• Patients with admission or complaints of Urinary Incontinence• Check for Infections

• Get UA and/or culture• Check for impaction (assess recent bowel

habits• Mobility: based on baseline abilities,,

check balance/gait with “Get Up and Go” for unsafe, unsteady, or weak mobility

• Patients with admission or complaints of Fall, Instability, and/or Dizziness

•Orthostatic BP and HR•drop of 20 points or more in systolic-notify MD

•Infections•check for new onset or incontinence, get UA/culture, assess for pneumonia, URI-reassess after hydrating

•Mobility•based on baseline, abilities check balance/gait with “Get Up and Go” for unsafe, unsteady, or weak mobility

•Medications•evaluate for recent additions or changes in sedatives, diuretics, antihypertensives, narcotics

• Patients with admission or complaints of Confusion, Altered Mental Status, Failure to Thrive• Check for Infections

• Get UA and/or culture• Check for impaction (assess recent bowel

habits• Check for Depression

• Assess for loss of interest, fatigue, irritability, agitation, change in appetite, sleep problems, cognition difficulties• If present-notify MD

• All Patients• Ask patient to count backwards from 20

• Unable- notify MD of possible delirium, undiagnosed dementia or combination

• Able- go to next step• Test for recall of 3 words and draw clock

with hands at 10 minutes past 11• Able-does not suggest delirium or

dementia• Unable-call Geriatric Clinical Nurse

Specialist or Senior Healthcare Consultant to administer Mini-Mental State Exam

ALL Patients

Confusion,

Altered Mental Status, Failure

to Thrive

Urinary IncontinenceFall,

Instability, and/or

DizzinessWhen in doubt: notify MD for interventions