跌倒：床放低、轮子锁定、呼叫铃触手可及

🧠 为什么重要

入院时和病情有任何变化后都要评估跌倒风险，使用Morse Fall Scale等工具：跌倒史、次要诊断、助行器具、IV管路、步态和精神状态。风险因素包括年龄、镇静剂和降压药、体位性低血压、尿急、意识混乱和视力差。干预措施包括：床调到最低位置并锁定轮子，呼叫铃和个人物品放在触手可及处，穿防滑鞋，照明充足且通道畅通，每小时巡视，定时协助如厕，为高风险患者使用床或椅子报警器，并协助行走。要让患者用上自己的眼镜和助听器。当意识混乱的患者翻越床栏时，床栏反而会加重伤害，而且四边床栏全部升起就构成约束。跌倒后，先评估患者再移动他们，测量生命体征并检查有无受伤，通知医务人员，并填写事件报告。

Assess fall risk on admission and after any change, using a tool such as the Morse Fall Scale: history of falls, secondary diagnoses, ambulatory aids, IV lines, gait and mental status. Risk factors include age, sedatives and antihypertensives, orthostatic hypotension, urinary urgency, confusion and poor vision. Interventions: bed in the LOWEST position with wheels LOCKED, CALL LIGHT and personal items within reach, NON-SKID footwear, adequate lighting and a clear path, hourly rounding, scheduled toileting, bed or chair alarms for high-risk clients, and assistance with ambulation. Use the client's glasses and hearing aids. Side rails can increase injury when a confused client climbs over them, and all four rails up counts as a restraint. After a fall, assess the client before moving them, take vital signs and check for injury, notify the provider, and complete an incident report.

🏥 真实场景

🌙 一名服用新利尿剂的患者被告知去洗手间时要呼叫帮助。0200时她需要去洗手间，看到护士正忙，便自己尝试起身。那位在白天早些时候给利尿剂、围绕药效高峰安排如厕时间、并把床边便椅放在触手可及处的护士，就不会接到那通呼叫。预判比警告更能预防跌倒。

🌙 A client on a new diuretic is told to call for help to the bathroom. At 0200 she needs to go, sees the nurse is busy, and tries alone. The nurse who gives the diuretic early in the day, schedules toileting around its peak, and keeps a bedside commode within reach does not get that call. Anticipation prevents more falls than warnings do.

📌 要点总结

• 使用镇静剂、利尿剂后以及精神状态改变后，要重新评估风险Reassess risk after sedatives, diuretics and changes in mental status
• 床放低并锁定，呼叫铃触手可及，穿防滑袜，通道畅通Bed low and locked, call light in reach, non-skid socks, clear path
• 四边床栏全部升起是约束，不是安全措施All four side rails up is a restraint, not a safety measure

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