Edinburgh Cancer Centre new nurse handbook
Falls Risk bundle should be completed within 24 hours of admission for all patients and re-assessed if patient falls, their condition deteriorates or following transfer.
ABCDE assessment prior to movement including.
Don’t move patient until they have been checked for signs/symptoms of fracture or potential spinal injury.
Top to toe assessment for injury by nursing staff or doctor.
Make a plan to get patient safely off the floor.
All falls to be reported to medical team at time of fall.
Where head injury is suspected or has occurred, GCS must be recorded, frequency and duration to be based on medical guidance.
DATIX and Appendix A to be completed.
