Clinical Judgement and Decision-making in Nursing: A Case Study - Post Fall Patient Assessment

ASSESSMENT TASK 2: Clinical Judgement and Decision-making in Nursing: A
Case Study
Post Fall Patient Assessment

Question 1
Risk if falls in the older patients is very high. The risk of falls can be increased due to
the physical health condition, chronic disease, changing occurring in muscular
strength due to old age, poor vision, cognitive disorders or the external environment
(Gale, Cooper, & Aihie Sayer, 2016). Falls occurring in the older patient increases
the risk of head, spine or femur related injuries and bleeding. The cause of the fall
may be complex and it is assumed that patient’s underlying condition and medication
may the reason behind the fall.
According to the Report of the Clinical Excellence Commission, post fall, that staff
must undertake the DETECT assessment- Detecting Deterioration, Evaluation,
Treatment, Escalation and Communicating in Teams (Clinical Excellence
Commission, 2013). Patient’s position and surrounding environment will be observed
and documented. Immediate assessment of the patient will follow the ABCDE
(Airway, Breathing, Circulation, Disability and Exposure) approach for a systematic
assessment of the patient (Thim et al, 2012).
All the vital signs including the heart rate, respiratory rate, blood pressure, oxygen
saturation, and temperature will be documented. Some of the early signs of
deterioration can be identified through fluctuating behaviour of the patient, such as
increased agitation or restlessness, changes in alertness and increased confusion.
Patient’s level of consciousness and assessment of the injury will be done that
includes, major head trauma, major skeletal deformities if present and main injury
will be identified and documented. The signs of injury may also include, bruising,
lacerations, swelling, redness, shortening of limb, abrasions, external rotation of

lower limb, bleeding, problem in weight bearing, and other signs of deformities
(Kwan & Straus, 2014).
Osteoarthritis is a musculoskeletal disease that increases the risk of falls among
elderly. The musculoskeletal pathology associated with osteoarthritis includes the
chronic pain in joints, generalised muscle weakness, deteriorating bone density and
inflammatory arthritis results in increasing the risk of falls. There are some important
risk factors associated with the pathophysiology of type 2 diabetes, such as diabetes
medication can result in altered consciousness, as well as “cognitive impairment,
musculoskeletal/neuromuscular lesion of the lower limbs or dizziness and
hypoglycaemia events with insulin use” (Yang et al, 2016, p. 765). The
environmental factors that might contribute towards falls include furniture in the
room, carpet and inappropriate walking aids.
A timely goal that would be appropriate for Ms Smith is to reduce the future risk of
falls. Therefore, the SMART goal would be:
S- Specific: Preventing falls and falls related injuries in future.
M-Measurable: Appropriate health history, history of falls, medication, physical
health condition, cognitive status and visual status will be documented. Any
alteration in the health will be immediately reported.
A-Achievable: the goal will be achievable as it will involve the special focus on the
patient’s history, patient’s current health condition, severity of falls, regular
assessment of patient to identify, physical or cognitive deterioration and patient will
be encouraged to ask for help when required.
R-Realistic: The goal is realistic as it can be achieved with the support of the
professionals and with appropriate care.