Posted: September 17th, 2017

Assessment Tools

Think of an elderly patient upon whom you performed a physical assessment, such as a new admission to the unit. Describe this patient by age, gender, and diagnoses. Based on your readings and the available assessment tools provided in the Try This resources (found in the Activities section of the unit), select which assessments would be necessary for this patient. What would need to be included in your plan of care to prevent complications? Defend your responses.

# case scenario:
BCAS arrives with Henry; 85 yrs; fell off his ladder while
cleaning his leaves troughs; suspect he has #’d right arm and ankle.
Bruise on forehead.

• Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model

Geriatric Giant: FALL and Injury

Screen for Falls:Have you had a fall in the last 6 months?

If YES, then refer for assessment (e.g. physiotherapist, occupational

therapist, specialized clinic, GP)*** Acutely ill older adults at

ALL at high risk for a fall and injury

Contributing Factors Contributing

Orthostatic hypotension (BP drop: lying to standing): systolic, drop of >20 or diastolic, any

standing): systolic, drop of >20 or drop, in up to 3 minutes•

Medications: diuretics, anti–hypertensives, sedatives, neuroleptics, benzodiazepines, narcotics Cerebrovascular disease, Lower limb weakness, gait problems, numbness .etc. impaired judgement/altered mental status sensory impairment (vision, hearing, proprioception balance)

ALERT!
Osteoporosis/Osteopenia

Loss of cross struts inside of bone leads to

fragility fractures

Vertebral #’s predict future hip #

TREAT early! Calcium & Vit.D

Bisphosphanates

calcitonin

estrogen

modulators, parathyroid hormone

Weight

bearing, resistant exercises

Safe environment

Bed rails down unless assessed otherwise

Pathways clear of clutter

Bed and chairs in locked position

Adequate and appropriate lighting

Assist with mobility

Safe and regular toileting

Mobility assist documented

Assistive devices within patient reach

Fall risk reduction

Call bell in patient’s reach

Bed lowered to patients knee height

Personal items reachable

Proper footwear available and in use

Engage patient and family

Discuss risk factors with patient and family

Communicate mutual plan

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