Case Study: #1 Mr. O’Brien
1. Which clients are at greatest risk for falls in the acute care setting? Consider physiological and environmental risk factors for falls. The majority of patient falls occur in patients who are young and the older adults. Individuals who are ill or who become injured are at risk. If a patient is weakened or has an altered mental state, they are susceptible to falls.
2. Identify seven areas of a fall risk assessment. History of falls, seizures or fainting, older than 70, confusion or disorientation, medications that may cause confusion or alter mind, cardiovascular problems, poor eyesight.
3. Discuss the initial nursing interventions when the nurse enters Mr. O’Brien’s room and finds him lying on the floor. Look over Mr. O’Brien to check for fractures, bleeding, or any other serious injury. Assist Mr. O’Brien back into bed, and teach him the importance of calling for assistance. Call doctor to inform him of fall, fill out incident report.
4. Discuss who should be notified about Mr. O’Brien’s fall and what type of documentation is needed regarding the incident. Mr. O’Brien’s physician, family, and nursing assistants should be notified about the fall. An incident report should be filled out.
5. What test(s) will the health care provider most likely prescribe because Mr. O’Brien is complaining of pain in his right hip. Mr. O’Brien will most likely get an x-ray done.
6. The nurse double checks to see that appropriate fall precautions are in place. Identify ten measures to help prevent falls in older adults. Orientation to the environment to provide familiarity, bedside table or overbed table with supplies and belongings within reach, assistance when needed, environment kept free of clutter, side rails remain up, beds kept in the lowest position, wheels on beds, wheelchairs or gurneys are kept locked, patient should wear slip-resistant shoes or socks, wipe or mop spilled liquids promptly, provide adequate lighting.
7. What can the nursing assistant do to help in maintaining Mr. O’Brien’s safety? See above.
8. The nurse must complete an incident report. Discuss the purpose of an incident report and list the elements/type of data to address when completing this report. An incident report documents what lead to the fall, contributing factors to a fall, level of injury sustained, consequences of the fall and any recommendations on actions to take after a fall. Witnesses and statements should be reported.
9. Write a nursing progress note regarding the fall to enter into Mr. O’Brien’s chart. Use the S.O.A.P.I.E. or Focus/D.A.R. method for writing a nursing note. (see next page for chart)
E(valuation) Patient states “I just slipped is all.”
Bed alarm sounded, patient found on lying on floor on his right hip.
Patient’s BP is 110/62, HR 88, RR 16 and c/o pain on right hip a “7/10” and describes pain as a “dull ache.”
Orient patient to environment, places belongings within reach, side rails up, bed in lowest position. Teach patient importance of call light and asking for help.
Orient client to environment. Placed bedside tables, and belongings within reach. Put bed in lowest position, with side rails up. Taught patient to use call light to call for assistance. Taught patient to utilize call light and bed controls. Increased patient’s awareness to fall risks and complications that may arise from a fall.
Client did not experience falls for the remainder of the shift. Client verbalized plans to ask for assistance and acknowledged complications due to a fall.
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. A form of low blood pressure that happens when you stand up from sitting or lying down; s/s are lightheadedness or fainting.
11. Explain the steps of assessing orthostatic...
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