question

What forms of medications can be given through a tube feeding?

answer

1. liquid forms 2. immediate-release solid dosage forms **capsules, enteric-coated and XRs "cannot" be crushed and administered by NG tube **capsules should never be opened

question

Before administering medications via a NG tube, the nurse must...

answer

obtain/have an order from the physician

question

When a medication is ordered to be delivered by NG tube and the medication is one that may not be delivered by this route, what should the nurse do?

answer

contact the pharmacy

question

EC, ER, SA, CR, SR, LA, XL, XT

answer

EC: enteric coated ER: extended release SA: sustained action CR: controlled release SR: sustained release LA: long acting XL: extended length XT: extended time **ALL these medications may not be given via NG tube because they may not be crushed**

question

What should the nurse do prior to administering medications via NG tube? When medications are administered through a feeding tube, when is the tube flushed, with what, and how much? What about patients on fluid restrictions?

answer

1. Assess for tube placement and fluid restrictions 2. Tube is flushed with 15 to 30 ml of water before and after medication administration 3. If patient is on fluid restrictions, use the least amount of NSS for flushing and remember to record on I/O

question

You have administered medications through an NG tube that is attached to suction. What do you do after administering the medication?

answer

1. Clamp Tube 2. Turn off suction for 20 to 30 minutes

question

Normal gastric emptying time is?

answer

1 to several hours

question

You have administered medications through an NG tube to a patient who is on continuous tube feedings. The drug reference says that medication must be given "between meals" not with food. What do you do? (7)

answer

1. Discontinue feedings 30 minutes prior to administration 2. Confirm tube placement 3. Confirm allowance residual volume (less than 200 ml) 4. Flush with 15 to 30 ml of water 5. Administer Medication 6. Flush with 15 to 30 ml of water 7. Resume feedings 30 minutes after administration

question

A nurse is taking care of a patient with a NG tube running at continuous suction. Before medication administration the nurse assesses residual volume and obtains 350 ml. What should the nurse do?

answer

The nurse has obtained a greater amount than the allowance residual volume of "less than 200ml", she will not administer the medication and contact the HCP

question

When and how is feeding tube placement verified?

answer

1. After initial placement - via X-ray 2. Before feedings/medications/liquid installation - via aspiration and pH 3. Before feedings/medications/liquid installation & @ times when tube is believed to have been moved - via visual inspection and measurement of correct tube length "outside nares"

question

When assess tube placement should the nurse use air bolus injection/auscultation

answer

No. it is very unreliable and can cause air to be placed in another area

question

How is pH measured?

answer

1 hours after patient has feeding, test aspirate (5-10ml) content using pH paper (wait 30 seconds before reading)

question

How much aspirate should be obtained for a pH measurement?

answer

5-10 ml

question

What are normal pH ranged for stomach? For upper intestines? For the respiratory tract?

answer

Stomach pH: less than 5.5 Upper Intestines: greater than/equal 7.0 Respiratory great than/equal to 6.0

question

A stomach pH is normally less than 5.5. What medications will affect stomach pH and how? What are other situations that can alter pH? How?

answer

1. H2RB inhibitors, PPIs and antacids 2. will cause the stomach pH to be between 4.0 and 6.0 3. The nutritional formula given with continuous tube feedings can buffer the pH of the GI

question

What does aspirate look like from the stomach? intestine? respiratory tract?

answer

Stomach: green; (may have off-white particles and brown if old blood) Intestines: straw colored to deep golden-yellow (may be green brown if w/bile) Respiratory tract: off-white to tan (may be tinged w/mucus) **REM: measurement of pH "DOES NOT" definitively differentiate between intestinal and pleural fluid

question

A nurse has obtained some aspirate from an NG to confirm placement, the aspirate contains a small amount of blood tinged fluid. What should the nurse do?

answer

This is totally normal "after insertion" of an NG tube

question

A nasogastric Salem sump is usually indicated for a patients that requires feedings for

answer

6 weeks or less

question

How does a Salem Sump NG tube function?

answer

a Salem Sump NG tube is placed in the stomach so that the stomach can serve as a reservoir for feeding The patient with a salem sump will have "normal physiological emptying" into the small intestines

question

What type of feedings can be given with a Salem Sump NG tube?

answer

bolus feedings

question

Salem Sump NG tubes should not be placed in patients with...

answer

1. Dysfunctional gag reflex 2. gastric stasis (retention of fluid in the stomach) 3. GERD 4. Nasal injury 5. patients unable to have head of bed (HOB) elevated

question

Due to the fact that the Salem Sump is less invasive than the PEG/G-tubes this places the patient

answer

at a higher risk of displacement than an endoscopically placed tube

question

Which NG tube provides better ease at verifying placement by aspiration?

answer

Levine tube *but can be more traumatic to the nares,throat than the Dobhoff (small bore feeding tube)*

question

A PEG tube (gastric) or Low Profile Gastrostomy Device is usually indicated for a patients that requires feedings for how long?

answer

for long-term (greater than 6 weeks) and with functional GI tract

question

A patient in need of a enteral feeding tube wants to know which tube posses them at a high risk for aspiration. A PEG tube or a J-tube?

answer

A PEG (G-Tube) posses a higher risk for aspiration than a J-tube

question

A naso-intestinal feeding tube is usually indicated for a patients that...(4)

answer

1. at higher risk of aspiration 2. have delayed gastric emptying 3. gastric tumor 4. stomach removed **decreases aspiration risk**

question

Nasointestinal feeding tube is placed in the...

answer

upper intestines

question

What are 2 disadvantages of the nasointestinal feeding tube and the J-tube

answer

1. PC Dumping Syndrome 2. Continuous feedings are better than bolus

question

J-tube feedings are indicated for

answer

long term feeding of patients with increased aspiration risk or have stomach problems

question

Tube feedings are started at _____ _____ at an infusion rate of ______ (____), then advanced by ______ (___) every _____ hours until desired rate is achieved, if tolerated.

answer

Tube feedings are started at [full strength] at an infusion rate of [10-40 ml/hr], then advanced by [10-20ml/hr] every [8-12] hours until desired rate is achieved, if tolerated

question

How would a nurse assess tolerance to tube feedings? (4)

answer

1. assessment for abdominal distention 2. assessment for vomiting 3. assessment for diarrhea 4. assessment of normal bowel sounds

question

A patient with a feeding tube is currently vomiting. What might this indicate? (2)

answer

delayed gastric emptying or an increase in residual volume

question

A patient with a feeding tube currently has diarrheal stools. What might this indicate? (3)

answer

1. feeding too fast 2. low-fiber formula 3. contaminated formula 4. dumping syndrome

question

In addition to assessing tolerance of feeding, what nursing assessments are appropriate for the patient receiving tube feedings?

answer

1. Evaluate nutritional status of patient 2. Monitor for complications (infection, tube movement, etc.) 3. Evaluate for therapeutic effect of NG tube connected to suction (gastric decompression) 4. Assess skin/oral mucosa integrity for breakdown/infection 5. Monitor I/O and stool pattern 6. Assess abdomen for distention and presence of bowel sounds (to confirm GI function)

question

A patient on a feeding tube should have regular weight assessments. How often should these assessments occur?

answer

1. Initially: every 2 to 3 weeks 2. every month thereafter **make indicated adjustments to caloric intake

question

A patient on a feeding tube should have regular laboratory assessments. What laboratory values are important to do? (4)

answer

1. Serum glucose 2. AST/ALT - live function tests 3. Albumin 4. Electrolytes

question

How often must you check for gastric residual during continuous feedings, and what amount of residual is acceptable? (3)

answer

1. q4-6 hours in the first 24 hours 2. q8 hours during continuous feedings 3. Acceptable = 10%-20% of the hourly rate **Take patients norm into consideration **More frequent assessments should be done on critically ill patients

question

What are the head-of-bed (HOB) rules for patients having tube feedings? (2)

answer

1. Elevate HOB 30 to 45 degrees (semi-fowler) during and 1 hours following feeding 2. If patient must lay flat (for whatever reason), discontinue tube feeding to prevent aspiration

question

After the insertion of a "naso-intestinal tube, the patient is placed in what position for up to 24 hours?

answer

right sided

question

What are the purposes of nasogastric tubes for gastric decompression? (4)

answer

1. decompress/drain the stomach of fluid, unwanted stomach contents (poison, medications, air) 2. Allow the stomach to rest/heal before or after surgery (ie. for post-op ileus) 3. relieve N/V 4. treat any bowel obstructions

question

How and why does irrigation of a NG tube being used for gastric decompression (suction) differ from irrigation of a feeding tube?

answer

1. When a NG tube tube is being used for decompression, it is irrigated with NSS and "not water". This decreases the risk of electrolyte imbalances, especially NaCl

question

Suction and Lumen characteristics for a Levin, Salem Sump and Moss Gastric Decompression tubes...

answer

Levin: low, intermittent - single lumen Salem Sump: low, continuous - double lumen Moss: low, continuous - triple lumen

question

Dumping Syndrome is usually caused by or related to

answer

the rapid distention of the jejunum from hypertonic formulas

question

What are manifestations of Dumping Syndrome? (5)

answer

Patient will have gas and diarrhea as well as abdominal bloating and cramps. The patient may also feel dizzy

question

When a patient manifests Dumping Syndrome, what should the nurse do?

answer

decrease the feeding rate

question

How can Dumping Syndrome be prevented?

answer

start feedings slowly and gradually increase rate "as tolerated"

question

Diarrhea is usually caused by or related to (5)

answer

1. Dumping Syndrome 2. Contaminated Formula 3. Medication reactions 4. Super-infections from antibiotics 5. Fast feedings

question

When a patient manifests diarrhea, what should the nurse do?

answer

slow the feeding rate

question

How can diarrhea be prevented? (3)

answer

1. limit formula hang time to 8 hours 2. Refrigerate open formulas and discard after 24 hours 3. Change delivery system (according to agency policy)

question

The inability to aspirate gastric content is usually caused by or related to

answer

1. a clogged tubed 2. tube opening against the mucosa

question

When the nurse is unable to aspirate gastric content, the nurse should

answer

inject air and then aspirate again

question

A plugged feeding or decompression tube is caused by or related to

answer

formula, medications, gastric contents occluding tube

question

When the nurse encounters a plugged feeding or decompression tube the nurse should

answer

irrigate with 30 ml of warm water

question

How can a plugged feeding or decompression tube be prevented? (2)

answer

1. Irrigate tube before and after feedings and medication administration 2. Irrigate tube every 4 hours during continuous feedings

question

When the nurse encounters a PEG tube leaking gastric fluid around the site, the nurse should

answer

check and adjust guard or balloon

question

A PEG tube that is leaking gastric fluid will cause the

answer

site to be moisten or the skin to be inflamed

question

Aspiration of formula can be cause by or related to

answer

1. dislodgment of tube 2. regurgitation

question

Aspiration of formula is manifested by? (4)

answer

1. dyspnea 2. coughing 3. formula in sputum 4. fever (infection)

question

If a patient is aspirating formula, the nurse should? (4)

answer

1. stop feedings!! 2. verify tube placement 3. reposition the tube 4. notify the MD

question

How to prevent aspiration of formula?

answer

1. check tube placement and residual volumes frequently 2. Maintain HOB elevated during and after feedings 3. Keep tube secure 4. Restrain patient (if ordered) - patient is dislodging tube

question

Nasal erosion is caused by or related to

answer

pressure of tube in nares pressure sore

question

If there is nasal erosion present, the nurse should? (4)

answer

1. clean nares 2. reposition and secure tube

question

Nasal erosion can be prevented by?

answer

1. Checking nares every shift 2. cleaning and moistening nares q4hrs 3. positioning and securing tube to avoid pressure

question

Nausea, Vomiting, distention is caused by or related to?

answer

1. feeding too fast 2. constipation 3. ileus

question

Manifestations of nausea, vomiting and distention include

answer

1. nausea 2. vomiting 3. distention 4. decreased or absent bowel sounds

question

If a patient is manifesting N/V or distention the nurse should? (2)

answer

1. assess abdomen 2. slow or stop feedings

question

N/V and distention can be avoided by?

answer

1. checking residuals 2. avoiding over-sedation 3. giving motility medications (as ordered)

question

When a feeding tube stoma is infected the nurse should ?

answer

1. Report to physician immediately 2. Consult wound care specialists (as needed)

question

Feeding tube stoma infections are prevented by?

answer

1. cleaning site w/soap and water (every shift) 2. applying topical antibiotics (as ordered)

question

When writing a narrative note for feeding tube insertion include...

answer

1. Type of tube/size 2. How patient tolerated procedure 3. Which nares 4. Aspirated content, pH 5. Length of tube from nares to end of tube 6. Type of suction and rate (ex. 100 at low, continuous suction 7. Character of secretion (noted from tubing contents) obtained via suction 8. Patient education provided (did pt/family demonstrate understanding --> via repetition, demonstration..) Example: 01/16/2014 1100 Abdomen distent; hypoactive bowel sounds. Fr-12 Salem Sump tube inserted via R. naris, 22 cm of tube from naris to end of rube. Gastric contents aspirated, pH 5, contents yellow. Patient tolerated w/out incident. AF Cruz, RN

question

Nasogastric suctioning pressure should be...

answer

100 to 150 mmHg

question

When an artificial airway is placed it required the nurse to use

answer

warmed, humidified air or oxygen, since the nasopharynx is bypassed

question

What is the purpose of an artificial airway?

answer

1. bypass upper airway obstruction 2. maintain a patent airway and prevent aspiration of oral/gastric secretions 3. permit mechanical ventilation 4. reduce the workload of breathing (tracheostomy eliminates dead air space between nose and trachea)

question

Endotracheal tube

answer

passed through mouth or nose and into the trachea

question

Endotracheal tubes are indicated for

answer

short term use (less than 3 weeks)

question

How is an endotracheal tube placed?

answer

inserted with laryngoscope, patient is usually sedated

question

An endotracheal tube has a cuff that is inflated to

answer

15 to 20 mmHg - prevents air leakage/aspiration around tube

question

How often should you check cuff pressure on an endotracheal tube?

answer

every 8 hours

question

During the insertion of an endotracheal tube a potential problem might be the inadvertent intubation of the right main stem bronchus. How can the nurse identify this problem?

answer

assess bilateral lung sounds

question

During the insertion of an endotracheal tube a potential problem might be the damage of the laryngeal nerve. How can the nurse identify this problem?

answer

paralysis of vocal cords (patient unable to speak)

question

Other potential problems from endotracheal tube placement might be

answer

1. depressed cough/swallow reflex 2. mechanical trauma 3. ulceration/stricture of the larynx or trachea 4. unintentional removal by patient 5. inability to speak (tube pases through larynx) 6. thickened secretions 7. increased risk of pulmonary infection

question

A tracheostomy tube is indicated for

answer

long-term use, longer than 3 weeks

question

With a tracheostomy tube the cuff is ______ at __________ and monitored every __________

answer

With a tracheostomy tube the cuff is [always inflated] at [15 to 25mmHg] and monitored every [8 hours]

question

If a patient with a tracheostomy tube doesn't require mechanical ventilation, the

answer

inflatable cuff is not necessary

question

Early complications of a tracheostomy tube may include...(7)

answer

1. bleeding 2. pneumothorax 3. air embolism 4. aspiration 5. SubQ/Mediastinal emphysema (bubble wrap under skin) 6. laryngeal nerve damage 7. penetration of posterior tracheal wall

question

Long term complications of a tracheostomy tube may include...(5)

answer

1. airway obstruction from secretions/cuff profusion over internal tube opening 2. infection 3. rupture of an artery 4. tracheo-esophageal fistula r/t cuff overinflation 5. tracheal stenosis after tube is removed

question

When is a patient able to speak through a tracheostomy tube

answer

when the cuff is deflated and tube is plugged or if a fenestrated tube is being used

question

What are nursing management tasks early post-operative phase (while stoma is healing) (3)

answer

1. Maintain airway by suctioning PRN (REM: over suctioning can cause irritation 2. Semi-Fowler's position to promote ventilation and drainage, minimize edema, and prevent strain on sutures 3. Facilitate communication (paper and pencil, Magic slate, call bell w/in reach)

question

For patients w/tracheostomy, EMERGENCY equipment that should be kept at bedside at all times includes (4)

answer

1. replacement tracheostomy tube and obturator 2. bag-valve-mask device 3. oxygen source 4. suction equipment/supplies

question

How often should tracheostomy care be done?

answer

1. at least daily 2. most often as needed, new tracheostomy may need attention every 1 to 2 hours

question

Always suction before tracheostomy care (only if required). Need for suctioning may be manifested by...

answer

1. Adventitious lung sounds 2. secretions in tube 3. decrease in SpO2 (pulse Ox) 4. tachypnea or acute respiratory distress 5. frequent/sustained coughing

question

When suctioning the tracheostomy tube...

answer

1. use sterile procedure 2. sterile suction catheter or in-line suction catheter (if ventilator in use) 3 it is normal for the patient to have sensations such as SOB and coughing

question

If patient needs suctioning of tracheostomy and is post-op the nurse has to

answer

administer medication for pain

question

When suctioning an adult only use a medium suction pressure of

answer

80-120 mmHg

question

Prior to suctioning remember to

answer

hyperventilate patent with high flow (100%) oxygen 3 to 6 times for 30 seconds to 3 minutes before passing catheter and between passes of catheter Give the patient 30 seconds to 1 minute to rest between passes of catheter ONLY SUCTION when coming OUT; twist catheter when withdrawing in circular manner Hyper-oxygenate for 1 to 5 minutes or until HR and O2 sats are at baseline

question

The maximum amount of suction passes are...

answer

3

question

The maximum suction time is

answer

10 to 15 seconds/pass

question

If suctioning the patient causes difficulty d/t thick secretions the nurse can (w/unit protocol or PCP order)

answer

instill 2-3 ml of NSS down the tracheal tube

question

Discontinue suctioning immediately if...(5)

answer

1. SpO2 drops below 90% 2. Patient becomes cyanotic 3. Bradycardia occurs 4. excessive tachycardia occurs (should not reach 140 bpm 5. other dysrhythmias occurs (in a monitored patient)

question

Following cleaning w/hydrogen peroxide of cannula make sure to

answer

thoroughly rinse inner cannula so that hydrogen peroxide doesn't enter airway (highly caustic/necrotic)

question

To minimize trauma or to stabilize outer canula

answer

hold faceplate securely while removing inner canula

question

When applying clean tape...

answer

leave soiled twill tape in place so tube doesn't become displaced/dislodged should patient move/cough

question

If the tracheostomy tube becomes dislodged,

answer

it must be immediately replaced with a new one

question

How should you replace a dislodged tracheostomy tube?

answer

1. insert obturator into tracheostomy tube 2. insert tracheostomy tube into stoma 3.. remove obturator --> obstructs patient's airway 4. secure ties 5. auscultate lung sounds 6. palpate for subcutaneous emphysema

question

How is the proper placement of a tracheostomy tube confirmed?

answer

chest x-ray

question

Postoperative care of a tracheostomy tube includes

answer

1. assessing bilateral breath sounds 2. respiratory assessment every 2 hours

question

Indicators of tube obstruction post-op include

answer

1. difficulty breathing 2. noisy respirations 3. difficulty inserting a suction catheter 4. thick, dry secretions 5. unexplained peak pressures (if mechanical ventilator is used)

question

Prevent tube obstruction by helping patient

answer

cough and deep breath providing inner cannula care humidifying the oxygen source suctioning

question

Tube dislodgment in the first 72 hours...

answer

is an emergency situation

question

If the tube is dislodged on an immature tracheostomy

answer

ventilate the patient using manual resuscitation bag and face mask another nurse calls the Rapid Response Team

question

**NEVER CUT dressing, small bits of gauze can be aspirated

answer

...

question

If the skin around a new tracheostomy is puffy and you feel a crackling sensation, when pressing on the skin

answer

notify the physician immediately

question

During the first 24 hours post-op perform cannula care

answer

as needed, every 30 to 60 minutes

question

Always deflate the cuff before

answer

caping the tube with the decannulation cap; otherwise; the patient has no airway

question

When a PEEP value is greater than 10 mmHg

answer

increase the cuff pressure

question

When a temperature probe is placed in a tubing circuit to analyze warmth of humidified water monitor the circuit temperature

answer

every hour by feeling tube and by checking the probe

question

Keep the temperature of the air entering a tracheostomy between

answer

98.6 and 100.4F, never exceed 104F

question

Hypoxia

answer

increase in HR, BP oxygen desaturation cyanosis restlessness anxiety dysrhythmias

question

Vagal Stimulation

answer

severe bradycardia hypotension heart block ventricular tachycardia asystole

question

Oral hygiene

answer

clean mouth with water help patient rinse mouth with NSS every 4 hours while awake or as he/she desires apply lip balm or water-soluble jelly to prevent cracked lips and promote patient comfort

question

Prevent aspiration

answer

thicken fluids avoid fruit (produces fluid when bitten) partially deflate the tube cuff during meals suction after initial cuff deflation to clear airway and allow better comfort during meals dry swallow is recommended if the patient coughs, stop the feeding until he/she indicates the airway has been cleared

question

A patient with a tracheostomy may speak

answer

cuffless tube fenestrated tube fenestrated tube is cuffed or covered cuff deflation (if tolerated) - patient places finger over tracheostomy tube during expiration

question

weaning of patient from tracheostomy tube

answer

1. gradual decrease in size -deflate the cuff as soon as the patient can manage secretions and doesn't need mechanical ventilation -tube changed to uncuffed --> if tolerated patient's tube size is decreased -if fenestrated tube --> it is capped for 24 hours and then removed 2. ultimate removal 3. dry dressing over stoma 4. tracheostomy button - to maintain stoma patency and assist spontaneous breathing

question

The focus of the assessment related to rehabilitation and chronic disease is on the

answer

functional ability of the patient

question

Determine the level of activity that can be accomplished

answer

w/out symptoms of fatigue, chest pain, SOB, or severe weakness

question

GI/Nutritional

answer

ask about usual bowel patterns before the injury or the illness bowel habits are always evaluated based on what is normal for that person

question

Braden Scale assess

answer

1. sensory 2. perception 3. skin moisture 4. activity level 5. nutritional status 6. potential for friction and shear

question

Inspect the skin for pressure ulcers how often?

answer

every 2 hours until the patient learns to inspect his or her own skin several times a day

question

Safety Patient Handling

answer

1. maintain a wide, stable base with your feet 2. put the bed at the correct height (waist level - providing direct care; hip level - moving patients) 3. try to keep the patient or work directly in front of you to prevent your spine from rotating 4. keep the patient as close to your body as possible to prevent reaching 6. reposition every 2 hours

question

Bed to Wheelchair or Chair

answer

1. wears transfer belt 2. place the chair at an angle to the bed on the patients "strong" side 3. While holding on to the transfer belt, ask the patient to stand and move his or her strong hand to the armrest 4. Patient must maintain body weight forward, and pivot 5. When the patient's legs touch the chair edge, guide the patient into a sitting position in the chair 6. Keep the transfer belt in place for transfer back into bed

question

Wheelchair or Chair to Bed

answer

1. Place the chair with the patient's strong side next to the bed 2. Ask the patent to stand, and move his or her strong hand to the armrest 3. Keep body weight forward, and pivot 5. When the patient's legs touch the bed edge, guide the patient until sitting and then reclining

question

Orthostatic hypotension

answer

drop in systolic by 20mmHg or drop in diastolic by 10mmHg

question

A straight (single point) cane provides less support than a walker or quadruped cane

answer

...

question

Walker assisted

answer

1. Place both hands on the walker 2. Lift walker 3. Move walker 2 feet forward, set it down on all 4 4. While resting on walker, take small steps 5. Check balance 6. Repeat

question

Cane assisted

answer

1. Make sure cane is at the height of the patient's wrist when the arm is placed at his her her side 2. Place strong hand on cane 3. Move cane and "weaker leg" forward at same time 4. Move "Stronger leg" one step forward 5. Check balance and repeat "CWS"

question

Pressure Ulcers

answer

if a reddened area does not fade w/in 30 minutes after pressure relief or does not blanch, they may be classified as pre-ulcer (Stage 1 Pressure Ulcers) -reposition patients in wheel-chairs every 1 to 2 hours -never rub reddened areas

question

Intermittent cauterization is incremented if the PRV

answer

is less than 100 to 150 ml **the patient should not go beyond 8 hours between cauterization

question

UTI

answer

unless the patient has symptoms of UTI (fever or burning) when voiding, the infection is NOT treated TO prevent UTI drink 8 to 10 glasses of water daily before dinner, stay away from carbonated beverages IF catheterized: drink 15 glasses of fluid Toilet the patient every 2 hours during the day, every 3-4 hours during the night Bladder capacity = 100 to 500 ml

question

Morse Fall Scale: NO Risk, Low Risk, High Risk

answer

No Risk: 0 to 24 --> Good Basic Nursing Care Low Risk: 26 to 50 --> Standard Fall Precautions High Risk: greater than 51 --> High Risk Fall Precautions

question

Folstein Mental Function

answer

Impaired: less than 19 Borderline: 19 to 23 Normal: 23 to 30

question

Braden Scale

answer

6 -pressure ulcer risk 20 - no risk

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