Fall Risk Assessment and Prevention Plan for Ms. Smith

Desklib provides solved assignments and past papers to help students succeed.

Contents
QUESTION 1.......................................................................................................................................1
QUESTION 2.......................................................................................................................................3
REFERENCES..........................................................................................................................................4
1

QUESTION 1
A. Following a fall it is mandatory for the nurse to assess the patient for any injury or
symptoms that are present associating the fall. Before moving Ms. Smith the nurse
should ask her opinion on what caused the fall and any of the symptoms she could
feel right now that is present due to any fall injury. After this the comprehensive
assessment should be followed including:
The comprehensive assessment will include quick recording of vitals, assessing for
any cranial nerve injury, nervous injury, any physical trauma, abrasion, bruising, look
for cognitive changes, orientation of pupils, note any pain or points of tenderness,
and observe motor function. Step two includes notification and communication; the
nurse should notify the physician or family member and communicate regarding the
incidence. Step three involves monitoring and reassessment for delayed symptoms
of any injury or fall and step four includes documentation of the incidence (Brown et
al., 2014).
B. Ms. Smith has a history of osteoarthritis and type II diabetes that has made her
physically weak and limited her mobility. The past incidences of falls also indicate
high risk towards falling. The room that she is engaged in also is not appropriately
infrastructure to reduce or prevent risk of falling, as she has to take medications
regularly and the desk with medicines is placed far from her bed that is one factor
that may have induced this fall. Hoops et al (2012), suggested that the older adults
with osteoarthritis are 2.5 times more at risk of falling and the mechanism behind it
was explained as the patient with osteoarthritis becomes dynamically unstable and it
results in inability to perform the compensatory stepping response.
C. To prevent future fall risk for Ms. Smith it is mandatory to develop a SMART goal.
The SMART goal is referred to as the desired, measurable, achievable and realistic
as well as long term outcome of the program. The SMART goals developed here is-
“To prevent the risk of falling for Ms. Smith for about 40% by using the fall prevention
tool kit and balance training in next 3 months that can ensure better quality life and
independent functioning for the patient.”
2

Specific- Prevention of falls to Ms. Smith due to physical limitations and in
capabilities in walking
Measurable- Providing appropriate interventions the risk of falls can be prevented by
40%.
Achievable- The patient consented for approving this intervention for fall prevention.
Realistic- Use of fall prevention kit and balance training
Timely- 3 months
D. The two majorly indicated nursing interventions for fall prevention among patients
with high fall risk in hospital and care home setting are-
Provide signs and secure a wristband identification to remind the healthcare provider
to implement fall precaution behavior.
Rationale- Signs are the vital strategy to remind the patient for risk of falling,
healthcare professionals also need to acknowledge the condition, assess the risk
and implement the actions to promote patient safety form falls (Forrest et al., 2012).
Move items used by the patient within easy reach such as water, medicines, light,
urinal or telephone.
Rationale- Items placed too far from the patient’s bed can indicate them to move and
cause hazard and contribute to falls (Forrest et al., 2012).
3

QUESTION 2
SBAR
Situation- I am ______________, this is a documentation of the recent incidence
that occurred with Ms. Smith. She fell from her bed and was lying down on floor
when was assessed by me. I am documenting this regarding development of her
further progress plan.
Background- Ms. Smith has a history of osteoarthritis and type II diabetes and is on
medication, she has limited mobility and uses a walking stick as she reported wobbly
movement when trying to walk on own. She also has history of two recent falls in
past six months. She is on metformin 500mg thrice a day and regular analgesics as
well as 1000mg paracetamol four times a day to manage her joint pain.
Assessment- This morning when my shift started I went inside Ms. Smith’s room
and found her lying on ground. She had experienced un-witnessed fall. I asked her
the cause of her fall and moved her comfortably to her bed to assess any injury or
signs of trauma. I used comprehensive post-fall assessment guide and documented
the findings. She is at rest now in her room.
Recommendation- I think that the frequently in use things in Ms. Smith’s room
should be shifted nearby to her reach that will prevent any contribution towards
further falls. Also the patient should be provided a sensory matt that can predict any
incidence of fall to the nurse’s station as early as possible.
4

REFERENCES
Brown, D., Edwards, H., Seaton, L. & Buckley, T. (Eds). (2014). Lewis's medical-
surgical nursing: Assessment and management of clinical problems (4th ed.).
Marrickville: Mosby.
Forrest, G., Huss, S., Patel, V., Jeffries, J., Myers, D., Barber, C., & Kosier, M.
(2012). Falls on an inpatient rehabilitation unit: risk assessment and prevention.
Rehabilitation Nursing, 37(2), 56-61.
Hoops, M. L., Rosenblatt, N. J., Hurt, C. P., Crenshaw, J., & Grabiner, M. D. (2012).
Does lower extremity osteoarthritis exacerbate risk factors for falls in older adults?.
Women’s Health, 8(6), 685-698.
5