Fall Interventions Monitor (Text Version)
Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Resident: _______________Mrs._P________________________ Room: ______401-A________
Directions: Monitor staff implementation and effectiveness of the Fall Intervention Plan each week. Revise interventions as needed and record below. Use one sheet for every 2 weeks.
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Date: 4/19/04 |
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Date: 4/19/04 |
Medications |
Are interventions effective: _X_ Yes ___ No
Changes:
Comments: Pt [Patient] adjusting to new environment. Agitation decreased
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Medications |
Are interventions effective: ___ Yes _X_ No
Changes:
Comments: Pt with occasional periods of agitation.
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Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No
Changes:
Comments: NA
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Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No
Changes:
Comments: NA
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Vision |
Are interventions effective: ___
Yes ___ No
Changes:
Comments: NA
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Vision |
Are interventions effective: ___ Yes ___ No
Changes:
Comments: NA
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Mobility |
Are interventions effective: _X_ Yes ___ No
Changes:
Comments: Staff Assisting with all transfers |
Mobility |
Are interventions effective: _X_ Yes ___ No
Changes:
Comments: |
Unsafe Behavior |
Are interventions effective: ___ Yes _X_ No
Changes:
Comments: Pt needs toileting 1-1½ hrs instead of 2 hrs. |
Unsafe Behavior |
Are interventions effective: _X_ Yes ___ No
Changes: Medicate with analgesic as ordered.
Comments: Monitor agitation in conjunction with analgesic effectiveness.
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Signature: ___________Susan_Brown_LPN_______________ Date: _______4/19/04_____________
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