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Fall Prevention Intervention Care Plan Cheat Sheet (DRAFT) by [deleted]

Fall Prevention Intervention Care Plan

This is a draft cheat sheet. It is a work in progress and is not finished yet.


Analysis of circum­stances surrou­nding patients who fell revealed that three types of patient falls occurred in hospitals and long-term care instit­utions. Because falls have different causes, the strategies for preventing patient falls are different for each type of fall. The following is a generic outline of care planning to prevent geriatric patient falls.

1. Toileting needs

O Ask the resident every one to two hours if he/she needs to use the bathroom.
O Answer call light promptly.
O Remind the resident to ask for assist­ance. Reorient to call light, if necessary.
O Eliminate side rails and assess need for bedside commodes.
O Indivi­dualize toileting schedule and/or bowel and bladder retrai­ning.
O Other: ______­___­___­___­___­___­___­___­___­___­______

2. Syncopal episodes

O Evaluate postural hypote­nsion and/or cardiac arrhyt­hmia. Consult with physician.
O Review medica­tions with pharmacy consultant and physician.
O Consider fluid volume deficit. Evaluate intake and output.
O Teach the resident to change positions slowly, especially from lying to sitting to standing.
O Maximize the resident’s time out of bed as much as clinically possible to increase tolerance.
O Keep the bed in the low position.
O Assist with all transfers.
O Consider use of TED hose.
O Perform a nutrition consul­tation.
O Other: ______­___­___­___­___­___­___­___­___­___­______

3. Confusion

O Frequently reorient the resident to surrou­ndings.
O Visually check the resident every two hours, or more frequently as determined by care team.
O Provide a calm, quiet enviro­nment with reassu­rances.
O Perform a nutrition consul­tation.
O Evaluate the resident’s electr­olytes.
O Evaluate for hypoxemia. Measure oxygen saturation as needed.
O Keep a small night light in the resident’s room.
O Answer the call light promptly.
O Use a bed and/or chair personal alarm.
O Perform a risk/b­enefit analysis regarding restraint use. Note:
O Encourage family­/social contacts for reorie­nta­tion.
O Assess for Falling Leaf criteria.
O Other: ______­___­___­___­___­___­___­___­___­___­______

4. Enviro­nmental hazards

O Eliminate potential hazards such as uneven surfaces, debris, or water on floor.
O Keep the call light and water within reach.
O Keep eyeglasses within reach.
O Keep assistive devices within reach.
O Ensure adequate lighting.
O Other: ______­___­___­___­___­___­___­___­___­___­______
O Other: ______­___­___­___­___­___­___­___­___­___­______

5. Weakne­ss/­uns­teady gait

O Evaluate for possible therap­eutic interv­ent­ions.
O Remind resident to request assist­ance.
O Keep call light within reach.
O Confer with rehabi­lit­ative services and the interd­isc­ipl­inary team.
O Assist the resident to obtain and wear approp­riate, non-skid shoes.
O Other: ______­___­___­___­___­___­___­___­___­___­______
O Other: ______­___­___­___­___­___­___­___­___­___­______

6. Sensor­y/p­erc­eption deficits

O Frequently reorient the resident to the enviro­nment.
O Keep furniture and other objects in the same position.
O Evaluate presence and adequacy of glasses and hearing aids.
O Assess the enviro­nment to maximize safety.
O Consult with vision­/he­aring specia­lists as needed.
O Refer to OT.
O Consider a conference with rehabi­lit­ative services.
O Other: ______­___­___­___­___­___­___­___­___­___­______
O Other: ______­___­___­___­___­___­___­___­___­___­______

7. Knowledge deficit

O Ensure assistive equipment is used approp­ria­tely.
O Be sure the resident is comfor­table with adaptive and assistive devices.
O Ensure the resident is able to use the call light. If the light is difficult to press, consider a foam pad call light or other adaptive call lights.
O Ensure frequent visitors are aware of the use of assistive and adaptive devices.
O Other: ______­___­___­___­___­___­___­___­___­___­______
O Other: ______­___­___­___­___­___­___­___­___­___­______