Appendix C8: Fall Interventions Plan 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_________________________ Room: ____401-A__________

Directions: Check all interventions that apply.

Risk Factor: Medications	Risk Factor: Mobility
Selected Interventions For changes in psychotropic meds: _X_ Monitor and report changes in anxiety, sleep patterns, behavior, or mood ___ Monitor and report drug side effects _X_ Behavior management strategies _X_ Sleep hygiene measures _X_ no caffeine after 4 p.m. _X_ up at night with supervision _X_ comfort measures _X_ pain management ___ regular exercise, limit napping ___ relaxing bed routine _X_ individualized toileting at night _X_ safe bathroom routine For changes in digoxin: __ Monitor apical heart rate; if <50, notify PCP.	Selected Interventions _X_ Increase staff assistance ___ early morning _X_ to and from toilet _X_ during all transfers ___ during ambulation ___ other: ________________________ ___ Correct height of bed, toilet, or chair ___ Keep bed at correct height as marked on footrest or wall ___ Use raised toilet seat ___ Use cushion in lounge chair ___ Lower lounge chair _X_ Increase bathroom safety _X_ Use adequate handrail support _X_ Use easy to manage clothing ___ Promote wheelchair safety ___ Use individualized, labeled wheelchair ___ Check brakes and instruct pt on use ___ Seating modifications ___ Use all prescribed seating items ___ Other: _______________________________
Risk Factor: Orthostatic Hypotension	Risk Factor: Unsafe Behavior
Selected Interventions ___ Low blood pressure precautions ___ Instruct pt to change position slowly ___ Instruct pt to sit on edge of bed and dangle feet before standing ___ Instruct pt to use dorsiflexion before standing ___ Instruct pt not to tilt head backwards ___ Provide staff assistance in early AM and after meals ___ If medication change: ___ Take postural VS __ day X 3 days. If systolic drops ≥20 mm Hg on day 3, notify PCP ___ Promote adequate hydration ___ TED hose ___ Other: _________________________________	Selected Interventions _X_ Behavior management strategies _X_ Increase assistance and surveillance _X_ Position or pressure change alarm ___ Movement sensor _X_ Locate patient near station ___ Intercom _X_ Toilet at regular intervals _X_ Increase activities involvement ___ Other ___________________________ _X_ Reduce risk of injury _X_ Low bed _X_ Floor mat _X_ Helmet, wrist guards, hip protectors ___ Nonslip mat ___ Nonskid strips or nonskid rug _X_ Nonskid socks _X_ Lower or remove side rails _X_ Increase comfort _X_ Pain management ___ Frequent rest periods ___ Recliner or chair with deep seat ___ Rocking chair ___ Wheelchair seating items ___ Exercise ___ Cradle mattress _X_ Sheepskin, air mattress or pillows ___ Other: _________________________________
Risk Factor: Vision
Selected Interventions ___ Low vision precautions ___ Use maximum wattage allowed by fixture ___ Increase lighting in room ___ Use adequate lighting at night ___ Add high-contrast strips on stairs, curbs, etc. ___ Use signs with large letters or pictures ___ Use high contrast to offset visual targets ___ Reduce glare ___ Corrective lenses ___ Keep eyewear within easy reach at all times ___ Encourage patient to wear glasses ___ Other: _________________________________

Signature: ___________Susan_Brown_LPN_______________ Date: _______4/19/04_____________

Current as of December 2012

Internet Citation: Appendix C8: Fall Interventions Plan Sample: The Falls Management Program Manual. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/apcfigtxt8.html