A 55 year old female is admitted to a medical surgical unit with dementia and falling at home. She has a right wrist fracture that is splinted. S1 and S2 auscultated, S3 appreciated; radial and pedal pulses palpable, +2 bilaterally; capillary refill less than 3 seconds in upper and lower extremities; +1 non-pitting edema found in bilateral lower extremities. Abdomen flat, nondistended. Bowel sounds present in all four quadrants. No pain on palpation.
The nurse knows that regular inspection of client’s rooms includes adequate lighting, regular rounding, helping the client to the bathroom, nurse call within reach, stable furniture, appropriate footwear, physical therapy for strengthening and balance, and personal items within reach are important to fall prevention. Client uses the call light to notify the nurse prior to getting out of bed. The nurse is helping the client to the bathroom on rounds.
Click to highlight all of the assessment findings that demonstrate that the interventions in the row next to them have been effective:
| Body System: | Assessment Findings: |
| Neurological | Client uses the call light to notify the nurse prior to getting out of bed |
| Neurological | helping the client to the bathroom |
| Integumentary | Client’s skin is intact with no evidence of additional injuries that were not present on admission that could have resulted from an additional fall |
| Cardiovascular | S1 and S2 auscultated, S3 appreciated; radial and pedal pulses palpable, +2 bilaterally; capillary refill less than 3 seconds in upper and lower extremities; +1 non-pitting edema found in bilateral lower extremities. |
| Gastrointestinal | Abdomen flat, nondistended. Bowel sounds present in all four quadrants. No pain on palpation. |
| Musculoskeletal | Increased muscle strength and improved balance |