Fall Risk Assessment And Prevention

True. Standardization reduces the likelihood of variability and omitting important information.

The correct answer advises the person to sit up in bed for a few minutes before standing up and then stand up for a minute before walking. This is a recommended approach to prevent dizziness when transitioning from lying down to standing up. By gradually transitioning from a lying position to a sitting position and then to a standing position, it allows the body to adjust to the change in posture and helps to maintain blood pressure, reducing the likelihood of dizziness.

Regular exercise and increased calcium and vitamin D intake can help prevent osteoporosis. Exercise helps to strengthen bones and increase bone density, reducing the risk of fractures. Calcium and vitamin D are essential for bone health, as they promote the absorption and utilization of calcium in the body. Adequate intake of these nutrients can help maintain strong and healthy bones, reducing the risk of osteoporosis.

(a) True. According to Vellas et al (1997), many people who fall, even those who are not
injured, develop a fear of falling. This fear may cause them to limit their activities, leading to
reduced mobility and physical fitness, and increasing their actual risk of falling.

The correct answer is "All of the above" because all three interventions mentioned - frequent/hourly rounding, communicating high risk to other caregivers, and engaging the patient and family in fall prevention education - are important components of an individualized care plan for a patient. Frequent rounding helps assess the patient's needs regularly, communicating high risk to other caregivers ensures continuity of care, and educating the patient and family about fall prevention promotes patient safety. Therefore, including all of these interventions in the care plan would be beneficial for the patient.

The fear of falling can significantly impact one's quality of life by limiting their ability to engage in activities they enjoy, such as hobbies or sports. It can also prevent them from visiting friends and family, as they may be afraid of navigating unfamiliar environments or stairs. Additionally, the fear of falling can discourage individuals from leading an active life, as they may avoid physical activities out of fear of injury. Therefore, all of the given options are valid consequences of the fear of falling.

True. False can have several long-lasting negative outcomes for a patient.

The most common risk factors for a fall include wearing inappropriate footwear, having weak muscles and poor balance, and consuming excessive amounts of alcohol. Wearing shoes that are not suitable for the activity or do not provide enough support can increase the risk of falling. Weak muscles and poor balance make it harder to maintain stability and can lead to falls. Alcohol consumption can impair coordination and judgment, making falls more likely. Therefore, all of these factors contribute to the risk of falling.

The ideal footwear should have a firm back and cover to provide stability and support to the foot. It should also have an adjustable fastening to ensure a secure fit. Ankle support is important to prevent injuries and promote proper alignment. Lastly, a non-slip sole is essential to provide traction and prevent slips and falls.

False. Patients often change their physiological and mental status during a hospital stay.
Reassessment is imperative to identify fall risk status changes.

Medication use may contribute to increased fall risk.

False. Medications can play a very large role in the patient’s risk for falls.

Patients who have a history of falls are at a higher risk of falling again in the future. This could be due to underlying health conditions or physical impairments that increase their vulnerability to falls. Impaired cognition, such as dementia or confusion, can also contribute to a higher risk of falling as it affects their ability to navigate their surroundings safely. Impaired mobility, such as weakness or difficulty walking, can make it more challenging for patients to maintain their balance and prevent falls. Additionally, being in a cluttered room can increase the risk of tripping or stumbling, further increasing the likelihood of a fall.

Answer: d
There are many risk factors for falls in older adults. Postural hypotension is a common risk. The nurse should instruct the client about postural hypotension and provide practical information regarding how to sit on the bed or chair, dangle the legs first and then rise slowly, supported by a walker if necessary. A diary of instances of an individual’s falls may predict future falls by tracking the events and behaviors at the time of the fall, but is not the most effective in preventing the fall. Attaching a sensor to the client or bed is reserved for clients who are at a serious risk for injury.

(d) Medication use in the elderly, for example use of medications with prominent anticholinergic side-effect profiles, can put a patient at increased risk of falls. It is not correct
to assume that a properly selected assistive device puts an elderly patient at risk of falls; on
the contrary, it may help stabilize their gait pattern. Hip fractures are the most common fall related
fracture. Motorized scooters are not a practical or effective solution to the problem of
falls in the elderly.

All answers are considered appropriate interventions for prevention of falls.

All of the options listed can help prevent falls in the elderly. Getting the GP to review medication ensures that any side effects or interactions that may increase the risk of falls are identified and addressed. Removing clutter from indoors and outdoors reduces the chances of tripping and falling. Installing lights in dark hallways and stairways improves visibility and reduces the risk of missteps. Keeping feet healthy and wearing appropriate footwear provide stability and reduce the risk of slipping. Eating a balanced diet and exercising regularly improve overall strength and balance, further reducing the risk of falls.

False. Outside of the room does not meet the definition. Staying Within Arm’s Reach is a policy
which requires a caregiver to be immediately available and within reach for patients at risk for
falling.

Hip fractures are one of the most serious consequences of a fall. When a person falls, the impact on the hip can cause the bone to break or fracture. Hip fractures can be extremely painful and can lead to limited mobility, loss of independence, and a decreased quality of life. In older adults, hip fractures can also increase the risk of complications such as pneumonia, blood clots, and pressure sores. Prompt medical attention and appropriate treatment are crucial to prevent further complications and promote healing.

(d) Amitriptyline is a drug with significant anticholinergic side effects that could be
associated with increased confusion and falls in the elderly. Discontinuing it would be a
quick and potentially effective intervention to decrease fall risk. Hip protectors might reduce
the impact of a fall, but not the probability itself. An evaluation of gait revealed some balance
issues, but not problems with proximal strength, so (b) would be insufficient without first
removing a potentially exacerbating medication. There is no evidence of hypoglycemia, so
(c) is not the right answer.