Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Resident:_____Mrs._P_______________ Rm #:_401-A_____ Date:___4/12/04_____
| Step | Description | Notes |
|---|---|---|
| Step 1 | Behavior stated clearly using action verbs | Gets up frequently, climbs out of bed and tries to ambulate unsafely. Appears anxious and fearful. |
| Step 2 | Relevant personal and medical history | Married for 45 years, mother of 3 children and 10 grandchildren. Catholic, homemaker, gardener. Husband lives at home with daughter and is unable to visit. |
| Step 3 |
Circumstances Time: 11 PM - 4 AM |
|
| Step 4 | Past staff approaches and resident reactions | Low bed with mat—helpful. Position alarm—partially effective. Staff gets there 50% of time before the fall Paint medications—responded well to prescribed analgesic |
| Step 5 | New interventions | Shorten time interval for toileting schedule. Provide snack and activity at night. Find at least 3 activities that interest patient. Continue to assess for pain using pain scale for dementia patients. |
Signature: _____Susan_Brown_LPN_________________________________________________
