Appendix B11: Fall Interventions Plan The Falls Management Program Manual Text DescriptionResident: ____________________________________________ Room: ___________________Directions: Check all interventions that apply.Risk Factor: MedicationsRisk Factor: MobilitySelected InterventionsFor changes in psychotropic meds:__ Monitor and report changes in anxiety, sleep patterns, behavior, or mood__ Monitor and report drug side effects__ Behavior management strategies __ Sleep hygiene measures __ no caffeine after 4 p.m. __ up at night with supervision __ comfort measures __ pain management __ regular exercise, limit napping __ relaxing bed routine __ individualized toileting at night __ safe bathroom routineFor changes in digoxin:__ Monitor apical heart rate; if <50, notify PCP.Selected Interventions__ Increase staff assistance __ early morning __ to and from toilet __ 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__ Increase bathroom safety __ Use adequate handrail support __ 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 HypotensionRisk Factor: Unsafe BehaviorSelected 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__ Behavior management strategies__ Increase assistance and surveillance __ Position or pressure change alarm __ Movement sensor __ Locate patient near station __ Intercom __ Toilet at regular intervals __ Increase activities involvement __ Other _____________________________ Reduce risk of injury __ Low bed __ Floor mat __ Helmet, wrist guards, hip protectors __ Nonslip mat __ Nonskid strips or nonskid rug __ Nonskid socks __ Lower or remove side rails__ Increase comfort __ Pain management __ Frequent rest periods __ Recliner or chair with deep seat __ Rocking chair __ Wheelchair seating items __ Exercise __ Cradle mattress __ Sheepskin, air mattress or pillows__ Other: _________________________________Risk Factor: VisionSelected 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: __________________________________________________ Date: ______________Image of Form Current as of February 2010 Internet Citation: Appendix B11: Fall Interventions Plan: 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/fallspxmanapb6.html
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