> 65 y/o, hx of falls, impaired vision/balance, altered gait, postural hypotension, confusion/disorientation, unfamiliar environment?
upon admission; according to facility policy; change in pt condition (LOC, surgical procedure); before/after activity that might increase risk; before admin. meds that affect cardiovascular or respiratory functioning?
1. nursing presence, 2.empowerment, 3.compassion, 4.competence
keeping freq. used items within reach (call bell, glasses, etc.); uncluttered environment; pt room is well lit, indicate fall risk in med rec and on pt door; assess pt vision; use side rails.
Assessment: collect data
Diagnosis: identify the problem
Planning: formulate an objective and decide on an action
Implementation: carry out the plan of action
Evaluation: collect data to determine if objective was met
age; circadian rhythm; gender; food intake; exercise; weight; emotional state/stress; body position; race?