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fall_risk_activity - Fall Risk Exercise...

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Fall Risk Exercise Mr. P., 45-years-old, is admitted to your unit with the diagnosis severe abdominal pain with vomiting, and                            diarrhea for three days.   He is alert and oriented and able to walk to the bathroom without difficulty.        Instructions: Using the assessment screen below, circle the number in points the points column and then total  to       determine Mr. P’s fall risk. Risk Factor  Definition                                                          Points  Confusion  Disorientation  Impulsivity  Patient is disoriented to time, place, and/or person. Patient is unable to retain or  receive instructions or displays impaired judgment. This may be a progressive  neurological state, drug induced, or behavioral in origin. Stroke patients (left hemi) may  exhibit impulsive, unpredictable behavior as a result of the cerebral insult.  Symptomatic  Depression  Medical diagnosis or nursing assessment finds the patient appears depressed, is not  interacting appropriately, is tearful, withdrawn, or the patient states they are  depressed. If the depression is managed with drugs and/or therapies in need NOT be  scored if the depression is therapeutically in control.  Altered  Elimination  Altered elimination from the clinical norm, such as incontinence, nocturia, frequency,  urgency or stress incontinence, diarrhea, or related to use of cathartics. This does NOT  include a Foley or indwelling catheter UNLESS it causes symptoms referenced above  while in use with the patient. When the catheter is removed, it can be a high-risk time  until normal elimination is established.  Dizziness  Vertigo  Medical diagnosis of vertigo or the patient reports they feel like they are spinning or the  room is spinning. Sway path may be present when the patient stands (circular motion  upon arising). This is often seen in the aging adult with poor gait and balance and can  occur as a result of some drug side effects.  Gender  Male  Any  Prescribed  Antiepileptics  Carbamazepine, Divalproex Sodium, Ethotoin, Ethosuximide, Felbamate,  Fosphenytoin,Gabapentin, Lamotrigine, Mephenytoin, Methsuximide, Phenobarbitol,  Phenytoin, Primidone, Topiramate, Trimethadione, Valproic Acid  Any  Prescribed  Benzodiazepine Alprazolam, Buspirone, Chlordiazepoxide, Clonazepam, Clorazepate Dipotassium,  Diazepam, Flurazepam, Halazepam, Lorazepam, Midazolam, Oxazepam,  Temazepam, Triazolam  TOTAL SCORE     Total Risk Score: ___________ Fall risk score 5 or greater: High Fall Ri Fall risk score 10 or greater: Very High Fall risk Page 1 of 6
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