It is important for the staff and the patient to understand the fall precautions. The nurses should also perform the universal fall precautions such as the 5p’s. Every time a nurse walks into a patient’s room, the nurse should always ask the 5 P’s such as pain, personal needs, position, placement, and prevent falls. The nurse should always ask the level of pain the patient is having and if they are comfortable. The patient’s personal items should be within reach and should use a call light when the patient needs toileting. …show more content…
This unexpected event could result from a medication error, malfunctioning equipment, or if violence has occurred between individuals, an incident report should be filled out and documented. If the incident that occurred was proceeded to court years after it had happen, the incident report could prevent a lawsuit. This is why an incident report is important and should be accurate to the situation of what occurred during the event (Why incident reports are a must, …show more content…
The nurse will also be assessing for signs and symptoms of orthostatic hypotension during each position change such as lightheadedness, dizziness, weakness, and syncope (Mager, 2012).
The steps of assessing orthostatic hypotension includes having the patient change positions at different times and taking the blood pressure at different times. The patient should begin in a supine position for at least five minutes. The patient should not cross their legs or feet and should remain still for the five minutes at rest. After the five minutes, the nurse takes the blood pressure to retrieve a baseline blood pressure. The nurse then instructs the patient to change to a sitting position on the side of the bed. Once the patient sits on the side of the bed, the nurse should immediately take the blood pressure and asking the patient if they feel dizziness or lightheadedness from changing positions. The patient is then instructed to stand and the nurse waits three minutes and then takes the blood pressure along with asking the patients if they feel dizzy or lightheadedness. The nurse should take precautions if the patient is showing signs and symptoms of orthostatic hypotension because the patient could fall (Naccarato, 2011). Mr. O’Brien is showing signs of orthostatic hypotension by him complaining of weakness, syncope, and dizziness. His orthostatic blood