文档介绍：Agitation/Delirium-infection,toxic/metabolic,S,dehydration/bloodloss,sleepdisturbanceMeds(dose/timing)-psychotropics,CVagents(digoxinespecially),anticoagulants(increasedriskofinjury),anticholinergic,bowelprepOrthostatichypotension,autonomicfailureFrequenttoiletingImpairedmobilityImpairedvision,inappropriateuseofassistivedevice/footwearHistoryofFalls(CV/lightheaded-dizzy,Dysequilibrium-lossofbalancewithnoabnormalmotionsensation,Vestibular/Vertigo,Weakness-Musculoskeletal/bination,other)Psychotropics,digoxin,type1aantiarrhythmic,diuretic(thiazides>loopdiuretics)Antihistamines/benzodiazipines-withdrawalhasshowndecreaseinfallsrisk,assessforsleepdisorder,avoidroutinePRNorders-trynon-pharmacologicalapproachesincludingquietsleepprotocolsonunitsAntidepressants-TricyclicshigherriskthanSSRI,butSSRI'shaveriskaswell,highlevelofphenytoin;lowdosamitriptylineaffectsgate;gabapentin10-25%ADRCardiacdrugs/antihypertensives-iforthostatic(dropinsys>20mmin3min)andsymptomaticAnticoagulants-subduralhematomasarerare;avoidonlyifveryunstablegaitorbalance,concurrentuseofalcohol,orotherdrugsthatinteractandincreasebleeding,pliantwithregimenorlabfollowupDrugstreatingnocturia(considertamsulosinduetolowerriskoforthostasis)Nursingfallriskassessment,diagnosesandinterventionsarebasedonuseoftheMorseFallScale(MFS)(Morse,1997).TheMFSisusedwidelyinacutecaresettings,