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Running head: FALL RISK ASSESSMENT FOR OLDER ADULTS
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Fall Risk Assessment for Older Adults
Abstract
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The Hendrich II Fall Risk Model was used to assess a hospitalized patient’s risk of
falling. The test was designed to be administered quickly and focused on eight independent risk
factors: confusion, disorientation, and impulsivity; symptomatic depression; altered elimination;
dizziness or vertigo; male sex; administration of antiepileptics; administration of
benzodiazepines; and poor ability to rise from a seated position in a chair (Hendrich, 2016).
Demographics
The patient assessed with this tool was seventy-nine-year-old Leo Green. Mr. Green was
admitted to the hospital for infective endocarditis. He presented to the emergency department
with fatigue, shortness of breath, aching muscles, and a high fever. His history includes heart
failure, diabetes mellitus, and hypertension. He was in the hospital two weeks ago for a surgery
which is where they think the infection was contracted from.
Mr. Green is on IV Vancomycin though a PICC line. He will be on this treatment
regimen for six consecutive weeks. His recovery requires a specialized treatment that is not
offered near his home, therefore he will stay in the hospital for the entire 6 weeks until finished.
The nurse administers his daily medications which include Lasix, Insulin Humalog, and
Carvedilol. His medical chart also includes an order for acetaminophen-oxycodone which he has
not been taking recently. Mr. Green is eager for discharge and has a calendar on his wall to count
down the days. His daughter moved into his home six months ago to help care for him. Mr.
Green has been living independently until then and was still engaged in activities and yard work.
Mr. Greens daughter was present in the hospital and is very engaged in helping with his
recovery. She has been assisting with minor daily activities since moving in with him such as
meal preparation and driving. activities. During the assessment Mr. Green shared that he lives in
a two-story home which will be vital to take into consideration during his discharge plan.
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FALL RISK ASSESSMENT FOR OLDER ADULTS
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Problem
The problem I chose to identify was the risk of falls in older adults. Falls are the most
commonly reported incident in the acute care setting. Falls are usually multifactorial in origin,
although certain medications such as benzodiazepines are an independent risk factor (Mauk,
2018). One of the primary responsibilities of nurses is to prevent falls and promote patient safety.
Mr. Green has an increased risk of falls because he is losing muscle and bone mass in the
hospital. He is also on a new medication for his infective endocarditis which may have side
effects that contribute to falling.
One of the most complicating factors for falls is restroom use. Studies show that nearly
one-third of reportable falls with injuries in hospitalized older patients are linked to bathroom use
(Hendrich, 2016). Another factor contributing to falls is due to loss of muscle and bone mass.
Mr. Green is spending the majority of his day on bedrest therefore causing him to lose muscle
strength over time.
Rationale
The best approach to decreasing falls in the acute care setting incorporates use of the
Hendrich II Fall Risk Model. This approach was chosen because it provides a determination of
falling based on gender, mental and emotional status, symptoms of dizziness, and known
categories of medications that increase risk. The tool screen for fall risk and is integral in
assessment after falls for secondary prevention of falls (Hendrich, 2016). The tool will provide
an accurate measurement of Mr. Greens fall risk. The outcome expected is a care plan
specialized to his risk and interventions to prevent a fall.
The Hendrich II Fall Risk Model is an important tool to use for Mr. Green because he has
new risk factors contributing to his risk for falling due to his new diagnosis. The expected
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FALL RISK ASSESSMENT FOR OLDER ADULTS
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outcome for using this tool is to identify that Mr. Green is at risk for falls and align interventions
that will reduce the risk factors present when possible.
Difficulties
One flaw in the Hendrich II Fall Risk Model is the tool does not take account of any
predisposing diseases or surgeries. Mr. Green recently had heart implant surgery and removal of
the implant due to infective endocarditis. He has two healing wounds on his groin area that make
ambulating more painful. This inhibits his mobility but was not accounted for in this tool.
Another limitation of the tool is the consideration for additional medications that may
contribute to fall risk. Laxatives increase the patient’s frequency of urination which will cause
the patient to toilet more often and have more opportunities to fall. He also may be administered
a benzodiazepine-like drug, but this assessment does not screen for medications other than
benzodiazepines and antiepileptics.
It would be unreasonable to assume the nurse will reassess for falls every time the patient
has a minor change in status. The Hendrich II Fall Risk Model identifies altered elimination as a
risk factor. Mr. Green scored positively for altered elimination because he recently had a catheter
removed and is at high risk for altered function until normal elimination is established.
Evaluation
Mr. Green’s total score is 6, indicating that he has a high risk of falling. To reduce his
risk, the nursing care plan is altered. Incorporating a schedule for increased observation and
toileting rounds based on his elimination patterns will help eliminate the risk-taking behaviors.
Mr. Green should be reminded frequently that he is at high risk for falls and should have a
thorough discussion with the nurse.
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FALL RISK ASSESSMENT FOR OLDER ADULTS
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Mr. Greens care plan should reflect increased ambulation and physical therapy to
maintain his muscle tone. He should be checked on frequently to see if he needs assistance to the
restroom. His care plan should also include frequent walks in the hallway and sitting up in a
chair. The nurse should check on him frequently and ensure he has all his personal items within
reach.
Falls rarely have one cause in older adults and are relatively multifactorial in origin or
have more than one cause at a time. To accurately assess the risk for falls it is important to
understand the key factors that contribute to falls (Mauk, 2018).
An important nursing intervention is to have the bed in the lowest position, identify that
he is fall risk, keep the room clutter-free, use adequate lighting, and keep at least half of the side
rail up. If he is restless and tries to ambulate alone, a bed alarm may be considered. Overall these
interventions will help keep Mr. Green safe during his in-patient care and help prepare him for
discharge.
Additional Considerations
Another important intervention is to involve both the patient and the family in the
discharge care teaching. Because his daughter is already very involved in his care it would be
beneficial to have the teaching done at a time where she can be present. It also may be useful to
have his daughter present during the next fall risk assessment. She may be able to provide
valuable information about his history and have input regarding his risk factors. Both the
patient and family can benefit from patient education and all be proactive and informed on
reducing the risk of falls.
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FALL RISK ASSESSMENT FOR OLDER ADULTS
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References
Hendrich, A. (2016). Fall risk assessment for older adults: The hendrich II fall risk model. Best
Practices in Nursing Care to Older Adults, 8(1). Retrieved February 19, 2019, from
https://consultgeri.org/try-this/general-assessment/issue-8
Mauk, K. (2018). Gerontological nursing: Competencies for Care (4th ed., pp. 454-465).
Burlington, MA: Jones and Bartlett Learning.

Unformatted Attachment Preview

Running head: FALL RISK ASSESSMENT FOR OLDER ADULTS Fall Risk Assessment for Older Adults Abstract 1 FALL RISK ASSESSMENT FOR OLDER ADULTS 2 The Hendrich II Fall Risk Model was used to assess a hospitalized patient’s risk of falling. The test was designed to be administered quickly and focused on eight independent risk factors: confusion, disorientation, and impulsivity; symptomatic depression; altered elimination; dizziness or vertigo; male sex; administration of antiepileptics; administration of benzodiazepines; and poor ability to rise from a seated position in a chair (Hendrich, 2016). Demographics The patient assessed with this tool was seventy-nine-year-old Leo Green. Mr. Green was admitted to the hospital for infective endocarditis. He presented to the emergency department with fatigue, shortness of breath, aching muscles, and a high fever. His history includes heart failure, diabetes mellitus, and hypertension. He was in the hospital two weeks ago for a surgery which is where they think the infection was contracted from. Mr. Green is on IV Vancomycin though a PICC line. He will be on this treatment regimen for six consecutive weeks. His recovery requires a specialized treatment that is not offered near his home, therefore he will stay in the hospital for the entire 6 weeks until finished. The nurse administers his daily medications which include Lasix, Insulin Humalog, and Carvedilol. His medical chart also includes an order for acetaminophen-oxycodone which he has not been taking recently. Mr. Green is eager for discharge and has a calendar on his wall to count down the days. His daughter moved into his home six months ago to help care for him. Mr. Green has been living independently until then and was still engaged in activities and yard work. Mr. Greens daughter was present in the hospital and is very engaged in helping with his recovery. She has been assisting with minor daily activities since moving in with him such as meal preparation and driving. activities. During the assessment Mr. Green shared that he lives in a two-story home which will be vital to take into consideration during his discharge plan. FALL RISK ASSESSMENT FOR OLDER ADULTS 3 Problem The problem I chose to identify was the risk of falls in older adults. Falls are the most commonly reported incident in the acute care setting. Falls are usually multifactorial in origin, although certain medications such as benzodiazepines are an independent risk factor (Mauk, 2018). One of the primary responsibilities of nurses is to prevent falls and promote patient safety. Mr. Green has an increased risk of falls because he is losing muscle and bone mass in the hospital. He is also on a new medication for his infective endocarditis which may have side effects that contribute to falling. One of the most complicating factors for falls is restroom use. Studies show that nearly one-third of reportable falls with injuries in hospitalized older patients are linked to bathroom use (Hendrich, 2016). Another factor contributing to falls is due to loss of muscle and bone mass. Mr. Green is spending the majority of his day on bedrest therefore causing him to lose muscle strength over time. Rationale The best approach to decreasing falls in the acute care setting incorporates use of the Hendrich II Fall Risk Model. This approach was chosen because it provides a determination of falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications that increase risk. The tool screen for fall risk and is integral in assessment after falls for secondary prevention of falls (Hendrich, 2016). The tool will provide an accurate measurement of Mr. Greens fall risk. The outcome expected is a care plan specialized to his risk and interventions to prevent a fall. The Hendrich II Fall Risk Model is an important tool to use for Mr. Green because he has new risk factors contributing to his risk for falling due to his new diagnosis. The expected FALL RISK ASSESSMENT FOR OLDER ADULTS 4 outcome for using this tool is to identify that Mr. Green is at risk for falls and align interventions that will reduce the risk factors present when possible. Difficulties One flaw in the Hendrich II Fall Risk Model is the tool does not take account of any predisposing diseases or surgeries. Mr. Green recently had heart implant surgery and removal of the implant due to infective endocarditis. He has two healing wounds on his groin area that make ambulating more painful. This inhibits his mobility but was not accounted for in this tool. Another limitation of the tool is the consideration for additional medications that may contribute to fall risk. Laxatives increase the patient’s frequency of urination which will cause the patient to toilet more often and have more opportunities to fall. He also may be administered a benzodiazepine-like drug, but this assessment does not screen for medications other than benzodiazepines and antiepileptics. It would be unreasonable to assume the nurse will reassess for falls every time the patient has a minor change in status. The Hendrich II Fall Risk Model identifies altered elimination as a risk factor. Mr. Green scored positively for altered elimination because he recently had a catheter removed and is at high risk for altered function until normal elimination is established. Evaluation Mr. Green’s total score is 6, indicating that he has a high risk of falling. To reduce his risk, the nursing care plan is altered. Incorporating a schedule for increased observation and toileting rounds based on his elimination patterns will help eliminate the risk-taking behaviors. Mr. Green should be reminded frequently that he is at high risk for falls and should have a thorough discussion with the nurse. FALL RISK ASSESSMENT FOR OLDER ADULTS 5 Mr. Greens care plan should reflect increased ambulation and physical therapy to maintain his muscle tone. He should be checked on frequently to see if he needs assistance to the restroom. His care plan should also include frequent walks in the hallway and sitting up in a chair. The nurse should check on him frequently and ensure he has all his personal items within reach. Falls rarely have one cause in older adults and are relatively multifactorial in origin or have more than one cause at a time. To accurately assess the risk for falls it is important to understand the key factors that contribute to falls (Mauk, 2018). An important nursing intervention is to have the bed in the lowest position, identify that he is fall risk, keep the room clutter-free, use adequate lighting, and keep at least half of the side rail up. If he is restless and tries to ambulate alone, a bed alarm may be considered. Overall these interventions will help keep Mr. Green safe during his in-patient care and help prepare him for discharge. Additional Considerations Another important intervention is to involve both the patient and the family in the discharge care teaching. Because his daughter is already very involved in his care it would be beneficial to have the teaching done at a time where she can be present. It also may be useful to have his daughter present during the next fall risk assessment. She may be able to provide valuable information about his history and have input regarding his risk factors. Both the patient and family can benefit from patient education and all be proactive and informed on reducing the risk of falls. FALL RISK ASSESSMENT FOR OLDER ADULTS References Hendrich, A. (2016). Fall risk assessment for older adults: The hendrich II fall risk model. Best Practices in Nursing Care to Older Adults, 8(1). Retrieved February 19, 2019, from https://consultgeri.org/try-this/general-assessment/issue-8 Mauk, K. (2018). Gerontological nursing: Competencies for Care (4th ed., pp. 454-465). Burlington, MA: Jones and Bartlett Learning. 6 Name: Description: ...
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