#7064
Beverly
Member

I used the nursing process model for decision making and problem solving in the following situation:
One of my resident who is total care had a fall recently. This resident’s last fall was 3 years ago. When informed that she had a fall, I quickly assessed the resident (head-to-toe, Vital signs). As of the assessment time, I observed the resident with an elevated head trying to cough out saliva which she often pocketing in her mouth. She was also noticed to be leaning to her right side while coughing. I assumed that in her effort to elevate herself while coughing and leaning, she may have slid off the bed. Her mattress also appeared to be higher on the left side and slightly low (leaning) on the right. That could’ve also been a cause of her rolling out. I contacted my RN and we planned preventing future falls by providing a proper mattress, applying bolsters when in bed and ensuring resident’s head is elevated at least 30 degrees when in bed. The resident was transferred to bed with a new and symmetrical mattress. Floor mats were placed on both sides of the bed. And as usual, the bed was left in lowest position with head elevated at 30 degrees. I checked on the resident 10 minutes later and noted her to be comfortable and lying in the centre with bolsters on both side of the bed.