QuestionFall Risk Case StudyMr. O’Brien is an alert and oriented 81-year-o

Fall Risk Case Study

Mr. O’Brien is an alert and oriented 81-year-old man admitted to the hospital with complaint of dizziness and syncope. His blood pressure on admission is 80/43. At the long-term nursing 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 are lying: BP = 120/84, heart rate = 73; sitting: BP = 114/73, HR = 83; standing: BP 96/61, HR = 92. When the assessment of orthostatic 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 the pain as a “dull ache” that is worse with movement of his right leg. His BP 110/62, HR is 88, and respiratory rate is 16.

Questions and Suggested Answers

1. Which clients are at greatest risk for falls in the acute care setting? What are the physiological and environmental risk factors for falls?
2. What are the seven areas of a fall risk assessment?
3. What are the initial nursing interventions when the nurse enters Mr. O’Brien’s room and finds him lying on the floor?
4. Who should be notified about Mr. O’Brien’s fall and what type of documentation is needed regarding the incident?
5. What tests will the health care provider most likely prescribe since Mr. O’Brien is complaining of pain in his right hip?
6. The nurse double checks to see that appropriate fall precautions are in place. What are ten measures to help prevent fall in older adults?
7. What can the nursing assistant do to assist in maintaining Mr. O’Brien’s safety?
8. The nurse must complete an incident report. What is the purpose of an incident report and list the elements/type of data to address when completing this report?
9. Mr. O’Brien was assisted back to bed with a Hoyer lift and two assists. His vital signs remained within his baseline throughout the remainder of the shift and he is afebrile. An X-ray of his right hip was negative for a fracture. There is no physical deformity of the right hip or other injuries apparent, but a moderate amount of ecchymosis of his right hip that extends around to his lower back and upper buttock is noted. His health care provider, Dr. Sutton, prescribed one tablet of oxycodone/acetaminophen 5/325 by mouth (PO) that decreased Mr. O’Brien’s pain to a “2/10” within forty minutes of administration. He remains alert and oriented, continues on bed rest, and used the urinal once for 200 cc of clear yellow urine. The bed alarm is on, the call bell is in reach, and there are two sides rails up. Mr. O’ Brien has verbalized an understanding of how and when to use the call bell. Write a nursing progress note regarding the fall to enter into Mr. O’Brien’s chart. Use the S.O.A.P.I.E. method for writing a nursing note.
10. Provide a brief explanation of what orthostatic (postural) hypotension is and identify the blood pressure and heart rate values that define orthostatic (postural) hypotension.
11. Explain the steps of assessing orthostatic vital signs. From a lying to standing position, is Mr. O’Brien exhibiting signs of orthostatic hypotension based on the vital signs the nurse collected?
12. What are the predisposing risk factors for a fall?
13. The use of a vest restraint could be considered for Mr. O’Brien to prevent another fall. What is a “restraint” and provide an example of physical restraints and chemical restraints?
14. What is the risk for a client’s injury associated with the use of restraints and the prescription requirements to implement restraints?
15. Identify five alternatives to using restraints.
16. Briefly address the following:

(a) What is the incidence of falls and fall-related deaths in the older adult population?

(b) Is there a difference in the incidence and mortality between men and women?

( c ) What are the common injuries that result from a fall?

(d) Describe the need for long-term care following a fall

17. The most common fracture resulting from a fall is a hip fracture. Discuss    the incidence of and mortality associated with a hip fracture, as well as the difference in the incidence of hip fractures between men and women.

18. What is a “HipSaver”?

19. Write an appropriate three part nursing diagnosis to include in Mr. O’Brien’s plan of care regarding his fall.

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