Contributing factors Fall -answerOlder age
Impaired mobility
Cognitive and/or Sensory impairment
Bowel and bladder dysfuntion
Side effects of
... [Show More] medications
History of falls
Nursing interventions Falls -answerComplete a fall risk assessment
Communicate identified risks with the health care team
Assign clients at risk falls to a room close to nurses' stations and assess frequently
Provide clients with nonskid footwear
Keep the floor free of clutter and maintain an unobstructed path to the bathroom
Orient the client setting (grab bars, call light), including how to use and locate all necessary items
Maintain bed in low position
Instruct the client who is unsteady to use the call light for assistance before ambulating
Answer call lights promptly to prevent clients who are at risk from trying to ambulate independently
Provide adequate lighting (nightlight for necessary trips to the bathroom)
Determine the client's ability to use assistive devices (walkers, canes, etc.).
Keep all items within reach
Use chair or bed sensors for client who are at risk
Lock wheels on beds, wheelchairs, and gurneys to prevent rolling during transfers or stops
Report and document all incidents per the facility policy
Nursing intervention Restraints -answerImplement nonpharmacologic measures such as distraction, frequent observation, or diversion activities
Prior to application, review manufacturer's instructions for correct application
Notify the provider immediately when restraints are implemented
Remove the restraints and assess client every 2 hr
Assess neurovascular and neurosensory status every 2 hr
Leave the restraint loose enough to prevent injury
Always tie the restraint to the bed frame (using loose knots that are easily removed)
Reassess the need for continue use
Document
Document Restraints -answerBehaviors making restraint necessary
Alternatives attempted and the client's response
Type and location of restraint and time applied
Frequency and type of assessment
Restraints should NEVER -answerInterfere with treatment
Be used because of short-staffing or staff convenience
Not written as PRN orders
Nursing intervention Seizure precaution -answerAssess seizure history, noting frequency, presence of auras, and sequence of events
Identify precipitating factors that may exacerbate or lead to seizu [Show Less]