NNDA: A Case Study

All of the patients on my unit in my former position were in the beginning and mid stages of Alzheimer’s with one or two very alert ones. The challenge was keeping the more alert residents from rapid mental decline. The key in maintaining the resident’s dignity is providing an environment where they can participate in their level of care,

Fall prevention and management is integral to the care process. Managing the risk of falling requires identifying factors that contribute to falls. The goal of the following policy and procedures would be to encourage each resident’s independence by removing the risk of falls where possible and reducing both the incidence of falls and the injuries that may accompany falls.

Anyone can be at risk for a fall due to their environment, though some are at a greater risk than others. Someone with confusion or cognitive impairment for example, is at greater risk for experiencing a fall both within the community and the home setting. Patients with dementia are three times more likely to fall than

Resident states “I am just a common and ordinary person that worked hard all my life.” She states “I am to old, 94, and not many people listen to me so I would have much of an affect on lives or make changes.” “I don’t really handle stress or problems well. I get really nervous in situations and I sometimes even have a panic attack,” resident states. She states “There Is no change since I come to this facility. I feel that it has worsen.” She is unhappy with the room situation because she has to share a bathroom. Resident states “Staff is always coming in and out of my room which makes me nervous. I have no privacy.” “I really want to have my own room with a private bathroom,” she states. Resident states “I lost my sister not to long ago. I

L. Holtz, a registered nurse (RN), mentions even with the use of tab alarms, residents still experience falls (personal communication, February 3, 2017). When a resident is first admitted into long term care, they undergo various assessments. One assessment is the Morse Fall Scale (MFS). The MFS is a rapid and simple method of assessing a patient’s likelihood of falling. It consists of six variables that include: history of falling, secondary diagnosis, ambulatory aid, intravenous (IV)/Heparin lock, gait/transferring, and mental status. There are three risk levels based on scoring: no risk, low risk, and high risk. L. Holtz pointed out interventions for high risk residents would include: tab alarms, floor alarms, and lower beds (personal communication, February 3, 2017). She also mentioned each resident is identified as a fall risk by a falling star poster which is attached to their name tag outside their door (L. Holtz, personal communication, February 3, 2017). Other interventions to reduce the occurrence of falls include: regular toileting, clutter-free areas, and well lighted area. Efforts and interventions are placed to assure the safety of the residents. However, even when these interventions are in place, falls still

The information contained in this report was gathered in a private nursing home over 2 weeks that for the sake of this essay, be called “facility x”

The purpose and scope of the “RNAO Falls Prevention CPG” are: “To increase all nurses’ confidence, knowledge, skills and abilities in the identification of adults within health care facilities at risk of falling and to define interventions for the prevention of falling. It does not include interventions for prevention of falls and fall injuries in older adults living in community settings. The guideline has relevance to areas of clinical practice including acute care and long-term care,

The home assessment will be conducted on a room to room basis using a falls risk assessment tool. By gathering and documenting this information it will provide more insight into Mavis’ health and lifestyle and give necessary information to other health care members which may be vital.

After searching the policy manual at work, I found the perfect topic that has a big effect on the residents. As the residents start to get older and their disease take over, some lose the ability to walk or have a loss of balance. Because of this, they are more apt to fall. The part of the facility where I work that is more prone to falls would be our Memory Care Unit. We have a gentleman who prior to coming to the facility was able to walk. Since he became a resident in our facility, he lost the strength to walk but in his mind he thinks he can still walk. Because of this thought process, he has had multiple falls.

I was able to assess Ms. PM’s ADLs with an interview and also by observing the patient performed some ADLs during the time, I provided care. Ms. PM was able to perform ADLs that are fundamental for self-care. She was able to use the bathroom by herself and she did not have any problems with feeding. She was not able to accomplish a great number of activities because the Dr. had recommended to rest in order to avoid any further complications of her pseudo-aneurism on her left groin after the placement of a stent on the coronary artery. Before hospitalization, Ms. PM was able to perform the routine activities of every day without needing assistance. The client is expecting to regain the ability to perform her basic ALDs. She was able before

Falls in acute care settings frequently occur regardless of the prevention measures used to eliminate the risk of falling and sometimes lead to fractures, hematomas, head injuries, and spinal cord. It can also lead to a decrease in confidence, independence, and mobility in elderly. However, to prevent a fall, risk factors must be accurately assessed in a hospital setting, in which the patient’s risk assessment information can translate into an action plan if this protocol is applied. Fall has a tremendous impact on the patient, but implementing an accurate assessment will help reduce the risk of falling and the hospital cost. These are just some potential results that could happen, and these results would be generalizable to the study population

Falls occur in every age group but we most often hear about them occurring in the elderly population. I chose to research this topic because I have worked in a nursing home, home health, and at a small community hospital where I have seen falls occur at each of these facilities. I truly feel that we as nurses should take a stand to do everything we can to prevent these falls from occurring. I have heard nurses say I hope that they do not fall because of the paperwork that follows but yet they do little to assess or improve the risk of this occurring. It is stated that from “2010 to 2011, four hundred and fifty thousand people aged 65 years and over were admitted to the hospital as the result of a fall” (Duffy, 2013, p.259). That number is staggering to me because of how many lives that would affect and the impact it has on our health care system.

Falls are a major problem in elderly population in the United States living in nursing facilities. Statistics from Agency for Healthcare Research and Quality (AHRQ) show that approximately 800,000 seniors fall each year and 1 in 3 of those will fall twice or one more time in a year. (Agency for Healthcare Research and Quality, 2012). Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater their chances of falling. Healthcare providers can help cut down a person’s risk by reducing the fall risk factors

Mrs. Green, who has been diagnosed with kossakoff dementia, has been admitted to the maple ward. She needs 24-hour personal care and assistance. She is independently mobile but has to be reoriented to her location constantly. Several times a day she has to be reminded that she is in a hospital. Mrs. Green has to be prompted and encouraged to eat and intake liquids. As a result of this poor intake, she has been referred to a dietitian. She is also being monitored via a chart for her food and fluid intake. Mrs. Green becomes restless and agitated sometimes, but she has requested to leave the ward on a number of times and has even tried following family and staff out of the facility. If she has the chance, she will leave the ward. Furthermore, she also invades the personal space of other patients, some of who have acted aggressively towards her. Mrs. Green isn't fully aware of her surroundings and requires 24-hour support and intervention. Her medication is administered by a registered nurse and she is compliant with this procedure. Mrs. Green has a short memory span and is disoriented to person, place and time. Her assessment shows that she doesn't have the capacity to consent to be admitted and treated.

Preventing falls in the hospital or a patient centered care facility are among the most talked about preventions. They have the ability to cause secondary diagnosis that may hinder or post pone discharging. The dictionary describes a fall as, “to come or drop down suddenly to a lower position, especially to leave a standing or erect position suddenly, whether voluntarily or not” (Cite). There are many factors that contribute to patient falling. Some are the shoes they wear on their feet when they walk or lack there of, medications that may contribute to loss of coordination, impaired vision, or a drop on blood pressure. Other causes could be lack of Physical Therapist training and not answering to call light promptly. Although all these factors may cause falls they could also be prevented my implementing the policies that are in place to prevent falls.