Assessment: For clients at risk repeat risk assessment every 8hrs

Safety: Falls RF: Sensory issues, hypotension, hx falls, pain,
dizziness, etoh use, 80+, gait, infants
More than ½ falls reserve in home, 80% 65+, 3rd injury related death.
Most common incident reported in hospitals and LTC.
Many cases involve falling from a bed, most likely at night, holidays, weekends.
Ranks 7th cod for elderly, highest in 85+, usually cause hip fracture.
Geriatric triad: Changes in cognitive status, falls, incontinent (all 3)
& monitor more freq. Identify meds that ^ risk for falling. Use
Morse Fall scale, Get up & Go test, comprehensive fall evaluation
Causes: Footwear, postural hypotension, tripping hazards, poor
lighting, alcohol, polypharmacy, meds
Interventions: Most important thing is to find out
who is at risk for falls.
Provide a safe environment: bed low, no clutter, lock
wheels/chairs/beds, call light close, nonskid socks –
brightly colored, orient to surroundings, assist when
needed. Assess, teach, support. Hourly rounding,
surveillance of older adults. Document.

Geriatric syn.: # of problems-does not fit into discrete disease

categories requires a multidisciplinary + comprehensive assessment Dizziness: Older pts seek help often for dizziness.
to identify the underlying cause. *Skin impairment, poor nutrition, Hard to differentiate between true dizziness
falls, functional decline. May develop gradually but onset acute. (sensation of disorientation r/t position) vertigo
(spinning sensation). Similar sensations nearsyncope
+ disequilibrium – minor (built ear wax) Serve
(dysfunction of cerebral cortex, cerebellum, brain
Impaired mobility: Common causes: sensory deficits, parkinson, diabetic neuropathy, stem, proprioceptive receptors
cardiovascular comp, osteoarthritis
Older pts should remain active as much as poss. If bed rest cannot be avoided pts should
preform active rom + strengthening exercises w/the unaffected extremities – caregivers +
nurse should preform passive rom – freq position changes