fall - Nursing Case Study

Pathophysiology

• Primary mechanism: Muscle Weakness - As individuals age, muscle strength decreases, leading to difficulty in maintaining balance. This can result in slips or trips, ultimately leading to falls. Regular exercise can help to maintain muscle strength and reduce the risk of falls.

• Secondary mechanism: Sensory Impairment - Reduction in vision, hearing, or proprioception (awareness of body position) can impair an individual's ability to navigate their environment safely. This increases the risk of falls due to unseen obstacles or uneven surfaces.

• Key complication: Bone Fractures - Falls are the leading cause of fractures in older adults, particularly hip fractures. These can lead to decreased mobility, increased dependence, and potential complications such as deep vein thrombosis or pneumonia.

Patient Profile

Demographics:

72, Female, Retired School Teacher

History:

• Key past medical history: Hypertension, Osteoporosis

• Current medications: Lisinopril, Calcium and Vitamin D supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Fall at home

• Key symptoms: Mild pain in right wrist, slight bruising, no loss of consciousness

• Vital signs: BP 130/85 mmHg, Heart rate 75 bpm, Respiratory rate 16 bpm, Temperature 98.2°F, Oxygen saturation 98% on room air

Section 1

Initial Assessment Findings:

Upon the initial assessment, it was noted that the patient had mild swelling on her right wrist, which was tender to touch. She reported a pain score of 4 on a scale of 1-10, with 10 being the most severe pain. The rest of the musculoskeletal assessment was unremarkable, with no other signs of trauma. Neurological examination showed intact cranial nerves, normal strength and sensation in all limbs, and a steady gait. However, the patient expressed concern about her increased unsteadiness during walking.

The patient's medical history of hypertension and osteoporosis, combined with her recent fall, raises concern for potential fractures and future fall risks. Her age and osteoporosis status increase her risk for fractures, which could lead to further complications such as immobility and increased dependence. Additionally, the patient's report of increased unsteadiness suggests potential balance issues, which could be due to muscle weakness or sensory impairment and could increase her risk of falls. It will be important to further assess her balance and muscle strength and to consider interventions to reduce her risk of future falls.

Section 2

New Diagnostic Results:

Upon receiving the result of the X-ray that was ordered, it was confirmed that the patient had a minor fracture in her right wrist. The X-ray showed a non-displaced distal radius fracture, which is a common type of wrist fracture. The fracture was stable, and the alignment of the wrist bones was still good, which is a positive sign for healing. Furthermore, her complete blood count (CBC) and basic metabolic panel (BMP) were within normal ranges. Her blood pressure, however, was slightly elevated at 145/90 mmHg, likely due to the pain and anxiety from her fall and injury.

Given the patient's history of osteoporosis and the confirmed wrist fracture, the healthcare team decided to order a dual-energy X-ray absorptiometry (DEXA) scan to better evaluate her bone density. The results of this test will provide more information on the patient's osteoporosis status and may influence the treatment plan for her current fracture and the prevention of future fractures. This new diagnostic information necessitates a reassessment of her pain management and possible need for orthopedic consultation.

Section 3

Change in Patient Status:

Following the DEXA scan, the patient's bone density was found to be significantly lower than average, suggesting advanced osteoporosis. As a result, the patient was at an increased risk of further fractures. She reported a pain score of 6 on a scale of 0-10 in her injured wrist. Her blood pressure remained mildly elevated at 148/92 mmHg, indicating that her pain and anxiety were not fully managed. The patient also complained of feeling unsteady when walking, likely due to anxiety from her recent fall.

The healthcare team implemented a fall prevention strategy, which included educating the patient about the importance of staying active to build bone strength, while also providing guidance on how to safely navigate her environment. The team also reinforced the importance of taking her prescribed osteoporosis medication regularly to slow the progression of the disease. The patient was advised to use a walker for support while moving around to prevent future falls. Her anxiety and pain management plan was reviewed, with mild analgesics administered for pain and a low dose of anxiolytic given to manage her anxiety. The effectiveness of these interventions will be evaluated during the subsequent assessments.

Section 4

New Diagnostic Results:

The patient's blood work returned, revealing slightly decreased calcium levels of 8.3 mg/dL (normal range: 8.6-10.2 mg/dL). This could be contributing to her osteoporosis and increased risk of fractures. Her vitamin D levels were also below the optimal range at 18 ng/mL (normal range: 20-50 ng/mL), indicating a potential deficiency, which could be impacting her body’s ability to absorb calcium and maintain bone health. However, her kidney function remained within normal limits, as indicated by her creatinine level of 0.9 mg/dL (normal range: 0.6-1.2 mg/dL).

The healthcare team decided to supplement her diet with calcium and vitamin D, aiming to improve her bone density. They advised her to increase her intake of calcium-rich foods like dairy products, green leafy vegetables, and fortified cereals. They also recommended exposure to sunlight for natural vitamin D synthesis and prescribed a vitamin D supplement. These interventions will be reevaluated with repeat blood tests in one month to gauge their effectiveness. This offers an opportunity for the patient to take an active role in managing her health condition.

Section 5

Change in Patient Status:

A week after implementing the dietary changes and supplement regimen, the patient reported feeling slightly more energetic and less lethargic. However, she also mentioned experiencing minor constipation, a common side effect of calcium supplementation. Her vitals remained stable with blood pressure at 120/80 mmHg, pulse rate at 72 beats per minute, and respiratory rate at 16 breaths per minute.

The nursing team then revised her dietary plan to include more fiber-rich foods, such as whole grains, fruits, and vegetables, to counteract the constipation. They also encouraged her to increase her fluid intake. In addition, they explained to her the importance of regular physical activity in promoting healthy bowel movements and overall bone health. This adjustment in her care plan would be monitored closely to ensure its effectiveness and her comfort.