Question

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Attach is the Risk and fall book. Please go through this book and help me to do a care map

Definition Risk Factors

Adults

Age ≥ 65 years; history of falls; living alone; lower limb prosthesis; use of assistive device (e.g., walker, cane, wheelchair)

Children

Absence of stairway gate; absence of window guard; age ≤ 2 years; inadequate supervision; insufficient auto- mobile restraints; male gender when < 1 year of age

Cognitive

Alteration in cognitive functioning

Environment

Cluttered environment; exposure to unsafe weather-related condition (e.g., wet floors, ice); insufficient light- ing; insufficient antislip material in bathroom; unfamiliar setting; use of restraints; use of throw rugs

Pharmaceutical Agents

Alcohol consumption; pharmaceutical agent

Physiological

Acute illness; alteration in blood glucose level; anemia; arthritis; condition affecting the foot; decrease in lower extremity strength; diarrhea; difficulty with gait; faintness when extending neck; faintness when turning neck; hearing impairment; impaired balance; impaired mobility; incontinence; neoplasm; neuropa- thy; orthostatic hypotension; postoperative recovery period; proprioceptive deficit; sleeplessness; urinary urgency; vascular disease; visual impairment

Client Will (Specify Time Frame)

• Remain free of falls
• Change environment to minimize the incidence of falls• Explain methods to prevent injury

Nursing Interventions and Rationales

Safety Guidelines. Complete a fall-risk assessment for older adults in acute care using a valid and reliable tool such as the Hendrich II Model. Recognize that risk factors for falling include recent history of falls, fear of falling, confusion, depression, altered elimination patterns, cardiovascular/respiratory disease impairing perfusion or oxygenation, postural hypotension, dizziness or vertigo, primary cancer diagnosis, and altered mobility (Gray-Miceli, 2008). The Hendrich II Fall Risk Model is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk (Hendrich, 2006). This tool screens for primary prevention of falls and is integral in a post-fall assessment for the secondary prevention of falls (Gray-Miceli, 2007 ).

0. Home Care

1. Some of the above interventions may be adapted for home care use.
   Implement evidence-based fall prevention practices in community settings and home health care pro- grams for older adults (Fortinsky et al, 2008).
   If the client was identified as a fall risk in the hospital, recognize that there is a high incidence of falls after discharge, and use all measures possible to reduce the incidence of falls. CEBN: The rate of falls is substantially increased in the geriatric client who has been recently hospitalized, especially during the first month after discharge (Mahoney et al, 2000).

Patient Problem #1 is Risk for Falls includes: answer all these question

1. Nursing diagnosis
2. Supporting evidence (subjective and objective data)

3. One SMART* goal.
4. Minimum of 3 EB* interventions.

Answer 1

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