|Mr. Coffee-Mate visiting with|
nurses last night at the nurses
station to ensure his safety.
However, last evening he experienced some mild confusion (disoriented to time and place only) and continued efforts to get out of bed without assistance. Due to his unsteady and weak gait the student nurses decided to move him closer to the nurses station and let him sit with them throughout the evening to ensure his safety.
I am happy to report that although he is alert and oriented this morning, for his safety, we have increased his fall risk status to "high" based on our fall risk assessment. Let's continue to work together to keep Mr. Coffee-Mate safe throughout his stay with us at the Dwight Schar College of Nursing Hospital.
New Nursing Diagnosis:
Risk for falls related to age 71 years, diminished mental status and decreased lower extremity strength and unsteady gait.
1. Mr. Coffee-Mate will remain free of falls throughout his hospital length of stay.
2. Nursing will increase fall status to "high" and institute fall precautions (i.e. magnet, fall risk band, bed and chair alarm), continue orientation to the environment, ask the family to stay with the client throughout the day and night and keep Mr. Coffee-Mate within viewing to ensure his safety throughout his hospital stay.
3. Continue to explain methods to Mr. Coffee-Mate to prevent injury during this shift.
1. Complete fall risk assessment with each shift assessment (Gray-Miceli, 2007).
2. Recognize and educate patient, HCP, and family today that when people attend to another task while walking, such as carrying a cup of water, clothing or supplies, they are more likely to fall (Lundin-Olsson, Nysberg & Gustafson, 1998).
3. Orient client to the environment each time nursing or other health care professionals enter his room.
4. Avoid use of restraints if at all possible each day; encourage the family to sit with client day and night and/or keep Mr. Coffee-Mate near nurses station to allow increased visual assessment of Mr. Coffee-Mate. Also, implement fall precautions as outlined (i.e. provide adequate lighting, keep bed in low position, enable chair and bed alarms accordingly, toilet frequently, provide non-skid footwear) (Cotter & Evans, 2012).
5. Evaluate the client's medications to determine whether medications increase the risk of falling. Consult with physician regarding the medications if needed immediately (Gray-Miceli & Quigley, 2011).
Mr. Coffee-Mate's energy and strength is improving. Let's keep his plan of care changing to meet his needs and let's keep motivating him through patient-centered care.
-- Professor Berryman