Text Description
Resident: ____________________________________________ Room: ___________________
Directions: Check all interventions that apply.
| Risk Factor: Medications | Risk Factor: Mobility |
|---|---|
|
Selected Interventions For changes in psychotropic meds: __ Monitor and report changes in anxiety, sleep patterns, behavior, or mood For changes in digoxin: __ Monitor apical heart rate; if <50, notify PCP. |
Selected Interventions __ Increase staff assistance |
| Risk Factor: Orthostatic Hypotension | Risk Factor: Unsafe Behavior |
| Selected Interventions __ Low blood pressure precautions __ Instruct pt to change position slowly __ Instruct pt to sit on edge of bed and dangle feet before standing __ Instruct pt to use dorsiflexion before standing __ Instruct pt not to tilt head backwards __ Provide staff assistance in early AM and after meals __ If medication change: __ Take postural VS __ day X 3 days. If systolic drops ≥20 mm Hg on day 3, notify PCP __ Promote adequate hydration __ TED hose __ Other: _________________________________ |
Selected Interventions __ Behavior management strategies __ Increase assistance and surveillance __ Position or pressure change alarm __ Movement sensor __ Locate patient near station __ Intercom __ Toilet at regular intervals __ Increase activities involvement __ Other ___________________________ __ Reduce risk of injury __ Low bed __ Floor mat __ Helmet, wrist guards, hip protectors __ Nonslip mat __ Nonskid strips or nonskid rug __ Nonskid socks __ Lower or remove side rails __ Increase comfort __ Pain management __ Frequent rest periods __ Recliner or chair with deep seat __ Rocking chair __ Wheelchair seating items __ Exercise __ Cradle mattress __ Sheepskin, air mattress or pillows __ Other: _________________________________ |
| Risk Factor: Vision | |
| Selected Interventions __ Low vision precautions __ Use maximum wattage allowed by fixture __ Increase lighting in room __ Use adequate lighting at night __ Add high-contrast strips on stairs, curbs, etc. __ Use signs with large letters or pictures __ Use high contrast to offset visual targets __ Reduce glare __ Corrective lenses __ Keep eyewear within easy reach at all times __ Encourage patient to wear glasses __ Other: _________________________________ |
Signature: __________________________________________________ Date: ______________
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