Alvin Stewart was a healthy, independent 65-year-old when he was hospitalized for partial lung resection for a nonmalignant tumor. (This case is a composite based on my experience.) Now, three days after surgery, his recovery has been complicated by inadequate pain control and chronic urinary retention and urgency, exacerbated by the general anesthesia. When asked to rise from the side of the bed or a chair, he has to push up with both hands. As he takes the first few steps he looks unsteady, walking with a noticeable sway, and he frequently grabs objects for support. Mr. Stewart is mildly disoriented from oxycodone (OxyContin and others), and he says that it causes him to feel dizzy and "forget exactly where I am."

The nurse discusses toileting assistance with him, and he expresses a strong desire to "go it alone and remain independent." She believes this desire for independence may prevent him from asking for or waiting for help when he needs it. The nurse had scanned Mr. Stewart's room for factors that might increase his risk of falling, but she knows that if his risk is high, additional interventions will be needed to reduce it. To ascertain his level of risk, the nurse uses the Hendrich II Fall Risk Model.

WHY USE THE HENDRICH II FALL RISK MODEL?

* confusion, disorientation, impulsivity

* symptomatic depression

* altered elimination

* dizziness, vertigo

* male sex

* administration of antiepileptics (or dosage changes or cessation)

* administration of benzodiazepines

* poor performance in the "Get-Up-and-Go" test of rising from a seated position

A look at the numbers.

Confusion and disorientation can be assessed through taking the history, interviewing, and observing patterns of behavior. If any or all of the following are present, the patient receives a score of 4 for this risk factor:

* impulsive or unpredictable behavior

* hallucinations

* agitation

* changes in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycles

* unrealistic, inappropriate, or unusual behavior

* disorientation to person, place, or time

* inability to follow directions or retain instructions in self-care or activities of daily living

Depression is assigned a score of 2. A patient may be considered depressed if she or he is so described in the history or if a diagnosis of depression has been determined. But a patient with a history of depression who isn't displaying symptoms doesn't receive a positive score-the depression is considered to be under therapeutic control. Clinicians should observe for any of the following signs of depression:

* prolonged feelings of helplessness, hopelessness, or being overwhelmed

* tearfulness

* flat affect or lack of interest

* loss of interest in life events

* melancholic mood

* withdrawal

* the patient's statement of depression

Altered elimination is given a score of 1. The following symptoms qualify:

* urinary or fecal incontinence

* urgency or stress incontinence

* diarrhea

* frequent urination

* nocturia

Dizziness or vertigo. Unless previously diagnosed or recorded in the patient's history, the scoring of dizziness or vertigo is based on the patient's report. The patient may describe symptoms with statements like "The room is spinning" or "I feel like I'm spinning." Another method for assessing dizziness or vertigo is to observe for swaying when the patient stands (as part of the Get-Up-and-Go test, described below). Does the patient sway in a small circle when standing still? This sign is often observed in aging adults with poor gait and balance. (In new mothers it can be an adverse effect of epidural anesthesia causing prolonged numbness and weakness.) Patients experiencing dizziness or vertigo receive a score of 1 for this risk factor.

Medications. Antiepileptics and benzodiazepines are the only drug classes that the model addresses directly. The adverse effects common to other medications-dizziness, altered elimination, unsteady gait, and confusion-are already represented. Antiepileptics and benzodiazepines are considered independent risk factors because they affect the central nervous system and can cause cerebellar ataxia, weakness, and gait changes. For the patient to receive a positive score, one of these drugs must be administered, not simply ordered. Patients taking an antiepileptic receive a score of 2 if the drug is administered, stopped, or changed suddenly. Patients who have been administered a benzodiazepine receive a score of 1.

To evaluate the patient's ability to stand up, the nurses should have her or him sit on a chair or at the side of the bed with the hands resting flat on the thighs. A patient who is able to rise in a single movement without using her or his hands scores a 0 on the test. The patient who pushes up with the hands and rises in one attempt scores a 1. The patient who pushes up multiple times but ultimately is able to rise scores a 3. A patient who is unable to get up without assistance receives a score of 4.

Mr. Stewart. After introducing herself, Mr. Stewart's nurse, Bettina Gonzales, begins assessing him using the Hendrich II model. "I'd like to ask you a few questions," she says. "They may seem strange, but they'll help us care for you better." Mr. Stewart nods. "Can you tell me who you are?" she asks. Drowsy and slightly confused, he states his name. When she asks him the time and his whereabouts, he says he isn't sure. She records a score of 4 in the confusion and disorientation section of the Hendrich II model.

Mr. Stewart's record doesn't show a history of depression, nor has he been prescribed any antidepressants. His manner also doesn't indicate depression; although he is clearly confused, he doesn't appear withdrawn, overwhelmed, or overly emotional. Ms. Gonzales enters a score of 0 in the depression section of the risk model.

Next, Ms. Gonzales asks another nurse to assist so they can conduct the Get-Up-and-Go test. Mr. Stewart is asked to slowly turn and swing his legs to the side of the bed. Both nurses support him as he does so. He can sit with assistance, but because he uses both hands to push off the bed, he scores 1 point. While standing, he sways slightly. "How do you feel?" Ms. Gonzales asks. "I'm dizzy," he says. "It's like the room is spinning around me." He falls slightly toward the other nurse, who steadies him. Mr. Stewart clearly has dizziness and vertigo, so he receives a score of 1 in that category.

Mr. Stewart has not been administered antiepileptics or benzodiazepines, and the nurse enters a score of 0 in each of these categories. She adds 1 point for male sex.

Finally, Ms. Gonzales asks, "How often do you feel the need to urinate?" "Often," he answers, "and when I have to go, I have to get to the toilet fast." The nurse adds 1 point for altered elimination.

Challenges that may arise. If the patient is unable to perform the Get-Up-and-Go test, score all the other risk factors that can be assessed. If the patient scores a 5 or above without this test and can attempt to get up, she or he should be considered at high risk for falls. Those who are unable to attempt even to rise but who have scored 5 or more in the other categories should be considered at high risk. Fall-prevention interventions should be implemented as soon as these patients begin to attempt rising; they can become high-risk patients within a short period, so ongoing assessment is critical. Also, patients rousing from a drug-induced coma or unconsciousness are at particularly high risk; frequent monitoring will prevent unexpected changes in fall risk.

If the patient is dizzy or exhibits poor balance, it's always best to have two caregivers present for support when the Get-Up-and-Go test is performed. Also, constant monitoring for adverse medication effects and drug-drug interactions is essential. Monitoring can also help detect subtle shifts in behavior, cognition, or gait and balance that can dramatically and rapidly increase fall risk.

SCORING AND INTERPRETING RESULTS

Mr. Stewart's total score is 8, indicating that he has a high risk of falling. To reduce his risk, the care plan is altered. For example, his confusion and dizziness are intermittent and of recent onset. And since his electrolytes are normal, the confusion and dizziness are most likely adverse effects of oxycodone. His physician is consulted to discuss alternative strategies for managing his pain. Because of challenges to his gait and mobility, his care plan incorporates increased observation: toileting rounds based on his pattern of elimination are scheduled, and a bed-exit alarm is installed. His yellow armband reflects his risk of falling and is a reminder to him and all staff. Most important, he should not be allowed to get up without assistance or be left alone in the bathroom. His family is informed of his needs and asked to assist with ambulation, toileting, and reminding him not to get up without assistance. Keeping Mr. Stewart mobile by getting him up and seated in a chair or on the side of the bed and going out for short walks in the hallway and gradually reducing his pain medication (if that's appropriate) should help to stabilize him and eventually reduce his overall risk of falling.

Other considerations. Because men are seen to be at greater risk, the nurse should discuss with male patients the need to accept help to avoid a fall. Inquire into the patient's preferences: for example, would he prefer to have a man help him while using the toilet? A frank discussion about harm and fractures from falls may help to reduce risk-taking behaviors.

For a fall-prevention program to be successful, employees must be able to communicate clearly with one another. This includes consistently using wristbands and other signs that indicate risk, including in reports at shift changes and in interdepartmental reports during testing and transfers, and maintaining good documentation. Even employees who don't have direct patient contact can contribute by keeping the environment safe. All health care employees must work as a team to ensure that all six elements of a fall risk reduction program are in place:

1. Assessing and reassessing fall risk in all patients.

2. Maintaining a safe environment.

3. Monitoring gait and mobility.

4. Enabling safe toileting.

5. Educating the patient and family.

6. Using interdisciplinary team management.

Mr. Stewart. Given Mr. Stewart's confused state, Ms. Gonzales speaks slowly as she informs him of the results of his assessment. She very clearly expresses the dangers: "Mr. Stewart, if you try to get up without help you could hurt yourself or even break a bone. Do you understand?" She attaches an exit alarm to the bed and demonstrates how it works. She plans the schedule for toileting rounds for the rest of the shift and informs her peers of it; she documents her findings and actions, and at the end of her shift, tells incoming staff about the schedule to ensure that it continues after the shift change.

Mr. Stewart's recovery progresses, and he is discharged home six days later. During his stay, his care plan and the interventions prevent a fall.

CONSIDER THIS

What evidence supports using the Hendrich II Fall Risk Model? The widely used Hendrich II Fall Risk Model is an easy-to-use predictive model. Since it was developed in 2003, hundreds of hospitals have incorporated it into their practices. Although it hasn't been widely studied, initial informal reports are positive, especially when the model is used consistently.

* Reliability. No data on reliability have been reported for acute care patients.

* Validity. Odds ratios for each risk factor, which range from 1.67 (altered elimination) to 7.43 (confusion and disorientation), support the validity of the tool. Odds ratios tell you the odds that a risk factor is predictive of a fall, with ratios greater than 1 indicating a positive relationship. The higher the number, the greater the predictive value of the factor.

[white circle] Sensitivity. Of high-risk patients, 74.9% were correctly identified as being at risk for falls.

[white circle] Specificity. Of patients not at high risk for falling, 73.9% were correctly identified as not being at risk.

Myths About Fall Risk

Findings of one study put some misunderstandings to rest.

A second finding identified the effects of medications on falls. Conventional wisdom suggests that increased fall risk results from an increase in the number of medications being given. We found this not always to be the case. Though polypharmacy (six or more medications) can produce adverse effects that increase the risk of falling, such effects are not always present. The two drug categories that proved to carry a statistically significant, independent fall risk were antiepileptic and benzodiazepine medications. Thus, a patient taking one of these drugs could be at greater risk for falling than a patient taking five or six medications from other drug categories.

The third significant finding was that a history of falls isn't necessarily predictive. A history of falling must be carefully examined to determine the factors that caused the fall. Simply put, a predictable fall always has at least one underlying risk factor; if this factor is no longer evident, the patient's risk of falling declines. But if the risk factor persists, so does the need for preventive strategies. For example, if a patient fell because of an underlying chronic condition that impairs her or his mobility, it could lead to another fall. In this example, the previous fall is not the risk factor. The impaired mobility is the risk factor.

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