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 For changes in digoxin: __ Monitor apical heart rate; if <50, notify PCP. |
Selected Interventions _X_ Increase staff assistance |
| 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_____________
