1. Which clients are at greatest risk for falls in the acute care setting? Consider physiological and environmental risk factors for falls. The majority of patient falls occur in patients who are young and the older adults. Individuals who are ill or who become injured are at risk. If a patient is weakened or has an altered mental state, they are susceptible to falls.
2. Identify seven areas of a fall risk assessment. History of falls, seizures or fainting, older than 70, confusion or disorientation, medications that may cause confusion or alter mind, cardiovascular problems, poor eyesight.
3. Discuss the initial nursing interventions when the nurse enters Mr. O’Brien’s room and finds him lying on the floor. Look over Mr. O’Brien to check for fractures, bleeding, or any other serious injury. Assist Mr. O’Brien back into bed, and teach him the importance of calling for assistance. Call doctor to inform him of fall, fill out incident report.
4. Discuss who should be notified about Mr. O’Brien’s fall and what type of documentation is needed regarding the incident. Mr. O’Brien’s physician, family, and nursing assistants should be notified about the fall. An incident report should be filled out.
5. What test(s) will the health care provider most likely prescribe because Mr. O’Brien is complaining of pain in his right hip. Mr. O’Brien will most likely get an x-ray done.
6. The nurse double checks to see that appropriate fall precautions are in place. Identify ten measures to help prevent falls in older adults. Orientation to the environment to provide familiarity, bedside table or overbed table with supplies and belongings within reach, assistance when needed, environment kept free of clutter, side rails remain up, beds kept in the lowest position, wheels on beds, wheelchairs or gurneys are kept locked, patient should wear slip-resistant shoes or socks, wipe or mop spilled liquids promptly, provide adequate lighting.
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