This document provides instructions for a case study on fall risk assessment and prevention for an elderly patient. It includes background information on the patient, subjective data collected, nursing diagnoses identified, and next steps outlined. The CNS's next steps are to review additional interdisciplinary assessment data focusing on cardiovascular health, functional status, environment, and medication usage to fully understand fall risk factors and develop an evidence-based fall prevention plan.

1. Instructions for Completing Case Study Review all slides in detail. Complete all required reading, including links to external material. Review questions and answers included throughout the case study. Once finished, click on the ‘CE Form’ link located at the end of the study. Answer the 3 questions included on the form, provide payment information for processing your $10.00 CE fee and return the form to the NACNS office. A valid email address is required for CE certificate delivery. * Continuing Education is optional. If you are not interested in CEs, please disregard the $10.00 fee. CONFIDENTIAL - Do not forward or share

2. CNS Advanced Practice Curriculum: A Case For Geriatric Nursing Evidence-based Practice Fall Risk Case Study # 1 Jean Bandos MSN,RN,GCSN,BC My Health Care Manager, Inc. Suzanne Purvis MSN,RN,GCNS University of Wisconsin Hospital and Clinics

3. Learner Outcomes At the completion of this case study, the learner should be able to: Assess a patient who is at risk for falling Explain the risk factors for falls prevention Describe the follow up needed for nursing staff in various health care settings, including the home setting Explain the case study implications for health care systems and need for CNS leadership in leading the safety initiatives for the older adult population who is at risk for falling

4. Required Reading Fall Risk Assessment Fall assessment for acute care using the Hendrick II Fall Risk Assessment http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf Fall Prevention Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC) (2008). Preventing falls among older adults, pp. 1-10. Retrieved August 19, 2010. http://www.cdc.gov/HomeandRecreationalSafety/images/CDC_Guide-a.pdf American Geriatrics Society Practice Guidelines: Prevention of Falls in Older Adults 2010. Retrieved January 27, 2010 . Clinical Practice Guideline: Prevention Of Falls In Older Persons Summary Of Recommendations > Guidelines & Recommendations > Clinical Practice > Health Care Professionals > The American Geriatrics Society

5. Recommended Reading Gray-Micelli D. Preventing falls in acute care. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 161-98. [74 references] http://www.guideline.gov/content.aspx?id=12265 American Geriatrics Society, British Geriatrics Society, American Academy of Orthopedic Surgeons Panel on Falls Prevention (AGS, BGS, AAOS) (2001). Guidelines for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49 (5), 664–681. http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations

6. CNS Spheres of Influence: Patient/Client Sphere

7. About the Patient B.A. is a 82 year-old man, admitted from emergency department to telemetry unit, for cardiac monitoring after as episode of syncope Wife, Mrs. A, reported that this is his 3 rd admission in 6 months for various reasons and he is becoming weaker Yesterday he had fallen at home prior to admission and reports neck and back pain r/t fall

8. Continued Information about Patient Retired professor and deacon at his church Mrs. A drove patient to hospital. Has two daughters. One daughter lives in close proximity, the other daughter is out of state. Mrs. A. reports that husband is having memory problems, is not taking medications as he should, and is becoming more fatigued. Does not have Health Care Power of Attorney

9. Subjective Patient Data You are reviewing staff nurse’s admission notes Problems # 1 c/o fall at home with neck and back pain Reports continued weakness over last 6 months Not taking medication as prescribed; polypharmacy Episodes of syncope #2 c/o fatigue Sleeping in chair at home Weakness #3 advance directive status undetermined #4 decline in memory

10. Subjective Data Patient plans to return to home setting post discharge Medical History includes: Afib, MI, CABG X3 vessels, pacemaker, CHF, Diabetes Social alcohol use and smoking in his remote past Allergies none

11. Questions # 1 What other subjective information specific to the problems 1, 2, 3 and 4 do you need to know?

12. Answer for Question #1: Problem 1 Fall assessment for acute care using the Hendrick II Fall Risk Assessment http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf Subjective assessment of past falls is needed to determine if this fall is an isolated incident or a pattern for the patient: frequency, location, witnessed not witnessed fall injury history, past hospitalization related to falls possible patient-related (i.e., medications), and environmental-related (i. e., unsafe walking surfaces)

13. Rationale for Answer to Question #1: Problem 1 Falls among older adults tend to occur from multifactorial etiology such as acute and chronic illness, as a syndrome to other diseases, and medication usage. You must also determine the underlying etiology of “why” a fall occurred with a comprehensive post-fall assessment.

14. Rationale for Answer to Question #1: Problem 1 In acute care, a best practice approach incorporates use of the Hendrich II Fall Risk Model which is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk of falls.

15. Answer for Question #1: Problem 2 The Pittsburgh Sleep Quality Index (PSQI) http://consultgerirn.org/uploads/File/trythis/try_this_6_1.pdf Subjective assessment of sleep patterns is needed to determine if sleep patterns are contributing to fatigue and risk for falls.

16. Rationale for Answer to Question #1: Problem 2 Insomnia occurs more frequently after age 70 The Pittsburgh Sleep Quality Index is easily used to assess the quality and patterns of sleep in older adults. It consists of 18 questions covering seven areas in which sleep problems occur and can be completed in about 10 minutes.

17. Answer to Question #1: Problem 3 No power of attorney. Determine patient’s wishes in this regard, and his desire to include his wife in advance care planning. Provide information on need for state specific advance directive planning and obtaining a power of attorney for healthcare. Consult social work if patient requires more information.

18. Answer to Question #1: Problem 4 Cognitive assessment for acute care Mini-Cognitive (Mini-Cog) http://consultgerirn.org/uploads/File/trythis/try_this_3.pdf Mini-Cognitive (Mini-Cog) combines the Clock Drawing Test with the three-word recall. The patient is asked to remember three unrelated words and later is asked to recall the three words. This clinically useful tool, rapidly administered, has a high level of sensitivity and specificity and less bias than some other instruments.

19. Rationale for Answer to Question #1: Problem 4 The Mini-Cog is appropriate for use in all health care settings. It is appropriate to be used with older adults at various heterogeneous language, culture and literacy levels.

20. More Subjective Data Mrs. A reported that husband’s fall happened at home walking from living room to bedroom. States has had periods of syncope. States house has hardwoods floors, multiple throw rugs, his lazy boy is in a carpeted room no grab bars in bathroom. Takes over 10 different medications for cardiac condition, diabetes, including anti-cholinergics, antihypertensives, analgesics, antiarrhythmics. Mrs. A states that he is forgetting to take his medications. Vision at times is blurred . Has not seen ophthalmologist in last 3 years.

21. Question # 2 Based on the subjective data, what does your initial nursing diagnosis for fall prevention include? List diagnosis and brief rationale for inclusion

22. Nursing Diagnoses High fall risk with risk of injury Impaired mobility Given history – and new information. Has multiple risk factor for continued falls: Fall x1, polypharmacy, compromised mobility, environmental hazards

23. Nursing Diagnoses (cont’d) 3. Fatigue/Sleep Disturbance Sleeps in chair, Does not sleep through night 4, Discharge Planning/Care Coordination Coordination of referrals relevant to linkages among health care providers 5. Cognitive Decline Not taking medications as prescribed Memory loss

24. Question #3 What additional data do you and the nurses on your unit need to collect at this point? Provide answers with rationale

25. Answer to Questions #3 Telemetry monitoring to capture any information regarding arrhythmias that may be contributing to syncope and fall risk BP lying, sitting and standing to capture postural hypotension that may be contributing to syncope and potential falls Blood Sugar monitoring to address any severe fluctuation of blood sugars contributing to fall risk Weight and nutritional status on admission to determine if malnutrition affecting weakness

26. Answer to Question #3 (cont’d) Fall risk assessment data to evaluate risk for falling in future and to address the environmental accommodations that can be made so staff can monitor patient closely. Post discharge plans need to address what environment the patient is returning to in order to make appropriate plans addressing environmental and medication safety concerns.

27. Question #4 As the CNS (not the staff nurse, clinical nurse leader, NP, MD, or social worker) what are your next steps?

28. Answer to Question #4 Need to review and collect additional information from the interdisciplinary team fall assessment data including but not limited to: History of falls/fear of falling Bowel and bladder incontinence Gait and balance Use of assistive device Environment Visual deficit Use of 4 or more meds: sedatives, cardiac related, psychotropics,etc Confusion Focus on cardio and disease progression

29. Answer to Question #4 (cont’d) Depression Impaired ADL’s Physical restraint Alcohol use Decreased functional reach Associated symptoms i.e. syncope episodes and decrease in memory Review of medications Hydration/nutritional status Pain status

30. Answer to Question #4 (cont’d) Need to assess safety factors for returning to home setting and or appropriate setting for patient Coordinate continuum of care plan addressing address safety concerns and prevention of future falls Medication Reconciliation post hospitalization

31. Question #5 What is your assessment of each of Mr. A’s problems at this point. Provide rationale for your assessment

32. Answer to Question #5 Assessment Patient is at high risk for future falls. Risk factors include: polypharmacy including medications that place him at high risk for falls, environmental hazards, balance and mobility concerns, visual deficit. Patient with possible sleep disturbance and risk of sleepiness during the day. Wife notes patient sleeping in chair at home, weaker, not taking his medications .

33. Rationale for Answer to Question #5 Falls among older adults are not a normal consequence of aging Falls are considered a geriatric syndrome most often due to discrete multifactorial and interacting, predisposing (intrinsic and extrinsic risks), and precipitating (dizziness, syncope) causes Fall epidemiology varies according to clinical setting: 1/3 older adults fall in their home each year Falls are the 8 th leading cause of unintentional injury Fall-related injuries recently accounted for 6% of all medical expenditures for persons age 65 and older in the United States

34. Question #6 In the patient/ client sphere, what is the CNS role in fall prevention?

35. Answer to Question #6 Management & treatment of hypertension, orthostatic hypotension, diabetes, diet, CHF Management of sleepiness: assess for patient’s bedtime routine @ home, provide interventions such at bedtime such as massage, quiet, music, warm milk Physical therapy for gait, mobility & muscle strengthening exercises Medication screen for high risk medications & polypharmacy Proper use of assistive devices such as glasses, shoes, cane, walker, etc. Assess environmental factors: is call light within use, does pt. know how to use it, floor clear of obstacles, patient can reach phone, use of appropriate fall alarms, facility’s fall risk program initiated so all staff know patient is at high risk for falls

36. Answer to Question #6 CNS to work with family to coordinate the post-discharge interdisciplinary care plan: Discharge medication reconciliation Appt. with ophthalmologist for vision check-up Home health agency to visit in hospital to set up home care Appt. with Primary Care physician after discharge Discuss options for respite care, if needed, with family O.T./P.T. evaluation for home safety

37. Answer to Question #6 Coordinate: Home Safety Evaluation Post Discharge Safety evaluation of home should include but not be limited to: no loose rugs appropriate carpeting that allows for use of assistive devices adequate lighting, especially when going to bathroom at night use of grab-bars, raised toilet seat assess for possible need for ramp, other access to outdoors

38. CNS Spheres of Influence: Nurse Sphere

39. Question #7 What is the role of the CNS in staff education?

40. Answer to Question #7 Educate Nursing Staff - What is a Fall? There is no universally accepted definition The definition is influenced by regulation, environment, and population Identify the definition used by the program or facility “ Any event in which a person inadvertently or intentionally comes to rest on the ground or another lower level…” Tideiksaar ( 2002). http://www.nurseassist.com/safetnet/qanda/qa05_wk03.html

41. Answer to Question #7 (cont’d) Educate regarding the causes of falls; that falls can be intrinsic or extrinsic, and are usually multifactorial Accident Environment (e.g.wet floor) Poor - fitting footwear Neurological Gait and balance disorder Medications– effect or side effect alcohol Cardiovascular Acute illness/infection Deconditioning Poor nutrition Poor judgment Altered functional status Slowed protective reflexes Disease progression

42. Answer to Question #7 (cont’d) Educate on high-risk medications High-risk medications associated with falls include psychotropics, benzodiazepines, sedatives, antidepressives, antihypertensives, analgesics, anticholinergics, anticonvulsants, antiarrhythmics, anticoagulants Patient noted to have polypharmacy, taking antihypertensives, antiarrhythmics, analgesics, anticholinergics which place patient at high risk for falls Consider consulting physician, pharmacist to reduce number of high risk medications.

43. CNS Spheres of Influence: System Sphere

44. Question #8 What is the CNS role in terms of interdisciplinary team work?

45. Answer to Question #8 The CNS facilitates the Interdisciplinary Team in Care Transitions CNS would introduce a care transition program within the healthcare system and research new programs addressing transitions of care such as : “ Opportunities for Improving Care Transitions " The Care Transitions Program focuses on improving coordination across the continuum of care. In particular, promoting seamless transitions of care for Medicare beneficiaries from the hospital to home, skilled nursing care, or home health care. http://www.cfmc.org/caretransitions/

46. Question #9 What is the role of the CNS in system-level fall prevention?

47. Answer to Question #9 The CNS develops system-level fall prevention programs that cross the continuum of care These programs include valid evidence that covers: Educational programs need for vision check-up, monitoring of blood pressure, and follow-up to assess safety at home appropriate footwear to prevent falls: supportive shoes with thin soles, avoid athletic shoes with heavy treads Discharge programs covering home monitoring blood pressure, blood sugar, nutrition, medication compliance, safety evaluation, continued muscle strengthening & gait training, assessment of ability to get around home, monitoring of sleep quality

48. Rationale for Answer to Question #9 The impact of a fall Ranges from no physical injury to consequences that include surgery, increased risk of death, and limitations of activity and self-care Ranges from no emotional impact to self-imposed restriction of activities to depression related to decreased independence If hospitalized, increased length of stay & cost

49. Additional Resources AHRQ: The Falls Management Program: a QI Initiative for Nursing Facilities www.medqic.org Medicare Quality Improvement Organization - Care Transitions QIO http://www.cfmc.org/caretransitions/ Tideiksaar,R. Falls in older people: prevention and management. 2002 Baltimore, MD: Health Professions Press University of Iowa Gerontological Nursing Interventions Research Center. Fall prevention for older adults. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core: 2004

50. Thank You For Completing This Case Study To retrieve your CE certificate, please click ‘here’ to access our CE form. Please answer all questions and return the form to the NACNS office to earn your CE certificate. *Continuing Education is Optional CONFIDENTIAL - Do not forward or share