Falls Case Study
Client Profile
Mr. O'Brien is an alert and oriented 81 year old man admitted to the hospital with complaints of dizziness and syncope. His blood pressure on admission is 83/43. At the long-term care facility where he lives, he ambulated with a walker independently but, since his episode of syncope, he has complained of weakness and needs another person to assist while walking as a fall precaution.
Case Study
Mr. O'Brien is admitted with prescriptions that include assessment of orthostatic vital signs every shift and fall precautions. The nurse explains to Mr. O'Brien how to use the call light and instructs him to call before getting out of bed so that someone can assist him with ambulation. The nurse completes a set of orthostatic vital signs. His orthostatic vital signs ate lying: BP 120/84, HR 73; sitting: BP 114/73, HR 83; standing: BP 96/61, HR 92. When the assessment of orthostatics is complete, Mr. O'Brien is settled in bed. The nurse raises two side rails at the head of the bed, and the bed alarm is turned on so that if Mr. O'Brien tries to get out of bed without assistance, an alarm will notify staff.
Later in the shift, Mr. O'Brien's bed alarm sounds. The nurse quickly goes to his room to find Mr. O'Brien lying on the floor on his right hip. He is alert and oriented and states, I had to go to the bathroom. I know I should have called for help but the nurses are busy. I figured I could go myself. Only two more steps and I could have reached my walker. I just slipped is all. Immediately following his fall, Mr. O'Brien complains of pain in his right hip that is a 7 on a 0-10 pain scale. He describes is pain as a dull ache, that is worse with movement of his right leg. His BP is 110/62, HR is 88, and respiratory rate is 16.
Answer the following questions:
1. Which clients are at greatest risk for falls in the acute care setting? Consider physiological and environmental risk factors for falls.
2. Discuss the initial nursing interventions when the nurse enters Mr. O'Brien's room and finds him lying on the floor.
3. The nurse double checks to see that appropriate fall precautions are in place. Identify 10 measures to help prevent falls in older adults.
4. The use of a vest restraint could be considered for Mr. O'Brien to prevent another fall. Define a restraint and provide good examples of physical and chemical restraints.
5. Discuss the risk of client injury associated with the use of restraints and the prescription requirements to implement restraints.
6. Identify five alternatives to using restraints.
7. Write an appropriate three-part nursing diagnosis to include in Mr. O'Brien's plan of care regarding his fall.
Older adults are at increased risk for orthostatic hypertension secondary to age related changes in blood pressure and changes in circulatory volume.The nurse assess whether the patient is feeling of dizziness , measure blood pressure of patient in lying down position and after 2-3 minutes make the patient to stand and measure blood pressure. Orthostatic hypotension is abnormal decrease in blood pressure that occurs as patient changes from supine to standing position.
1.Falls is a common and preventable source of mortality and morbidity in older adults.Mostly children and older adults are at greater risk for falls.
Cellular and extracellular changes of old age cause decline in function. Body's ability to maintain stable internal environment declines with cellular aging . The old age people are very vulnerable to falls because they have diminished senses, cardiovasculslls should be followed when caring for an elderly patient. Cognitive changes include confusion, loss of judgement ,musculoskeletal changes include altered posture, decreased muscle strength and neurologic changes like loss of balance, dizziness all contribute with visual changes (difficulty in light accomodation, decreasing visual acquity) for falls risk in elderly patients.
Environmental risk factors are slippery floors , uneven surface in floor, lack of rails for grabbing while walking, lack of good lighting, congested pathways, not locking wheels of bed in acute care setting .
2.Check vital signs and check for altered level of consciousness . Check the skin for any bruises , or injury. Check the central nervous system for sensation and movement in the lower extremities.Observe the leg rotation, and ask for hip pain, look for shortening of the extremity, and pelvic or spinal pain. Note any pain and points of tenderness.Notify the physician.Carry patient and make him lie in bed .Monitor patient for nearl 3 days . Document in nurses notes and risk information system .
3. A clean safe bed with locked wheels and side rails, correct fitting foot wear, adequate lighting in room, call service alarms, non slippery floors , help in activities of daily living, hip protectors in elderly, falls prevention risk assessment , a tag for notifying that the patient is at risk for falls, restraints if needed.
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