资源描述：
《跌倒所有的高危因素》由会员上传分享，免费在线阅读，更多相关内容在行业资料-天天文库。
1、Ifanyofthesemedicalfactorsarepresent,gotoStandardFallPreventionInterventions:·Agitation/Delirium-infection,toxic/metabolic,cardiopulmonarychange,CNS,dehydration/bloodloss,sleepdisturbance·Meds(dose/timing)-psychotropics,CVagents(digoxinespecially),ant
2、icoagulants(increasedriskofinjury),anticholinergic,bowelprep·Orthostatichypotension,autonomicfailure·Frequenttoileting·Impairedmobility·Impairedvision,inappropriateuseofassistivedevice/footwear·HistoryofFalls(CV/lightheaded-dizzy,Dysequilibrium-lossof
3、balancewithnoabnormalmotionsensation,Vestibular/Vertigo,Weakness-Musculoskeletal/giveway,combination,other)·Psychotropics,digoxin,type1aantiarrhythmic,diuretic(thiazides>loopdiuretics)·Antihistamines/benzodiazipines-withdrawalhasshowndecreaseinfallsri
4、sk,assessforsleepdisorder,avoidroutinePRNorders-trynon-pharmacologicalapproachesincludingquietsleepprotocolsonunits·Antidepressants-TricyclicshigherriskthanSSRI,butSSRI'shaveriskaswell,highlevelofphenytoin;lowdosamitriptylineaffectsgate;gabapentin10-2
5、5%ADR·Cardiacdrugs/antihypertensives-iforthostatic(dropinsys>20mmin3min)andsymptomatic·Anticoagulants-subduralhematomasarerare;avoidonlyifveryunstablegaitorbalance,concurrentuseofalcohol,orotherdrugsthatinteractandincreasebleeding,ornon-compliantwithr
6、egimenorlabfollowup·Drugstreatingnocturia(considertamsulosinduetolowerriskoforthostasis)Nursingfallriskassessment,diagnosesandinterventionsarebasedonuseoftheMorseFallScale(MFS)(Morse,1997).TheMFSisusedwidelyinacutecaresettings,bothinhospitalandlongter
7、mcareinpatientsettings.TheMFSrequiressystematic,reliableassessmentofapatient'sfallriskfactorsuponadmission,fall,changeinstatus,anddischargeortransfertoanewsetting.MFSsubscalesincludeassessmentof:1.Historyoffalling;immediateorwithin3monthsNo=0Yes=252.S
8、econdarydiagnosisNo=0Yes=153.AmbulatoryaidNone,bedrest,wheelchair,nurse=0Crutches,cane,walker=15Furniture=304.IV/HeparinLockNo=0 Yes=205.Gait/TransferringNormal,bedrest,immobile=0Weak=10Impaired=206.MentalstatusOrientedtoown
