Fall Risk and Cognition Assessments
Mrs. L is an 89-year-old widow who lives independently in her home. She drives, and she is an avid quilter. Her daughter lives within 2 miles and checks in daily with Mrs. L by phone or in person.
Mrs. L has been admitted to your hospital with the diagnosis of R/O pneumonia.
Her past medical problems include the following:
· Bilateral hip replacements
· Detached retina × 2 (right eye)
· Orthostatic hypotension
· Falls at home × 1
· Urinary frequency
· Insomnia (sleeps about 3 hours per night)
Mrs. L takes no medication, “not even an aspirin.”
Mrs. L uses her call button frequently to request assistance to the bathroom. Upon rounding, her nurse found Mrs. L on the floor, having crawled out of her bed with the side rails up. She was assessed and was found to have no injuries. Her gown was wet with urine. When asked to describe what happened, Mrs. L stated the following: “I called for help to the bathroom and no one came. So rather than wetting the bed, I managed to crawl over the side rails. I slipped on the floor trying to get to the bathroom.”
1. What are Mrs. L’s known risk factors (in the hospital) for falling?
· Medical conditions
· Unsafe behaviors
2. Using the Hendrich II Fall Risk Model (
), determine Mrs. L’s fall risk score.
3. Mrs. L states she is “plagued by insomnia.” Using the Pittsburgh Sleep Quality Index (
), 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?
4. Mrs. L is asked to complete the “Clock Drawing” portion of the Mini-Cog (
). 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?
5. Having assessed Mrs. L’s fall risk and her cognitive state, develop three safety goals for each of the following:
· Environmental and equipment
· Gait and mobility
· New medications
· Anxiety, depression, and unsafe behavior
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