A nurse is caring for an older adult client newly admitted to the medical unit.

Exhibits

Click to highlight the pieces of information that indicate the client is at risk for falls. To deselect a piece of information, click on that piece of information again.

Nurses' Notes

1000:

An older adult client admitted following a fall down approximately five steps. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two. Client states, "I feel fine. I just slipped." Client has a history of falls and orthostatic hypotension per client's partner. Client uses a walker and wears rubber-soled slippers at home. Client ordered new glasses following an eye exam last week but has not received them yet. Partner states they both do exercises that focus on coordination, three times per week.

Vital Signs

1000:

Temperature 37° C (98.6° F)

Heart rate 72/min Respiratory rate 20/min

Blood pressure

Lying: 130/90 mm Hg

Sitting: 128/88 mm Hg

Standing: 98/60 mm Hg

Oxygen saturation 97% on room air

The key pieces of information that indicate the client is at risk for falls include:

1. Admitted following a fall down approximately five steps – Indicates a recent fall history.
2. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two – Suggests potential confusion or altered mental status.
3. Client has a history of falls and orthostatic hypotension per client's partner – A significant risk factor for future falls.
4. Client uses a walker – Indicates mobility impairment.
5. Client ordered new glasses following an eye exam last week but has not received them yet – Vision impairment increases fall risk.
6. Blood pressure: Lying: 130/90 mm Hg, Sitting: 128/88 mm Hg, Standing: 98/60 mm Hg – Orthostatic hypotension (drop in BP upon standing) can cause dizziness and falls.