Dallas Berrier
Case Study: Falls
Guilford Technical Community College
March 11, 2018
1. Provide a brief explanation of what orthostatic hypotension is and identify the vital signs and their values that define orthostatic (postural) hypotension.
In the Journal of Gerentological Nursing, Momeyer (2014) describes orthostatic hypotension as being the sudden drop in blood pressure as a result from changing positions from lying or sitting to standing. Mr. O 'Brien 's vial signs are consistent with the definition of orthostatic hypotension. His blood pressure continues to fall upon position changing and his heart rate is increasing in order to try to compensate for the fall in blood pressure.
2. Explain the steps of assessing orthostatic
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Identify Mr. O 'Brien 's predisposing risk factors for a fall. Discuss three other risk factors related to falls.
Some pre-disposing risk factors that Mr. O 'Brien already has include his age being greater than 65, he lives in a skilled nursing facility, he has a low blood pressure with a history of syncope, and he is showing signs related to orthostatic hypotension. Other risk factors related to falls can be physiological or environmental. Examples found in the Medsurg Nursing journal include medications the patient may be taking, clutter in the room that makes it easy for a client to trip, and co-morbidities the patient may have such as diabetes which can result in hypoglycemia leading to a fall (Woodall, 2016).
9. The use of a vest could be considered for Mr. O 'Brien to prevent another fall. Define what a "restraint" is and discuss different examples of physical and chemical restraints. What actions must be taken before restraints can be used? What alternatives must be considered
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Of these risks include agitation, strangulation, complications from the restrained part of the body being immobile, pressure sores, and incontinence which can lead to moisture associated skin breakdown. Documentation included with the provider 's orders should include the measures that were taken prior to restraint use to try to avoid using them, date/time of the restraint intervention, what type of restraint was used, the rationale for using a restraint, a full patient assessment, patient and family education about use of restraints, and a re-assessment of the patient every 2 hours and the restraints should be removed at this time for at least fifteen minutes. A new order must be implemented every 24 hours for adults and every 2 hours for children (Bauer & Weust