫生间及浴室内Stick morewarning signsin thehospital,especially in toilet andbathroom.
6.5为患者提供拐杖、轮椅、平车等便利设施,轮子加以固定Provide crutches,wheelchair andtrolley,fix wheels.
6.6呼叫器放置在患者易触及位置,卫生间设置紧急求助铃Put call bell ataccessible place,put emergencycallbellintoilet.
6.7卧床时使用护栏,离床活动应有人陪护,教会患者使用合适的助行器患者头晕时,应保证卧床休息烦躁、海妄、有精神症状的病人,必要时使用约束带Put guard rail onbed,escort patientswith fallrisks tomove,teach patientsto useproper walk-aid.When thepatient feelsdizzy,he shalllie inbed.Use restraintband forpatientswithmania,delirium orinsanity ifnecessary.
6.8避免穿大小不合适的鞋和衣裤,夜间睡前尽量少饮水Wear shoesand clothesof propersize,restrain waterintake beforegoing tobed at night.
6.9患者在救护车、轮椅、推车、检查床间转移时,应有陪护Escort patientswhile transferto ambulance,wheelchair,trolley oranother bed.
6.10患者应在康复师指导下进行康复训练,康复训练时有人在旁进行保护Patient shallhave rehabilitationtraining underthe guidanceof physiotherapistand withprotection.7发生跌倒/坠床的处理Handling fall/drop frombed
7.1发现病人跌倒/坠床后立即按《跌倒/坠床应急预案》处理,并及时报告值班医生及护士长u Whenfall/drop frombed happens,deal withit asper Fall/drop emergencyplan”immediately,report tothe doctoron dutyand headnurse intime.
7.2护士进行再评估和记录,加强健康宣教并采取改进措施The nurseshallcarryout reassessmentand recordit,reinforce healtheducation andtake improvementmeasures.
7.3当班护士填写不良事件报告表,上报护理部The nurseon dutyshall fillin reportof adverseevent andreport tothe nursingdept.
7.4护理部每月对已发生跌倒/坠床的病人进行原因分析,包括对采取的预防措施所导致的预期或未预期的后果进行分析,提出改进意见,并报医院质量与安全管理委员会批准后执行医院将患者因跌倒/坠床所致的II、III级伤害率作为质量与安全的监测指标之一The nursingdept.shall analyzethe causeoffall/drop frombed everymonth,including analysison preventivemeasures whichresulted inexpected orunexpected consequences,propose improvement,report tothe quality and safetymanagement committeeofthehospital forapproval.The hospitalregards classII andIIIinjuryrate resultedfrom fall/drop frombed asoneofthe monitoringindexes ofqualityandsafety.8跌倒/坠床的健康教育Health educationon fall/drop frombed预防跌倒“10知道”“10know”-howto preventfall
8.1当您有服用安眠药或感头晕,血压不稳时,下床时应先坐在床缘,再由家属扶下床After youtake hypnoticsor feeldizzy,BP isunstable,sit onbedside beforeleaving thebed,ask yourfamilymemberto helpyou.
8.2当您需要任何协助而无家属在旁,请立即以信号灯通知护理人员When youneed helpbut yourfamilymemberisnotby yourside,press signallamp toinform thenurse.
8.3若发现地面有水渍,请告诉工作人员,并避免在有水渍处行走,以防不慎跌倒When youfind wet floor,tell thestaff,do notwalk onwetfloortopreventfall.
8.4请将物品尽量收于柜内,以保持走道宽敞Put yourpersonal belongingsinto cabinet,keep passagefree.
8.5护士已将床栏拉起时,若需下床应先通知护士将床栏放下来,切勿翻越After thenurse mountsguard railof bed,tell thenurse toput itdown beforeleaving thebed,do notcross theguard rail.
8.6当您所照顾的病人有躁动、不安、意识不清时,请将床栏拉起,并予以约束保护When thepatient youattend feelsrestless orunconscious,please mountguardrailof bedand restrainhis behavior.
8.7请您向护士叙述可能导致您跌倒的原因Please tellthenursepossible causeoffall.
8.8请穿防滑鞋,切勿赤脚行走Please wearanti-slip shoes,do notwalk barefoot.
8.9病房夜间开启地灯Turn onbottom lampof wardatnight.
8.10如厕时,有紧急事故请按厕所内信号灯告知护理人员When emergencyhappens intoilet,please pressthe signallamp.。