HSR-320 Goodwin College – You are a nurse caring for a 79-year-old patient who was admitted to the medical–surgical unit where you practice nursing.

QUESTION

You are a nurse caring for a 79-year-old patient who was admitted to the medical–surgical unit where you practice nursing. He was admitted from a long-term care facility with Clostridium difficile, requiring IV antifungal therapy. He has a history of dementia, is pleasantly confused, and is reported to wander the facility continually when he is awake. He sleeps during the day and is awake for most of your night shift

1. In your safety assessment, which of these factors could be significant threats to the patient’s safety?
2. List the factors that indicate whether this patient would be a fall risk.
3. Score his fall risk using the Hendrich II Fall Risk Model.
4. Outline potential interventions you could implement to prevent his falling.

ANSWER

 Ensuring Patient Safety: Managing Fall Risk in a 79-Year-Old Patient with Clostridium difficile and Dementia

Introduction

Providing a safe environment is a vital aspect of nursing care, particularly for vulnerable patients. This essay focuses on a 79-year-old patient with Clostridium difficile, dementia, and a history of wandering. Assessing the factors that pose threats to the patient’s safety, identifying fall risk indicators, scoring fall risk using the Hendrich II Fall Risk Model, and outlining potential interventions to prevent falls will be discussed.

Factors Threatening Patient Safety

 Wandering Behavior: The patient’s history of wandering poses a significant threat to their safety as it increases the risk of falls, disorientation, and potential injuries.

Fall Risk Indicators

Dementia: The patient’s cognitive impairment, specifically dementia, increases the risk of falls due to impaired judgment, decreased spatial awareness, and reduced ability to recognize environmental hazards (Agrawal et al., 2021).

Wandering Behavior: The patient’s continuous movement and aimless walking increase the likelihood of falls.

Sleep-Wake Cycle Disruption: Sleeping during the day and being awake at night disrupts the patient’s circadian rhythm, potentially leading to fatigue, decreased attention, and increased fall risk.

Scoring Fall Risk using the Hendrich II Fall Risk Model

The Hendrich II Fall Risk Model assesses fall risk based on specific indicators, assigning scores to each item. The total score determines the patient’s fall risk level. The model includes factors such as confusion, symptomatic depression, altered elimination, dizziness, and use of antiepileptics or benzodiazepines. A comprehensive assessment using this model would help quantify the patient’s fall risk level accurately (Hendrich et al., 2020).

Potential Interventions to Prevent Falls

Enhanced Supervision: Assign a dedicated healthcare provider to closely monitor the patient, especially during periods of increased activity and wandering.

 Environmental Modifications: Remove tripping hazards, ensure clear pathways, install grab bars in bathrooms, and use bed alarms to alert staff when the patient tries to get out of bed unassisted.

Regular Reorientation: Engage the patient in reality orientation techniques, such as frequent verbal reminders about their location and current situation, to reduce confusion and disorientation.

Encourage Mobility with Assistance: Collaborate with physical therapy to develop a safe mobility plan, including supervised walking exercises and the use of assistive devices like walkers or canes.

 Medication Review: Evaluate the patient’s medication regimen, specifically antiepileptics and benzodiazepines, to minimize any adverse effects on balance or cognitive function.

 Adequate Lighting: Ensure well-lit pathways and rooms to enhance visibility and reduce the risk of falls (Woltsche et al., 2022).

Conclusion

Ensuring patient safety is a crucial aspect of nursing care, especially for individuals with complex conditions and heightened fall risks. By identifying factors threatening patient safety, assessing fall risk using standardized models, and implementing targeted interventions, healthcare providers can mitigate the risk of falls and associated injuries. Through a comprehensive approach that considers individual patient characteristics and environmental modifications, nurses can enhance patient safety and improve overall outcomes.

Note: When implementing interventions, it is important to consider individual patient preferences, involve the interdisciplinary team, and tailor care plans accordingly.

References

Agrawal, A. K., Gowda, G. S., Achary, U., Gowda, G. S., & Harbishettar, V. (2021). Approach to Management of Wandering in Dementia: Ethical and Legal Issue. Indian Journal of Psychological Medicine, 43(5_suppl), S53–S59. https://doi.org/10.1177/02537176211030979

Hendrich, A., Bufalino, A., & Groves, C. (2020). Validation of the Hendrich II Fall Risk Model: The imperative to reduce modifiable risk factors. Applied Nursing Research, 53, 151243. https://doi.org/10.1016/j.apnr.2020.151243

Woltsche, R., Mullan, L., Wynter, K., & Rasmussen, B. (2022). Preventing Patient Falls Overnight Using Video Monitoring: A Clinical Evaluation. International Journal of Environmental Research and Public Health, 19(21), 13735. https://doi.org/10.3390/ijerph192113735

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