NRS3392 - Clinical Reasoning Cycle: Fall Prevention & Patient Safety

This report presents a clinical reasoning cycle focused on fall prevention in elderly patients, particularly those in rehabilitation settings following events like strokes. It addresses risk factors, HAAD and JCI standards, and a detailed patient scenario involving a 76-year-old female admitted for Cerebrovascular Accident (CVA) with right-sided weakness. The report outlines the collection of cues, information processing, problem identification, action plan, and evaluation phases of the clinical reasoning cycle. Interventions include adhering to hospital protocols, continuous patient surveillance, multidisciplinary team involvement, and family education. The reflection section highlights the challenges and improvements needed in fall prevention strategies. Recommendations include using movement tracking devices, balancing patient needs with fall prevention, involving family in decision-making and physiotherapy, and cross-checking medications. The report concludes that stroke is a significant risk factor for falls and emphasizes the importance of comprehensive strategies to ensure safe healthcare delivery to the elderly.

Running head: CLINICAL REASONING ON FALL
CLINICAL REASONING ON FALL
Name of the Student
Name of the university
Author’s note

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CLINICAL REASONING ON FALL
Clinical Reasoning Cycle for fall
Millions of elderly fall and suffer from hip fractures or traumatic brain injury, as reported by the
Center for disease control and prevention. As per the report published by the Portuguese health
national reports, 4200 incidents of falls and 85 incidents of fall related deaths have been reported
(Simpson, Miller & Eng, 2011) . Slips and falls and fall related injuries have been
considered as one of the prioritized standards of Joint Commission International (JCI)
and Health Authority of Abu Dhabi (HAAD) (Hospital Standard, 2008).
Cardiovascular attacks have been found to be the most common contributing
factors of falls among the elderly (Simpson, Miller & Eng, 2011; Abreu,
Mendes, Monteiro & Santos, 2012). Fall generally occurs due to the altered
balance between the brain and the body (Simpson, Miller & Eng, 2011). In
order to manage falls in elderly it is necessary for an extensive planning and
decision making. The decision making process has got seven standards,
such as identifying the triggering agent of falls, setting the criteria, weighing
it, seeking for any alternatives, testing and troubleshooting of the problems
(Griffith University, 2013). This essay aims to focus on the risk factors of fall,
its triggering agents, JCI and the HAAD standards of falls, clinical cycle
reasoning related to the scenario faced and possible recommendations.
Risk factors
According to Simpson, Miller and Eng, (2011), falls can be defined as an event
which results in a person coming to rest inadvertently on the ground, with

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the inability to correct in due time and is determined by circumstances
involving multiple factors that affect stability". Falls can be cause din the
elderly due to the effect of certain hypertensive medications that causes
dizziness (Simpson, Miller & Eng, 2011). Some of the other contributing
factors are hypoglycemia and hypertension (Clinical Excellence Commission,
2008; Tsur & Segal, 2010). Ischemic stroke is also another risk factor that
can contribute to falls in elderly. Other risk factors include bladder and bowel
incontinence, confusion and aviation and postural hypotension (Oliver,
Healey & Haines, 2010).
HAAD and JCI Standards
HAAD is a renowned and certified health authority by the JC
international ((HAAD JAWDA, 2015). HAAD have established the strategies
for preventing falls in the elderly. HAAD has established JAWDA as a key
performance indicator for detecting the rate of the falls in adults. It will also
keep a record of the rate of the sentinel events in hospitals, due to falls
(HAAD JAWDA, 2015).
Clinical Reasoning Cycle
Clinical reasoning cycle helps a health care provider to collect the cues, process the
pathogenesis related to the signs and symptoms, assessment, planning and implementing the
interventions, measuring the outcomes, reflecting and learning form the outcomes.
Patient scenario

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A 76 years old female named Nilou, has been admitted in the rehab ward on 10th
February due to the Cerebro Vascular Accident (CVA), a frontal affected region
and right sided weakness. The vital signs are all normal. The patient is a
widow staying in Al Gharbiya Region of Abu Dhabi, with two sons and one
daughter. They visit their mother regularly but no one stays with the patient
at night.
Collection of cues
Collection of cues occurs in three parts. In the initial review the patient
has informed that she had been suffering from hypertension and diabetes,
for the last 25 years. She takes rosuvastatin, aspirin, ezetimibe and
amlodipine, for hypotension and takes glargine and insulin injection for
diabetes. The lab tests for the complete blood count and the levels of the
urea and electrolytes are normal. No blockage was detected in the vascular
ultrasound carotid Doppler. There was acute infarction present in the frontal
region, recorded in the magnetic resonance angiography. There was an
incident of a fall, where the patient complaint that the bathroom was not
nearby and there was no help present to assist her in the bathroom.
The second step involves the assessment of the motor functions of the
left side, where it graded 5 out of 5. The right side of the head showed some
weakness and scored 2 out of 5. The Glasgow comma scale was ranging
between 14 to 15. BP was 127/75, RR- 80, HR- 80 . Blood sugar was 17.1.

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After the application of 10 units of insulin the blood sugar level was found to
be 13.4 just after an hour.
The third step is Recall. The Morse fall score altered from 60 to 85 due
to the incidence of fall, right sided hemiplegia, patient confusion (Plessis,
2015). Furthermore the region of the brain that is the site of motor functions,
concentration, emotion and the self awareness was also affected which
might have caused the patient to make irrational decisions.
Information processing
The processing of the information consists of six- sub stages, such as
the interpretation, discrimination, relation, drawing of inferences, matching,
and prediction.
Interpretation- The Glasgow comma scale was within the accepted range,
high blood sugar level, high Morse fall risk, decreased strength and sensation
of in the right side, confusion due to the affected regions of the brain.
Discriminate- High Morse score, confusion and right sided hemiplagia.
Relation- Muscular weaknesses causing imbalance
Inference- To keep the patient in close monitoring
Matching- Cardiovascular attacks are related to higher risk of fall.

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Prediction- risks of falls in clinical settings might be due to certain factors like
medications, lack of trained staffs, lack of mobilizing aids and weak fall
prevention strategies.
According to (Tsu and Segal, 2010) a large proportion of fall occurs at
the bedside in a clinical setting. Having a near miss in the clinical setting can
cause the nurse to alert the quality management setting. Proper
investigation may cause termination of the unskilled staffs or those who
have breached the standards. Whereas a patient might get a femoral
fracture, hip fracture, traumatic brain injury and delay in the healing as the
patient is an elderly (Oliver, Healey & Haines, 2010; CDC, 2016; Simpson,
Miller & Eng, 2011).
Identification of the problems
There are two main diagnoses related to high risk of falls are impaired
step mobility and the altered psychological status.
Action plan
In this phase of the cycle the nurse formulates the interventions
against all the problems. The first step is abiding by the hospital protocols
regarding the falls. It is first necessary to assess the patient. Interventions
can be taken such as keeping the patient under continuous surveillance,

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accompanying the patient in the toilet, using the yellow risk band for fall
risks, placing the bed in the lowest and comfortable position, putting up the
side rails (Plessis, 2015). A multidisciplinary team should be used to ensure
that the patient regains movement on the right side. Physiotherapy and an
occupational therapist can be used. The family members should also be
included in the collaborative care approach and should be taught about the
daily exercises recommended by the physiotherapist (Plessis, 2015).
Evaluation
The goal is accomplished when the patient is discharged from the
setting without any record of falls. In addition the family has been given
information regarding the maintenance of safe home environment like
ensuring a non slippery pathway (Simpson, Miller and Eng, 2011).
Reflection
The experience was quite challenging and I was perturbed as she had
shifted out of the bed more than once without a fall. I felt that my care had
been incomplete as restraining her to remain in the bed depressed her. A
one to one observation could have been done but it is the objective that had
prevented me from doing so. Yet I feel that I have tried to contribute my best
for giving a proper discharge to the patient. I have been successful in
educating the patient and the family regarding the usage of bells when in
bed. The improvements that can be achieves would be mentioned in the
following sections of recommendations.

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Recommendations
There are several loops and gaps left in the fall prevention strategies
even after the adoption of advanced technologies and the preventive
measures. Hence a comprehensive strategy is required to so. Oliverm Healey
and Haines, (2010) have suggested the use of a movement tracking device
that helps in patient tracking without the requirement of one to one
observation. Such a device would not only save time but would also be cost
effective. According to Agency for Healthcare Research and Quality (AHRQ),
the requirements of the elderly patients should always be balanced with fall
prevention (AHRQ, 2013). Another fruitful intervention is to include the
family in the decision making process and in the physiotherapy sessions,
such that they can help out the patient with the exercises even in the
absence of the physiotherapists. The final recommendation is to ensure the
cross checking of the medication, as the patients is under hypertensive
medications and wrong doses can cause unconsciousness and fall (AHRQ,
2013).
Conclusion
Slips and falls are still the biggest possible risk in the field of geriatric
care and lots of efforts are currently put and more has to be incorporated in
order to decrease the risks. It is evident that stroke is one of the main risk
factor as it give rise to hemiplegia and an affected patient will not be aware
of his brain and body balance. Bedside falls are also found to be quite

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common. Many strategies have been set as standards for allowing the
caregivers to ensure a safe health care delivery to the elderly population.

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