Postpartum fall risk assessment

rn/writer, RN · Jan 26, 2007

I don't know if it's volume of blood loss alone so much as it is blood loss in combination with other factors such as H&H, dizziness, low B/P, low O2 sats, etc. A biggie is their med situation. Are they on a PCA and have they been pushing the button like crazy? Are they on other opiates? Combinations of the above factors can enhance the fall risk tremendously.

You might want to start investigating at a 500 ml loss, but I've had moms who lost 800-1000 who were asymptomatic and others who lost only 300 ml and yet scared the bejabbers out of me the first few times they got up.

You also have to take their pre-pregnancy and pre-delivery status into consideration. Do they have a hx of orthostatic problems? Some women do.

Fall risk can be aggravated by simple things like still being attached to an IV/PCA and having a Foley. Many times, I've had to have the mom stop in her tracks while I untangle the various tubing and lines that seem to take on a life of their own when moving.

I'd be interested in hearing how you progress with your assessment tool as we are looking at similar considerations. Fall prevention is often associated with the elderly and infirm. We sometimes don't give it proper attention with otherwise healthy young women.

Elvish, BSN, DNP, RN, NP · Jan 26, 2007

Our PP risk assessment falls into 5 categories:

EBL >500ml (although rn/writer is right)

Mental status (most are a&o x3 but you never know..)

Ambulation independent? (vs. use of cane, walker; again not usually applicable)

Gait

Meds (psychotropics, continuous PCA/epidural/Duramorph, benzodiazepines)

You either get a 0 or a 1. (ex. if EBL was 300 you'd give them a 0; for 800 you give them a 1.) Anything under 3 is low risk, although of course you assess each patient individually.

In that part of the assessment, we also chart safety measures taken -- fall precautions instituted, call bell within reach, comfort measures, toileting (if needed), SO at bedside.

There is a place to freehand exceptions and/or changes. If a lady s/p c/s has an EBL of 1000ml, has an epidural, and later on develops confusion, we chart that in this section. It sounds confusing but looking at it it's not that hard. We chart every 2 hrs that the falls assessment is unchanged or, if there are changes, what they are and the measures taken.

HTH.

htrn · Jan 26, 2007

Thanks for your response RN/writer. This is in response to your friend and mine, JCAHO, patient safety standards. You're right, people don't think about our post-partum mom's being at risk for falls until we have to pull them out from between the toilet and the wall when they pass out. Not the right time to be thinking about it. I got to spend some time in our ER at the end of my shift several months ago after tripping over EFM cables in a dark room and landing on all fours on the floor - whiplash of all things.

You bring up very good points, and we have addressed most, if not all of them. I know that PP hemmorhage is a huge risk factor, and 500ml or a drop in HGB of 3.5 mg/dl for a lady partsl delivery and an EBL of 1000ml for c-sections is considered a reportable incident to the state.

I have included an expectation that all patients will be oriented to the room, call light within reach, instructed to call for assistance first time OOB after delivery and PRN after that, low level light in the room at night unless specifically requested otherwise by the patient and walkways remaining clear. We have also decided that everyone will assessed for fall risk as things like: hx of falls, epidural/spinal, uncontrolled pain, use of narcotic or sedating medication, medical equipment that can impeded ambulation (IVs, foleys, EFM, etc...), excessive blood loss, etc...

I would be happy to e-mail you a copy of our policy/procedure when we get it done. Any other ideas would be appreciated.

33-weeker · Jan 27, 2007

Perhaps take into consideration whether or not this is her first parturition. It seems primips get dizzy/fall/faint more than multips -- not saying multips can't be at risk, of course.

Length of time since delivery and previous dizzy/faint/fall this admission could be parameters, too.

SmilingBluEyes · Jan 28, 2007

Obrnheather, excellent post. I think it's so helpful. Thank you!

sissyboo · Jan 28, 2007

Something I've never thought much about...Sounds good!

NurseLatteDNP, MSN, DNP, RN · Jan 28, 2007

I fainted after having my first baby. I guess it was just blood loss, because I was not on any meds and I did not have any alarming labs that could cause it.

**canoehead, BSN, RN** · Jan 28, 2007

I think anyone who has had a child should be on fall precautions for at least 12h whether they think they need it or not. If they get up with standby assist three times (document it) without dizziness, gushing, unsteady gait etc, and they have no tubes they can come off.

If they have one tube (an IV say) they get 24h of precautions. Plus the documented three trips without needing assistance.

More than one tube and they need a nurse to corral the lines if nothing else, so they are automatically on precautions forever.

To heck with fall scales, thats how we do it in our heads, right? It makes sense so why create another piece of paper to fill out? Make it a written policy and then just do it without the additional paperwork.

htrn · Jan 28, 2007

I like your ideas about 12hrs of precautions and the thought about tubes - thanks. We have an 'egress test' that we are instituting throughout the hospital that all pts are supposted to be evaluated with prior to being allowed OOB. After the test they are assigned a colored 'flag' that goes above their bed and communicates to all providers how well this person ambulates. A green flag means no problems, red flag means bed rest, black flag means we haven't done the test yet and then other colors to reflect 1/2 assists, equipment needed etc... Part of our 'back saving' policies.

Keep 'em coming folks. Thanks abunch.

imenid37 · Jan 28, 2007

Thanks Heather. I just finished creating a peds fall risk assessment. I guess PP is coming too. Great info.

MemphisOBRNC, BSN, RN · Jan 28, 2007

Heather, ditto on the great post. What state do you practice in? I had not heard the Hgb drop of 3.5 being state reportable. (In am in Tennessee) Just out of curiosity, what other OB related reportables (state of hospital) do you have?

On another JCAHO note, do you do DVT/ thrombosis screening and prophylaxis on your moms? We are using the same form as the rest of the hospital which does not address pregnancy. Many of the nurses check 'hypercoagulable state' yielding an automatic score of 3. The other items listed in the 3 category include things like previous clot or stroke, non-ambulatory status, surgery lasting more than ?? hours, etc. The MD must mark which orders are to be done, which means TEDs at a minimum. Pregnancy will probably be added to the form in a much more appropriate location requiring no intervention unless something unusual is going on with the patient.

We are having a corporate mock survey tomorrow.