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Asked by BrigadierMongoose2118
Based on the fact that the patient experiences dizziness when in an upright position and has confused mental status, this would be indicative of a high fall risk. To ensure their safety, the nurse would implement fall precautions. This includes educating the patient and their family to have the patient rise slowly when changing positions and to call for assistance using the call light. In addition, since the patient has an altered mental status, it would be appropriate for the nurse to set a bed alarm. This will alert the healthcare team if the patient attempts to get out of bed without assistance. Also, since the patient is reporting incontinence episodes, it would be important for the nurse to ensure regular repositioning of the patient at least every two hours. This helps prevent pressure injuries from developing due to prolonged immobility. The nurse should also perform frequent skin assessments to monitor for any signs of pressure injuries and take appropriate measures to prevent them.
SCIENCE
HEALTH SCIENCE
NURSING

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