{"text":"Falls Assessment Care Plan : - \nPlease tick all applicable nursing interventions . . : \n[Date: [Date: F, [Date:, . [Date: [Date: [Date: [Date: | \n'Ward: Ward:=. ngd: Wfard: _ Ward: 'Ward: \nNURSING INTERVENTIONS _ \nR R T \n1 Falls prevention and general\u2019safety preca\ufb01tions discussed with patient and family. ) \n2 Move to more obs\u00e9rvable area of ward {6 optimise supervision. . >l \n3 Advise patient they may \u00e9xperience dizziness when they mobilise initially. - , . \u2018 , - .- \n4 Requires assistance with mobilisation. \u201d \n5 Observe trip hazard due to invasive lines, drains and catheters. \n6 Do not leave the patient unattended when using commode, toilet, in shower or the \nbathroom area - \n7 If patient is unable\/unwilling to cooperate with intervention, advise medical staff and MDT. \n8 Monitor lying and standing \/ sitting BP and pulse. ) . - \n\u00b0 A. Patient requires footwear or ppdiatr_y referral. (Date referred: \/ requested : . ) \nB. Request family \/ carer to provide suitable footwear. . \n10 Commence continence assessment, follow Local Guidelines. \n11 Refer to Occupational Therapist. \n12 .Select suitable seating (refer to policy). \n13 Non slip mat on chair \/floor following advice from therapists. L - \n14 Refer to Physiotherapist. \n15 Review Transfer techniques. \u2018 \n16 Request medication review. \n17 Bed\/chair monitor in use. \n18 Falls map in use for seven days for patient who has second or subsequent falls. \n19 Bed rails\/bumpers to be used (refer to policy). \n20 Patient requires low bed \/ mattress-on the floor (refer to policy.) \n21 Patient requires one to one nursing care. \u2019 . \u2019 ' \n22 Refer to Hospital Falls Prevention Co-ordinator (see criteria on front cover). \n23 Other interventions. \nReview Cannard score weekly \/ monthly as per policy. Enter action code(s) selected in action taken section on Falls Risk Assessment page 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