Nursing Assignment: Risk Factors and Management for Falls and Pressure Injuries

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NURSING ASSIGNMENT
Name of the student
University Name
Author’s note

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Part 1
1. Risk factors that put Maude at the risk of falls injuries and pressure injuries
The case study is about Mrs. Maude, who was admitted to the Medical ward, with a generalised
abdominal distension, loss of appetite and nausea. Again Mrs Manser had past history of
congestive heart failure and generalised pain due to osteoarthritis. Mrs `Manser is susceptible to
falls due to nausea. It is known that the patient had history of abdominal distension that can be
the cause of nausea. Again, it has also been mentioned that the patient had past history of
congestive heart failure (Lee, Lee & Khang, 2013). Patients with heart failure are predisposed to
falls, due to a variety of reasons. Reasons like exercise intolerance might cause falls in elderly
patients.
Again there had been studies showing a linkage between heart failure and osteoporosis due to
calcium wasting and hyperaldosteronism. Patients suffering from osteoarthritis are more prone to
falls, this due to fact that ta progressive loss of the articular cartilage, subchondrial bone sclerosis
and osteophyte condition and inflammation of the synovial joint, thus increasing the chance of
falls.
Mrs Manser was reported to have been suffering from visual impairment, which might have
contribute to falls. Again, Mrs Manser had undergone a knee replacement surgery and had been
suffering from chronic pain, due to which he is reluctant to move. Restricted mobility might
develop a localised skin injury or the underlying tissue causing pressure ulcers in elderly
patients. Some of the other common risk factors are advanced age, friction, shear and poor
nutrition (Gillespie et al., 2016). It is evident from the case study that the patient had been

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suffering from Bowel problems, which might indicate towards the fact that the patient was not
following proper eating habits. Poor nutrition might lead to the development of pressure ulcers.
Tissue perfusion might be poor after a surgery and continuous friction with the skin due to lying
in one side might cause pressure ulcers.
Nursing management plan for preventing Maude from falling and sustaining pressure
injuries
Some of the important nursing management plan includes the assessment of the risks of
fall by using some fall assessment scales like The Morse fall scale, The Hendric II Fall risk
model, the Briggs Risk Assessment Form. It helps in the evaluation of the mobility of the patient,
mentation, fall history, toileting. As stated in the NSQSH standards, the health service
organisations should follow the best protocols for preventing falls, mitigating any harm from
falls and a post fall prevention set up (Australian Commission on safety and Quality in health
care, 2017). The following interventions are required to reduce the rate of falls for the elderly
population such as appropriate reorientation strategies, access to the hearing aids and glasses, use
of walking aids, frequent rounds for surveillance, call bells, patients and family education about
the fall risks, early and repeated mobilisation, use of non-slip footwear, reduction of the barriers
to transfer or ambulation and minimising the use of the restraints and using of the bed alarm
when required. Some of the other suitable interventions for the fall risks involves checking the
bed height in the inpatient service, checking if the floor is wet (Lee, Lee & Khang, 2013) .
The pressure ulcers can be a real problem for the adults with restricted mobility. One
identified with the pressure it is necessary to educate the patients about the risks and help them to
mobilise as soon as possible. In this case the patient is reluctant to mobilise because of the pain