section name header

Notes

Risk FactorIntervention
Assessment Data
  • Age >65 yr.
  • History of falls.
  • Monitor frequently.
  • Pt should be close to nurses’ station.
  • Implement fall prevention interventions.
Medications
  • Polypharmacy.
  • CNS depressants.
  • BP/HR lowering.
  • Diuretics.
  • GI motility meds.
  • Review meds with physician.
  • Assess for meds that may affect BP, HR, balance, or LOC.
  • Educate about use of sedatives, narcotics, and vasoactive meds.
  • Encourage nonopioid pain management.
Mental Status
  • Altered LOC or orientation.
  • Routinely reorient Pt to situation.
  • Maintain a structured environment.
  • Use pressure-sensitive bed/chair alarms.
Cardiovascular
  • Postural hypotension.
  • Change positions slowly.
  • Review MAR for possible changes.
Neurosensory
  • Visual impairment.
  • Peripheral neuropathy.
  • Difficulty with balance or gait.
  • Provide illumination at night.
  • Minimize clutter and remove unnecessary equipment from room.
  • Provide protective footwear.
  • Provide appropriate assistive devices and instruct on proper use.
GI/GU
  • Incontinence.
  • Urinary frequency.
  • Diarrhea.
  • Ensure call light is within easy reach.
  • Create toileting schedule.
  • Provide bedside commode or urinal or unobstructed, well-lit path to bathroom.
Musculoskeletal
  • Decreased range of motion.
  • Amputee.
  • Provide range-of-motion exercises and stretching.
  • Provide PT or OT consults.
  • Provide appropriate assistive devices.
Assistive Devices
  • Use of cane, walker, or WC.
  • Ensure that assistive devices are not damaged and are appropriately sized.
  • Instruct Pt on proper and safe use.
Environment
  • Cluttered room.
  • Tubes and lines.
  • Minimize clutter; remove unnecessary or infre-quently used equipment.
  • Ensure call light is within easy reach.

Subtopic(s)