Appendix C3: Unsafe Behavior Worksheet Sample The Falls Management Program Manual Note: This form has been filled out with information for the sample case study patient, Mrs. P.Resident:_____Mrs._P_______________ Rm #:_401-A_____ Date:___4/12/04_____StepDescriptionNotesStep 1Behavior stated clearly using action verbsGets up frequently, climbs out of bed and tries to ambulate unsafely. Appears anxious and fearful.Step 2Relevant personal and medical historyMarried for 45 years, mother of 3 children and 10 grandchildren. Catholic, homemaker, gardener. Husband lives at home with daughter and is unable to visit.Step 3CircumstancesTime: 11 PM - 4 AMFrequency: 3-4 time per weekLocation: RoomPersons present: Often aloneSituation: Dementia, new environmentMotivation: Sometimes to use bathroom. ? PainFeelings: Fear, anxietyAgenda: Physical need to urinate, misses usual environment Step 4Past staff approaches and resident reactionsLow bed with mat—helpful.Position alarm—partially effective. Staff gets there 50% of time before the fallPaint medications—responded well to prescribed analgesicStep 5New interventionsShorten time interval for toileting schedule.Provide snack and activity at night.Find at least 3 activities that interest patient.Continue to assess for pain using pain scale for dementia patients.Signature: _____Susan_Brown_LPN_________________________________________________ Current as of February 2010 Internet Citation: Appendix C3: Unsafe Behavior Worksheet Sample: The Falls Management Program Manual. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/apcfigtxt3.html
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