KEY ISSUE

Risk for falls related to altered

level of consciousness (obtunded),
and neuromuscular impairment.
Cues: Limited ROM, decreased
muscle mass, strength and control

SCIENTIFIC BASIS DESIRED

OUTCOME
A fall is defined as an
event which results in Identified: 3/9/15
a person coming to
After 2 to 3 days of
rest inadvertently on
student nurse and
the ground or floor or patient interaction, the
other lower level.
patient will be free of
Fall-related injuries
injuries caused by
may be fatal or nonpossible falls such as
fatal1 though most are bruising,
non-fatal.
inflammation, skin
lesions, redness and
(Source:
pain.
http://www.who.int/m
ediacentre/factsheets/f
s344/en/)

INDEPENDENT
INTERVENTIONS
Date identified: 3/9/15
1. Noted age and sex.
R: Elderly clients are of
greater risk because of their
decline in their functions.
2. Evaluated developmental
level, decision-making,
level of cognition and
competence.
R: To know how to
approach and how to
teach the patient to his
level of understanding
3. Assessed muscle strength,
gross and fine motor
coordination.
R: In order to find out if
the patient has any
difficulty with regards to
maintaining proper body
mechanics.
4. Provided information
regarding client's
disease/condition(s) that
may result in increased risk
for falls.
R: In order for the
patient to take the needed

ACTUAL OUTCOME
3/9/15
Within 8 hours of
student-patient
interaction, there had
been no incidence of
falls as reported by the
S.O. and it was noted
that the patient has no
evidence of injuries
noted due to possible
falls such as bruising,
inflammation, skin
lesions, redness and
pain.
3/10/15
Within 8 hours of
student-patient
interaction, there had
been no incidence of
falls as reported by the
S.O. and it was noted
that the patient has no
evidence of injuries
noted due to possible
falls such as bruising,
inflammation, skin
lesions, redness and
pain.

precautions for him not

to fall.
5. Reviewed medication
regimen and how it affects
the client.
R: Many side effects of
the drugs can place the
client at a risk for falls
such as: confusion,
vertigo and dizziness.
6. Raised side rails of the
bed.
R: To prevent client
from falling in the bed.
COLLABORATIVE
INTERVENTIONS
1. Refer to physical or
occupational therapists as
appropriate.
R: May require exercises
to improve strength or
mobility,
improve/relearn
ambulation, or identify
and obtain appropriate
assistive devices for
mobility, bathroom
safety, or home
modification.

3/11/15
Within 8 hours of
student-patient
interaction, there had
been no incidence of
falls as reported by the
S.O. and it was noted
that the patient has no
evidence of injuries
noted due to possible
falls such as bruising,
inflammation, skin
lesions, redness and
pain.

2. Refer to other resources as

indicated.
R: Client/caregivers may
need financial
assistance, home
modifications, referrals
for counseling,
homecare, sources for
safety equipment, or
placement in extended
care facility/