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CASE Study Fall risk assessment
Nursing Capstone (NURS 497)
West Coast University
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CASE STUDY
Fall Risk and Cognition Assessments
Mrs. L is an 89-year-old widow who lives independently in her home. She drives, and she is an avid quilter. Her daughter lives within 2 miles and checks in daily with Mrs. L by phone or in person. Mrs. L has been admitted to your hospital with the diagnosis of R/O pneumonia.
Her past medical problems include the following:
Bilateral hip replacements Detached retina × 2 (right eye) Osteoarthritis Depression Orthostatic hypotension Falls at home × 1 Urinary frequency Insomnia (sleeps about 3 hours per night) Mrs. L takes no medication, “not even an aspirin.”
Mrs. L uses her call button frequently to request assistance to the bathroom. Upon rounding,
her nurse found Mrs. L on the floor, having crawled out of her bed with the side rails up. She was assessed and was found to have no injuries. Her gown was wet with urine. When asked to describe what happened, Mrs. L stated the following: “I called for help to the bathroom, and no one came. So rather than wetting the bed, I managed to crawl over the side rails. I slipped on the floor trying to get to the bathroom.”
- What are Mrs. L’s known risk factors (in the hospital) for falling? Environmental: No response to call light and side rails being up.
Medical conditions: Orthostasis hypotension, detached retina, urinary frequency
Unsafe behaviors: Crawling over the side rails, Mrs. L does not take a medication, negligence from the nurses for not responding to call light.
- Using the Hendrich II Fall Risk Model (in Doc Sharing), determine Mrs. L’s fall risk score (attached below).
Mrs. L score was 8 which indicates a high-risk fall 3. Mrs. L states she is “plagued by insomnia.” Using the Pittsburgh Sleep Quality Index (attached
Environmental and equipment- Avoid putting all four side rails up, only put at most three out of four side rails up. Nurses should always respond to call light to prevent future occurrence of patient crawling over side rails.
Gait and mobility- responding to call light is paramount in care of this patient due to high risk for fall. Patient must be taught to get up slowing due to orthostasis hypotension, patient needs assistance with gait and mobility needs to utilize her assistive device when ambulating like wheelchair.
New medications- Mrs. L will have medication and new medication to help manage her existing condition and help with her poor sleeping pattern.
Anxiety, depression, and unsafe behavior- To help improve her mind, help her make good judgement to avoid risky behaviors, medication complaint is important to help with management of anxiety.
- Write a 1 paragraph summary describing Mrs. L’s risk for falls in your own words.
Mrs. L is 89 year who lives alone in her home which put her at risk for fall due to her age. This patient has a diagnosis of osteoarthritis which a disease that affect the bone and joint in the body putting this patient at high risk for fall if pain is not controlled. Patient also have a diagnosis of detached retina x2 in the right eye which indicate that patient visual field is limited with sudden flashes of light or shadows in visual field. Patient is also not taking her medication as prescribed and only about 3hours sleep each night. One of the major contributing factors is pneumonia which can cause forgetfulness, or a sudden change in mental ability.
Reference Weill Cornell Medicine. (n.). Pneumonia: What you need to know. weillcornell/news/pneumonia-what-you-need-to-know
CASE Study Fall risk assessment
Course: Nursing Capstone (NURS 497)
University: West Coast University
