Abigail Cantonelli, age 80, injured her left knee and wrist when she fell on an icy sidewalk. She has been on your orthopedic and neurologic unit for several days. She has a history of cardiomyopathy, for which she receives furosemide. Her vital signs are stable and she rates her pain as aching, intermittent, and a 2 on a scale of 1 to 10 (10 = worst pain). Because Mrs. Cantonelli has an increased risk of falling, she has been prescribed physical therapy and cane-walking instructions before discharge. Although the physical therapy staff has already initiated the cane-walking instructions, you will need to ambulate Mrs. Cantonelli with her cane during your shift. While you are ambulating down the hall, she says, “Oh, dear! I feel dizzy.” She begins to lose her balance and fall toward you.
Prescribed Interventions
- Physical therapy for cane-walking instruction
- Ambulate every shift with cane assistance
- Furosemide 20 mg PO every morning
- Potassium chloride 10 mEq PO every day
- Naproxen 275 mg PO q6-8h prn pain
Developing Clinical Reasoning and Clinical Judgment
- Identify Mrs. Cantonelli's risk factors for falling.
- Describe the actions you would implement when Mrs. Cantonelli begins to fall.
- Considering these risk factors, what special assessments and precautions should you implement before assisting her to ambulate or while assisting her with ambulation?
Suggested Responses for Integrated Nursing Care
- Falls are the leading cause of unintentional injury death in people aged 65 years and older (CDC, 2018). Because of Mrs. Cantonelli's age, history of falls, and impaired mobility, she continues to be at risk for falls. Her weakness and pain from her injuries also contribute to this risk. In addition, she is taking furosemide, a diuretic. This medication contributes to an increased risk for falling and subsequent injury (Kapas, 2021). Implement fall-prevention interventions (refer to Chapter 4).
- Before ambulating Mrs. Cantonelli, implement several assessments and precautions to prevent orthostatic hypotension. Assess for orthostatic hypotension (refer to Chapter 2). Have her sit on the side of the bed for a few minutes and make sure she does not feel dizzy, weak, or lightheaded (refer to Chapter 9). Because she has a history of cardiomyopathy, assess for shortness of breath and chest pain. If she cannot tolerate sitting up on the side of the bed without having these symptoms, then she will not tolerate standing up or ambulating. Assess her pain level immediately before ambulation (Chapter 10). If you have to medicate her for pain, then wait until the pain medicine has had time to take effect before ambulating. Because she is weaker on her left side, assess strength on her right side to ensure she will be able to support her weight with the cane (refer to Chapter 9). If she has difficulty maintaining her balance, apply a safety belt (gait belt) before she begins to ambulate with the cane (some institutions require the use of a safety belt).
- While Mrs. Cantonelli is ambulating with her cane, observe her closely. Assess her technique with the cane. Observe for symptoms such as dizziness, chest pain, and shortness of breath. As she continues ambulating, evaluate how she tolerates this activity (Chapter 9). Before she is discharged from the hospital, assess her self-confidence as well as her overall ability to use the cane.
- If Mrs. Cantonelli begins to fall, it is important to protect her while also protecting yourself. If you feel her start to fall, maintain a wide base of support, grasp the safety/gait belt firmly and slowly guide her down toward the floor, supporting her on your thigh and large quadriceps muscle and protecting her head (Wintersgill, 2019) (refer to Chapter 9). Assess her orientation and stay with her while waiting for help from another health care provider. Take her vital signs to determine if there is a change from baseline. Thoroughly explore other factors that may have contributed to her fall, and plan interventions that will prevent future falls. If Mrs. Cantonelli continues to have problems with falling or difficulty using the cane, consider having her use a walker.