Question Answered step-by-step History of Incident Mrs. P is a 93 year old female admitted to your… History of IncidentMrs. P is a 93 year old female admitted to your facility. She has had Alzheimer’s disease for approximately 7 years and has been cared for by her husband and daughter at home. Her other past medical problems include: diabetes mellitus, hypertension, osteoarthritis, depression and a history of falls. She is on hypertension medications. Over the past several months, her family has found it increasingly difficult to care for her at home due to worsening agitation and insomnia. Mrs. P has been at your facility for 3 days and has slept only ours per night. She is extremely restless and anxious and often cries out for her husband. She constantly wants to get up from her chair or bed. Mrs. P was found on the floor by staff at 8 pm and apparently had fallen onto her buttocks; no injuries were found. Mrs. P was assisted to bed for the night. A waist restraint was placed on her and all four side rails were positioned in the upright position.Later that evening Mrs. P was found on the floor. Her undergarments were soiled and she continued to cry out for her husband. She was assessed to have no injuries resulting from the fall. The nurse obtained an order for a sedative from the physician and Ativan 1 mg was administered at 1 am. She was put back to bed and finally went to sleep for the night.1. What should be included in your immediate assessment and evaluation of Mrs. P after the fall?Nurse’s documentation following the fallMrs. P was found on the floor in her room at 8:00 pm this evening. Resident states “I was needing to use the restroom.” It has been reported that Mrs. P has been agitated and restless off and on since admission and has been showing signs of unsafe behavior- attempting to transfer without staff assistance, getting out of bed at night with disturbed sleeping patterns.Vital signs – 100/60, 66, 20, 98.6, Blood Glucose = 70, Orange juice given, blood glucose after juice = 100. SpO2 = 98%Postural BP standing 90/60, HR 80. No evidence of orthostatic hypotension at this time. Resident in her room alone at time of fall, attempting to get up out of chair unassisted-wants to use bathroom. Gait slightly unsteady and needs the assistance of one person for transfers. Resident ambulates in regular socks.Dr. Roberts notified at 8:30 pm. Resident’s daughter was notified by telephone at 9:00 pm. Resident’s status and immediate measures taken were explained to daughter. Daughter was reminded of her mother’s care plan conference on Friday.2. What are Mrs. P’s known fall risk factors (extrinsic factors, intrinsic factors, unsafe behaviors)?3. What are possible fall risk factors that need further evaluation for this patient?4. What interventions to reduce Mrs. P’s fall risk are important to consider?2. What are Mrs. P’s known fall risk factors (extrinsic factors, intrinsic factors, unsafe behaviors)?3. What are possible fall risk factors that need further evaluation for this pati Health Science Science Nursing NSG 417 Share QuestionEmailCopy link Comments (0)
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