Posted: July 18th, 2015
Think of an elderly patient upon whom you performed a physical assessment, such as a new admission to the unit. Describe this patient by age, gender, and diagnoses. Based on your readings and the available assessment tools provided in the Try This resources (found in the Activities section of the unit), select which assessments would be necessary for this patient. What would need to be included in your plan of care to prevent complications? Defend your responses.
# case scenario:
BCAS arrives with Henry; 85 yrs; fell off his ladder while
cleaning his leaves troughs; suspect he has #’d right arm and ankle.
Bruise on forehead.
• Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model
Geriatric Giant: FALL and Injury
Screen for Falls:Have you had a fall in the last 6 months?
If YES, then refer for assessment (e.g. physiotherapist, occupational
therapist, specialized clinic, GP)*** Acutely ill older adults at
ALL at high risk for a fall and injury
Contributing Factors Contributing
Orthostatic hypotension (BP drop: lying to standing): systolic, drop of >20 or diastolic, any
standing): systolic, drop of >20 or drop, in up to 3 minutes•
Medications: diuretics, anti–hypertensives, sedatives, neuroleptics, benzodiazepines, narcotics Cerebrovascular disease, Lower limb weakness, gait problems, numbness .etc. impaired judgement/altered mental status sensory impairment (vision, hearing, proprioception balance)
Loss of cross struts inside of bone leads to
Vertebral #’s predict future hip #
TREAT early! Calcium & Vit.D
modulators, parathyroid hormone
bearing, resistant exercises
Bed rails down unless assessed otherwise
Pathways clear of clutter
Bed and chairs in locked position
Adequate and appropriate lighting
Assist with mobility
Safe and regular toileting
Mobility assist documented
Assistive devices within patient reach
Fall risk reduction
Call bell in patient’s reach
Bed lowered to patients knee height
Personal items reachable
Proper footwear available and in use
Engage patient and family
Discuss risk factors with patient and family
Communicate mutual plan
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