PDAR

A case of a 53 y/o, Female, right-handed, patient with a chief complaint of headache with a pain

scale of 3/10 and lightheadedness.

10/14/19 0630H

P > Risk for Fall

D> (+) Headache with a pain scale of 3/10

 (+) lightheadedness

A> Maintained side rails up

 Elevated head of bed to 45O

 Monitored BP accordingly.

 Monitored blood sugar levels accordingly.

 Assist the patient at all times.

 Instruct the patient to drink lots of water.

10/14/19 0838H

R> Headache was reduced to down to 2/10.

 (-) lightheadedness

 No incidence of fall injuries noted.