Case Study: The Hendrich II Fall Risk Model

As people age, they face difficulties with seeing and also with mobility, declines in their physiological systems impact balance, range and speed. These physiological problems can result in falls, which tend to be really problematic for the elderly living alone at home. The Hendrich II Fall Risk Model (HFRM) was used on Mr. T.C to assess his fall risk; this tool is used in acute care facilities to estimate the risk for falls in adults (Hendrich, 2013). The client scored a 6, any score exceeding a 5 is considered a high risk for fall. Being a male is one of the predetermined risk points that make one susceptible of falling as well their symptomatic depression, both which the client falls under. The Get-Up-and-Go Test is also a predetermined risk factor of HFRM; it determines the client’s ability to rise from a seated position. It took the client 3 attempts to fully stand up from a seated position.

The skin of the elderly tends to be thinner and more delicate, which means an older person has an increased possibility of developing a pressure sore

during a lengthy stay in the same position. The Braden Scale for Predicting Pressure Sore Risk (BS) is an assessment tool that is routinely used by nurses to evaluate a client’s possibility of developing pressure ulcers. The BS scale, which comprises of six classifications: sensory perception, moisture, activity, mobility and nutrition as well as friction was used to examine the client for pressure sore risks. The total score ranges from 6 to 23, with a score of 18 or less indicating a risk for a pressure ulcer; Mr T.C scored a 19 out of 23. He mentioned he missed his wife’s cooking and he doesn’t see the point of cooking for only himself all the time, although he goes out and grocery shop when he runs out of food.
Mr. T.C was also assessed for his functional independence. The elderly value their independence greatly; they don’t want to be perceived as a burden to their the family or the community. It is prudent to assess their independence as they can become reluctant to ask for assistance from loved ones as well as healthcare workers. The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, is the most appropriate tool to evaluate functional status as a way to determine the client’s capacity to complete activities of daily living independently; this tool is typically used to discover problems in older adults when performing activities of daily living and to appropriately plan their care (Shelkey & Wallace, 2012). The tool uses a (yes-or- no) measurement, with 1 point given for every ADL in which the client is independent and 0 points given for every ADL in which the client is dependent. The maximum potential score is 6, demonstrating independence in all ADLs (bathing, dressing, toileting, transferring, continence, and feeding); the lowest is 0, meaning the client needs assistance with each activity. Mr. T.C can eat freely, stay continent, go to the toilet independently, and dress autonomously, but needs help bathing and transferring. This gives the Mr. T.C a score of 4, which is moderate impairment. The client has difficulty standing up independently and it takes about two to three tries to accomplish this task.
Senior adults who are living at home as well as long-term establishments can be at risk for abuse and neglect. The Elder Assessment Instrument (EAI) offers a method for nurses to monitor older adults for potential mistreatment and can be used in most environments. This extensive 41-item assessment tool was used on the client to assess a multitude of problems that can occur within the elderly; from neglect and abandonment to exploitation as well as abuse. There isn’t sufficient evidence to believe that the client is being abused; although Mr. T.C suffers with lack of daily social interactions, and upon assessing his body the client had a 2x2 inch discoloration noted on the right anterior knee. After investigating and questioning the discoloration, the client stated he fell 2 weeks ago while going to the bathroom and fell at least 4 times this year alone.
Aging affects the body and overall the client showed some normal signs of aging; he started wearing glasses 22 years ago to correct his presbyopia, gradually becoming weaker and takes more energy to stand up from a seated position, also have episodes of urinary incontinence which is customary in some elderly people due to weakness of the sphincter muscles. The abnormal aging signs that we present in the client included the ulcer on the sole his foot, the stage 1 lung cancer and episodes of tachycardia. The problem areas discovered in the assessment included the altered circulation in his right leg, the diabetic ulcer in his right foot, the mild depression the client seems to be dealing with and the potential for falls as well. For the altered circulation of the right leg, as a short-term goal the patient demonstrated the ability to put his right leg in a dependent position before the meeting is over; the long term goal is that the client will have an absence of swelling, and improved ambulation as manifested by walking and a peripheral pulse rate between 60-100 bpm in less than 7 days. To implement this the client was encouraged to perform light exercises, since exercising help improved circulation and to stop smoking since smoking cause decreased circulation. For the diabetic ulcer, as a short term goal the client was able to demonstrate 3 measures that he can do to prevent putting pressure on the foot ulcer during the meeting; as a long term goal the client’s ulcer will not grow in size and tissue perfusion will be adequate for healing. To implement this client was helped to set up a meeting with a podiatrist and was encouraged to buy diabetic shoes that can alleviate pressure.
Signs of moderate depression were also noticed in the client and as a short term goal the client was able to express feelings, perceptions, and fears of her current situation during the meeting; for the long term goal the client will be able to describe three effective coping tactics for dealing with stressful situations.

To implement this the client was allowed to verbalized feelings and silence was observed to give the client time to express his feelings. The client mentioned falling 4 times this year and as a short-term goal the client identified factors that increase the potential for injury by the end of the meeting; for a long-term goal the client will make essential physical changes in the home to ensure improved safety within a week. To implement this the path to the bathroom was cleared, the door of the bathroom was left open and items that increase falls like unnecessary extension cords and small rugs were

removed.
An important task of nursing is teaching and Mr. T.C’s education about the altered circulation in his right leg involved client being able to recognize the signs and symptoms that needed to be reported to a physician like a change in skin temperature, color, sensation, or manifestation of a fresh lesion in the extremities. For the ulcer in the sole of the right foot the client was taught to examine his feet daily, particularly the sole and amongst the toes for cuts, welts, cracks, swellings, redness as well as carbuncles and any sign of irregularity. For the mild depression that was discovered, the teaching involved for the client to get help for depression because not only it improves the client’s quality of life, it also can assist him with managing his diabetes better by giving him more energy and a more optimistic outlook. The client also has a history of falls and was educated on a list of actions to prevent falls at home like having his the vision checked regularly; with reduced vision the client may miss vital cues that help to evade objects and preventing falls. The client was also taught to sleep with a night-light, to remove small rugs on bare floors as well as wearing slippers and shoes with non-slip soles.