A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change
Which action is the nurse's priority when evaluating the patient?
a. Identify factors interfering with goal achievement.
b. Counsel the nursing assistive personnel on duty when the patient fell.
c. Remove the fall risk sign from the patient's door because the patient has suffered a fall.
d. Request that the more experienced charge nurse complete the documentation about the fall.
ANS: A
When goals and outcomes are not met, you identify the factors that interfere with their achievement. The nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistive personnel; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation.
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