CHARTING BY

EXCEPTION

GROUP MEMBERS :
FIKA NUR ROHMAH 201810420311080
RIA AMALINA A. 201810420311081
AFINI ANINDITA R. 201810420311083
SANTI RAHMAIDA 201810420311084
BASIC DATA :
Mrs. O’Donnell is a 72 year old female admitted via ER 3 days ago for UTI, fever,
weakness. Was found on the floor of her home by her daughter. C/O “not feeling
well” for 1 week prior to admission. A&O x3 and “doesn’t know what all the fuss is
about, I had to go to the bathroom all the time and just got a little dizzy.” Does
not recall how she got on the floor at home. Falls have not been a problem
previously, per the daughter. Now needs assist x1 to BSC, reminders to use call
light. Pt still c/o urgency/frequency and will be incontinent if assistance is not
prompt. Vital signs an hour ago were: T = 98.9F (oral), P = 88, R = 22, BP 138/76,
pulse ox = 98% on Room Air, no c/o pain. Does not like the “force fluids” order
because “it makes me have to use the bathroom too much.”
PHYSICAL EXAMINATION :
• Gender :F
• Age : 72
• Race : Caucasian
• Weight : 63kg (~139 #)
• Height : 165cm (5’5”)
• Allergies : NKDA
• Immunizations : Flu/PNA/Td October 2010
• Past Medical History : osteoarthritis, HTN
• Attending Physician/Team : Dr.Brown/hospitalist
SUPPORTING INVESTIGATION :

• Religion : Prot
• Major Support : daughter (Claudia)
• Phone : 301-555-1236
DATA ANALYSIS :
N Date & Documentation
o Time
1 17 May (1)enter the room immediately check pt id band,
First 10 identify issues of personal safety in the environment
minutes before approaching patient, call for help, verbalize
that vital signs need to be taken, get equipment &
document, verbalize need to put something down on
floor to soak up fluid before stepping in it.
-------------------------------------------------------------------Nurse
    (2) put on gloves while looking over the
situation---------------------Nurse
    (3) assess the patient for LOC, pain, obvious injury,
etc without moving the patient, provide comfort/
reassurance-----------------------------------Nurse
2 Next 10 with info from above assessment , reassure and
minutes comfort the patient. continue assessment , recognize
that pt is on fall precautions---------------------------------
Nurse
3 Last 10 (1) query for pt weight (how many need to help?),
minutes obtain a slider board or lifting sheet/device. (all)
assist in lifting pt as one unit back to
bed.--------------------------------------Nurse
    (2) apply fall risk items (yellow bracelet, socks,
blanket) ,need to contact physician & family
,documentation in pt’s medical record
,documentation on appropriate incident/ occurrence
form----------------------------------Nurse
IMPLEMENTATION :
1. Assessment of patients with falling risk can be done with
multifactorial assessment within the specified time period of the
patient. assessing the patient's cognitive problems, patient's urinary
problems, a history of falls, as a result of falls, oversees sandals that
are worn by patients(slippery or missing), health problems that can
increase risk falls, medication that is being undertaken, balance
problems, patient movement problems.
2. Preventive intervention patients risk falling. Interventions carried
out in patients at moderate risk or height falls with injuries require
precautions which is more intersive to maintain safety and security
patient
TERIMA KASIH