DATE RISK ASSESSMENT and INDIVIDUALISED INTERVENTIONS Initial

DATE RISK ASSESSMENT and INDIVIDUALISED INTERVENTIONS Initial MOBILITY RISKS Does the patient: Initial Screen Re- Screen 1 Re- Screen 2 If risk identified initial box Require assistance with mobility/transfer? Have poor coordination, balance, gait or uncorrected visual impairment? FUNCTIONAL ABILITY RISKS Is the patient unsteady, disorganised or require assistance when attending to ADLs? INTERVENTIONS Initial if appropriate for patient Assess, document and provide mobility aids and level of assistance required. Discuss and confirm with the patient what level of assistance they require (including mobility aids), and/or their need to call and wait for assistance. Refer to Physiotherapist for a comprehensive mobility assessment. Refer to Occupational Therapist (OT) for functional assessment. MEDICATIONS/MEDICAL CONDITION RISKS Some medications are associated with falls. Has the patient been prescribed: If risk identified initial box -Psychoactive medication e.g. benzodiazepines, antipsychotics, antidepressants? -New or old medication that may affect their blood pressure? Does the patient take more than 5 medications of any sort? Does the patient report dizziness or presented following a fall/collapse? INTERVENTIONS Initial if appropriate for patient Liaise with Medical Officer (MO) or Pharmacist for review of medication associated with falls. If reporting dizziness, check lying/standing blood pressure. If a postural drop >20mmHg systolic or SCIENCE HEALTH SCIENCE NURSING

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