What assessment tool would be used to determine the patient's risk for falls? Provide evidence to support your answer.
The St. Thomas’s Risk Assessment Tool in falling elderly inpatients (STRATIFY) would suitably be used in the assessment of this patient. It is based on the assessment of a total of five fall risk factors namely transfer and mobility risk, agitation, visual impairment, frequent toileting as well as fall presentation as a complaint which are rated on a scale of 1 to 5. These are essentially the major risks that are common in elderly patients who are risk of falls.
Actual: NANDA-I diagnosis: Acute confusion which is related to declining cognitive capabilities and as evidenced by the patient wrong perception that he is at home, that we are in the year 1994 and that he is currently trying to trace his wife (Treas & Wilkinson, 2014; p.29).
Risk: NANDA-1 diagnosis: Risk of injury as which is related to poor physical and mental coordination and evidenced by the patient’ unsteady and slow gait, poor vision and hearing and general weakness all but indicate that the patient is at risk of injuries (Jarvis, 2015; p.171).
Patient Outcome: To reduce the risk of falls for the patient in post discharge.
Interventions the RN would implement to ensure the patient remains free from falls
Reduce the patient’s mobility needs while at home (Independent nursing intervention): When the patient’s movements are limited, the chances of falling will be significantly minimized as there will be minimal chances of the patient interacting with environmental risk that cause falls such as physical barriers, staircases, and furniture (Treas & Wilkinson, 2014; p.38)
Include a caregiver in the post discharge plan (inter-independent nursing intervention): It is important that the patient’s daily activity even for self-care roles is minimized to reduce the chances of strain which ultimate.ly could expose them to falls and injuries amidst the presenting limitations (Jarvis, 2015; p.159).
Modification of bed and walking rails (inter-independent nursing intervention): Low bed height and the presence of walking rails would help the patient in achieving a substantial steady movement within short distances within the house and thus avoid falls and injuries (Treas & Wilkinson, 2014; p.47).
Teaching and training the patient on walking, toileting and the very basic activities (inter-independent nursing intervention): The care giver should take time to teach and train the patient on the techniques of walking on the rails and the modified aspects within their living room (Jarvis, 2015; p. 144).
How does the RN know the patient understands that the teaching provided about a safe environment in the hospital or the home environment was effective?
The RN can determine the patient’s grasp of content by determining how well they respond to simple instructions at the time of assessment. If the patient can walk steadily across the room, a task that they would previously not have done, then the RN can determine that the patient is learning as desired (Jarvis, 2015; p.173).
Jarvis, C. (2015). Physical examination & health assessment (7th ed.). St. Louis, MO: Saunders/Elsevier.
Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis Company.