Fall Interventions Plan (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: 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_____________
Return to Appendix C