Fall risk assessment - ATI TEMPLATE PDF

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Summary

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Description

ACTIVE LEARNING TEMPLATE:

Nursing Skill

LVN STUDENT NAME _____________________________________

risk assessment SKILL NAMEFall ____________________________________________________________________________

fundamentals client safe

REVIEW MODULE CHAPTER ___________

Description of Skill Fall risk assessment is used to assess if pt is low, moderate or high fall risk, based off the findings of the assessment care plan is created to prevent falls or injuries. Cognitive/mental status assement along with physical ambulation assessment.

Indications dizziness, lightheadedness, unsteady gait, irregular cardiac arrhythmias

Outcomes/Evaluation pt will be free of falls and/or injuries or physical harm

Potential Complications if call lights are not answered quick enough pt will attempt to ambulate without assistance which could lead to fall/injuries.

ACTIVE LEARNING TEMPLATES

CONSIDERATIONS

Nursing Interventions (pre, intra, post) STEADI (stopping elderly accidents, death and injuries. advise pt where RR is , educate on bed and call light control, remove obstacles, clean/safe enviroment, side rails, keep bed in low position, wear nonslip socks/shoes.sicker and posted at door pt is fall risk , alarm on pt, Red slipper program, consult with therapist. pt to be placed in small groups with intense, focused supervision, bright colored arm bands with alert, answer call lights immediatey

Client Education orrientate pt to their enviroment, teach pt where the restroom and objects are in the room, keep and clean and clutter free walk way, teach pt to call and ask for help, client exercise, diet/hydration education. educate pt on the importance of asking for help.

Nursing Interventions nurse will answer call light asap alarm will be placed on pt at all times for in the event pt tries to get out of bed the alarm will sound and nurse will respond. nurse will place nonslip socks/shoes on pt nurse to be patient and helpful not rush patient

THERAPEUTIC PROCEDURE

A9...