NURS 498L Assignment Fall Prevention
Jaclyn Hendricks
West Coast University
1/12/2020
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KNOWLEDGE ASSIGNMENT 2
1. What are Mrs. L’s known risk factors (in the hospital) for falling?
Environmental
NURS 498 L Assignment Fall PreventionThe environmental risk factors that may have caused Mrs. L to fall include poor lighting,
slippery surfaces, and inappropriate walking aids.
Medical conditions
The medical conditions that may have caused Mrs. L to fall comprise: past history of falls,
visual and cognitive impairment, problems with walking, osteoarthritis of the knee and hip,
depression, orthostatic hypotension, frailty, and urinary frequency.
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Unsafe behaviors
Other risky behaviors that may have led to Mrs. L fall include prolonged bed rest, fear and
anxiety, poor balance in her bed, and impatience.
2. Using the Hendrich II Fall Risk Model (https://consultgeri.org/try-this/general-
assessment/issue-8.pdf), determine Mrs. L’s fall risk score. NURS 498L Assignment Fall Prevention
Hendrich II Fall Risk Model was developed by nurses to assess a patient’s risk of falling
in the acute care context. The tool offers a means of forecasting which patients are likely to fall.
It focuses on eight independent risk factors: – confusion, disorientation, impulsivity;
symptomatic depression; altered elimination; dizziness, vertigo; male sex; administration of
antiepileptics (or dosage changes or cessation); administration of benzodiazepines; and poor
performance in the “Get-Up-and-Go” test of rising from a seated position (Hendrich, 2016).
Each of the risk factors is given a particular score. Using this model, the following is Mrs. L’s
fall risk score:
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KNOWLEDGE ASSIGNMENT 3
Hendrich II Fall Risk Model ™
RISK FACTOR RISK POINTS
SCORE
Confusion/Disorientation/Impulsivity 4 4
Symptomatic Depression 2 2
Altered Elimination 1 1
Dizziness/Vertigo 1 0
Gender (Male) 1 0
Any Administered Antiepileptics (anticonvulsants):
(Carbamazepine, Divalproex Sodium, Ethotoin, Ethosuximide, Felbamate, Fosphenytoin, Gabapentin, Lamotrigine,
Mephenytoin, Methsuximide, Phenobarbital, Phenytoin, Primidone, Topiramate, Trimethadi- one, Valproic Acid)1 2 0
Any Administered Benzodiazepines:2
(Alprazolam, Chloridiazepoxide, Clonazepam, Clorazepate Dipotassium, Diazepam, Flurazepam, Halazepam3,
Lorazepam, Midazolam, Oxazepam, Temazepam, Triazolam) 1
0
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Get-Up-and-Go Test: “Rising from a Chair”
If unable to assess, monitor for change in activity level, assess other risk factors, document both on patient chart with date and time.
Ability to rise in single movement – No loss of balance with steps 0 0
Pushes up, successful in one attempt 1 0
Multiple attempts but successful 3 2
Unable to rise without assistance during test
If unable to assess, document this on the patient chart with the date and time. 4 2
(A score of 5 or greater = High Risk) TOTAL SCORE 11
© 2013 AHI of Indiana, Inc. All rights reserved. United States Patent No. 7,282,031 and U.S. Patent No. 7,682,308.
Reproduction of copyright and patented materials without authorization is a violation of federal law.
(Borson, n.d.)
Mrs. L’s total score is 11, indicating that he has a high risk of falling.
3. Mrs. L states she is “plagued by insomnia.” Using the Pittsburgh Sleep Quality Index
(http://uacc.arizona.edu/sites/default/files/psqi_sleep_questionnaire_1_pg.pdf), measure Mrs.
L’s quality and patterns of sleep. Could Mrs. L’s sleeping pattern contribute to her risk for
falls? What actions will you take based on your analysis?
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KNOWLEDGE ASSIGNMENT 4
The Global Pittsburgh Sleep Quality Index of Mrs. L is 15. Based on this score, there is
no doubt that Mrs. L’s sleeping pattern contribute to her risk for falls. To reduce this risk, she
requires to improve her sleeping habits. First, ensuring that there are no artificial lights at night
that can prevent her from sleeping. Secondly, making sure that her bedroom is quiet, dark, and
cool, and the bed is comfortable. At her age, Mrs. L is more sensitive to noise, hence, it is
important to reduce it as low as possible. Thirdly, maintaining a consistent sleep schedule, such
that she go to bed and wake up at the same times daily. Fourthly, Mrs. L should eat a sleep-
friendly diet during the day and reduce inactivity. Last but not least, there is a need to minimize
her stress and anxiety, which may hinder the sleep.
4. Mrs. L is asked to complete the “Clock Drawing” portion of the Mini-Cog (http://mini-
cog.com/wp-content/uploads/2015/12/Universal-Mini-Cog-Form-011916.pdf). She draws the
clock showing 3 PM. Her drawing is missing the numbers 3, 4, and 5. One clock hand is
pointing at 9 and the other is pointing at 12. For the “Three Word Recall” portion, Mrs. L
remembers two words. What is her Mini-Cog score? NURS 498L Assignment Fall Prevention
The Mini-Cog score of Mrs. L is 2. A score less than 3 means that she has a cognitive
impairment. However, most of the people with clinically meaningful impairment will score
higher (Dellinger, 2017).
5. Having assessed Mrs. L’s fall risk and her cognitive state, develop three safety goals for
each of the following:
Environmental and equipment
NURS 498 L Assignment Fall PreventionDue to the fact that environment factors such as poor lighting, slippery surfaces, and
inappropriate walking aids increase the risk of Mrs. L falling, it is important to provide adequate
lighting, safe footwear, and installation of better bed rails.
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KNOWLEDGE ASSIGNMENT 5
Gait and mobility
Low-level exercises might prevent falls and injury by increasing endurance and
strengthening muscles; stimulating cardiorespiratory role; enhancing and maintaining joint
motion, postural reflexes, and posture; and improving attentiveness. Besides, gait can be
enhanced through focused exercise or repetition of particular voluntary activities related to
instability (Dellinger, 2017).
New medications
Prescribe her ibuprofen, benzodiazepine, or acetaminophen to decrease fever and improve
her sleeping habits. The medications should be taken in the morning rather than the evening. As
Dellinger (2017) asserts, it is essential to assess the medications because some of them may
increase the risk of falls.
Anxiety, depression, and unsafe behavior
Encourage Mrs. L to take naps during the day to minimize her nighttime sleep requirements.
Physical activities and exercises will be vital to ensure that she is active. Education is also an
essential component of preventing fall risk. Mrs. L will be educated how she can stay at bed,
whenever the caregiver is not around as well as help her understand the potential hazards in the
home to increase safety. For instance, she can be advised to avoid darkened areas in the
house/hospital, or ensure she does not stand on the bed. NURS 498L Assignment Fall Prevention
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KNOWLEDGE ASSIGNMENT 6
References
Borson, S. (n.d.). Mini-Cog screening for cognitive impairment in older adults. Retrieved
from https://mini-cog.com/
Dellinger, A. (2017). Older Adult Falls: Effective Approaches to Prevention. Current Trauma
Reports, 3(2), 118-123. doi: 10.1007/s40719-017-0087-x
Hendrich, A. (2016). Fall risk assessment for older adults: The Hendrich II Fall Risk model. Try
This, 8. Retrieved from https://consultgeri.org/try-this/general-assessment/issue-8.pdf
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