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)
S(ubjective)O(bjective)A(assessment)P(lan)I(nterventions)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 vital signs. From lying to a standing position, is Mr. O’Brien exhibiting signs of orthostatic hypotension based on the vital signs the nurse collected? First take the blood pressure of the client, lying down. Secondly, take the blood pressure sitting up in bed. Thirdly, take the blood pressure of the client standing up. Both the systolic and diastolic numbers will decrease with each step.
12. Identify Mr. O’Brien’s predisposing risk factors for a fall. His syncope, orthostatic hypotension age, and medication’s side effects.
13. The use of a vest restraint could be considered for Mr. O’Brien to prevent another fall. Define a restraint and provide examples of physical restraints. A restraint is a device intended for medical purposes that limits a patient’s movement to the extent necessary for treatment, examination or protection of the patient. Examples: hand mitts, safety vests, wheelchair belts, straitjackets.
14. Discuss the risk of client injury associated with the use of restraints and the prescription requirement of implement restraints. Use of restraints increases restlessness, disorientation, agitation, anxiety and feelings of powerlessness. For these reasons, a prescription must be obtained from their care giver.
15. Identify five alternatives to using restraints. Assistance, cushioning, safer environment, regular ambulation and use of toileting, close staff observation.
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 woman? If so, explain. (c) What are the common injuries that result from a fall? (d) What are the potential social implications for the older adult who has suffered a fall? (e) 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. More women than men have hip fractures, and about 30% of people with a hip fracture die in the following year.
18. What is a “HipSaver”? A hip protector. It’s a pad that absorbs the force of a fall from a patient. The garment is worn by the patient, with pads on the left and right hip to protect the patient from the force of a fall.
19. Write an appropriate three-part nursing diagnosis to include in Mr. O’Brien’s plan of care regarding his fall. Patient is at risk for impaired mobility related to syncope as evidence by pain in hip and right leg due to fall.
Case Study: #2 Mrs. Damerae
1. Prior to surgery, the health care provider chooses to place Mrs. Damerae’s right leg in Buck’s extension (traction). Why is this intervention prescribed prior to surgery? To maintain the desired traction pull and proper alignment; to prevent external rotation of the hip.
2. A trochanter roll is another option for Mrs. Damerae. What is a trochanter roll and how would it be useful? A trochanter roll is a wedge (usually a rolled towel) placed from the crest of the ilium to mid-thigh to prevent external rotation of the hip when the patient is in a recumbent position.
3. How might Mrs. Damerae’s age affect her hospitalization and recovery? The elderly are more prone to hip fractures due to degeneration of their bones. She may take longer heal due to her age.
4. Briefly discuss how Mrs. Damerae’s past medical history played a role in her injury. Her osteoporosis made her susceptible to fractures due to a bump or fall, which she had.
5. Mrs. Damerae’s surgeon informs her of the potential complications of hip surgery. Identify at least three complications the surgeon will address.
Mortality rate due to blood clots, pneumonia or infection. Dislocation is common, as is infection or thromboembolism.
6. Prioritize five nursing diagnoses appropriate for Mrs. Damerae following surgery. Risk for infection, risk for bleeding, risk for falls, impaired walking, impaired comfort.
7. Explain how the nurse should move Mrs. Damerae in order to position her safely on her side to wash her back. Should move patient on unaffected side, with abduction pillow in place.
8. The nurse applies graduated compression stockings (TEDs) and sequential compression devices (SCDs) as prescribed. What is the rationale for these interventions? To increase venous circulation to the heart and prevent pooling of blood.
9. Mrs. Damerae asks for assistance to the bathroom. The nurse checks to see that the appropriate equipment is available in the bathroom before assisting the client to ambulate. What is the nurse looking for in the bathroom? A raised toilet seat and possible bars to assist patient.
10. Mrs. Damerae is assisted back to bed. She asks that the head of her bed be raised so she can read. How high should the head of bed be raised and why? 30 or less is preferable, as to avoid flexion or external rotation.
11. Mrs. Damerae is seated in a reclining char. What reminders will the nurse give Mrs. Damerae regarding positioning while sitting and why is positioning so important? Do not cross legs, do not get up at 90 degree angle. Positioning is important as to not dislocate hip.
12. Identify the indications of a possible hip dislocation that the nurse should watch for. One leg shorter than the other, pain, inability to move, loss of feeling in foot or ankle.
13. If the nurse notices any of the above signs, discuss the appropriate
action for the nurse to take. Notify charge nurse and physician.
14. Alendronate sodium is prescribed for Mrs. Damerae. What is the rationale for the use of alendronate sodium? Discuss the client education regarding proper administration to maximize the benefits of alendronate sodium and adverse effects. Increases bone mass and reduces incidence of fractures, including those of the hip and spine. Teach patients to take at least one half hour before the first food, beverage or medication of the day with plain water only, as food and liquids will reduce absorption of the medication. Wait 30 minutes after taking the medication to eat, drink or take other medications. There are gastrointestinal adverse reactions.
15. Following discharge from a rehabilitation unit, a visiting nurse will provide follow-upcare for Mrs. Damerae. On the first home visit, the nurse conducts a home safety assessment. Identify at least five components of a safe home environment. Working smoke detector inside the home, nonskid bath mats, no throw rugs, prescription and over-the-counter medication is in a safe place, grap bars in the bathrooms, adequate lighting, steps or stairs should have handrails, no clutter, keep stairs or walkways clear, hazardous items are secured and in containers.