Unsafe Behavior Worksheet (Text Version)
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_____
Step 1 |
Behavior stated clearly using action verbs |
Gets up frequently, climbs out of bed and tries to ambulate unsafely. Appears anxious and fearful. |
Step 2 |
Relevant personal and medical history |
Married 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 3 |
Circumstances
Time: 11 PM - 4 AM
Frequency: 3-4 time per week
Location: Room
Persons present: Often alone
Situation: Dementia, new environment
Motivation: Sometimes to use bathroom. ? Pain
Feelings: Fear, anxiety
Agenda: Physical need to urinate, misses usual environment |
|
Step 4 |
Past staff approaches and resident reactions |
Low bed with mat—helpful. Position alarm—partially effective. Staff gets there 50% of time before the fall Paint medications—responded well to prescribed analgesic |
Step 5 |
New interventions |
Shorten 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_________________________________________________
Return to Appendix C