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Fundamentals of Nursing

Chapter 9

Fundamentals of NursingChapter 9

Chapter 9

Unfolding Case Study

1.
The most concerning cue is the patient’s inability to remain safely in bed. It is also concerning that the patient is restless and agitated, as this may be indicative of an underlying problem.
2.
Based on the cues assessed, the nurse should be concerned about the patient’s increased risk for falls. Additionally, the nurse may have concerns related to the patient’s mental status since they are exhibiting signs of restlessness and agitation following the procedure.
3.
The patient was given oxycodone, which could alter their mental status and their ability to remain safe when out of bed. Additionally, the patient just returned to the unit from a procedure where sedation and pain medications were likely administered. Other factors that may potentially be affecting the patient’s ability to remain safely in bed include age, sensory impairments, and/or vision problems. It is important for the nurse to assess for and address these underlying issues to decrease the patient’s risk for falls.
4.
The nurse should implement fall risk precautions including moving the patient’s room closer to the nurse’s station, applying fall risk socks and arm bands, keeping the bed locked and in the lowest position, and turning on the bed alarm. The nurse should assess why the bed alarm was off and if the patient is able to turn it off themselves. If they can do so, other interventions such as a 1:1 sitter may need to be initiated.
5.
Before anything else, the nurse must ensure that the patient is safe and uninjured from the fall. After getting the patient back to bed, the nurse should conduct a thorough physical assessment and document any apparent bruising or marks left from the fall. The nurse should also notify the provider about the fall, as they may want to order imaging to look for internal injury, especially of the head. After confirming that the patient is not injured from the fall, an incident report must be filed by the nurse.
6.
The patient should remain safely in bed and free from harm after the implementation of fall precautions. The patient and patient’s family members should also express understanding of the care plan and need for fall risk precautions. If the patient continues to get up from the bed without assistance, the care plan will need to be revised and reevaluated to find more effective solutions.
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