Geri Quiz 2 with verified solutions
graded A+ passed
fall definition - correct answer ✔✔unintentional coming to rest on a lower area (ground); considered
geriatric syndrome specific to OA
1 out of ___ OA's (65+) falls each year - correct answer ✔✔3
Highest fall incidence occurs in - correct answer ✔✔in institutional LTC setting -> have more co-
morbidities than those living in community
___ fall more (almost 2x) than men - correct answer ✔✔women
Why OA's fall: - correct answer ✔✔In hurry, not careful, don't look where they are going, step over pets,
stand on something unsafe, no lights on, no footwear
Consequences of falls: ___ end in hospitals and ___ end in nursing home - correct answer ✔✔Hospital
(20%) + nursing home admissions (50%)
Other consequences of falls - correct answer ✔✔Physical injury + fear of falling again: (cascade to
dependency)
cascade to dependency - correct answer ✔✔Reduce activities (-> loss of muscle strength), unnecessary
dependency, loss of function, less socialization, poor quality of life (a cycle of falling)
Risk factors for fall - correct answer ✔✔-Age-related factors, improper use of mobility aids
-Medication :
Benzodiazepines (Valium + Ativan), antipsychotics, sedatives, hypnotics, antidepressants, sleep aids
o Unsafe clothing (poor fitting socks, shoes)
,o Dx-related symptoms, environmental hazards, caregiver-related factors
Fall risk assessment completed when: - correct answer ✔✔patient is admitted, transferred to new unit,
level of care changes, change in condition, after a fall
Fall risk assessment usually addresses issues such as - correct answer ✔✔• History of falls - pt w/ history
of fall in last 3 mo. biggest predictor of having another fall
• LOC, elimination, BP, orthostatic changes, co-morbidities, vision
Patient with a history of fall within the last three months: - correct answer ✔✔biggest predictor of
another fall
Two fall assessments: - correct answer ✔✔-Hendrich II Fall Risk Model
-Tinetti Assessment Tool
Hendrich II Fall Risk Model - correct answer ✔✔looks @ risk factors for falls; used in acute care setting
-If pt confused, depressed, problems w/ elimination - risk factors for HII
Tinetti Assessment Tool - correct answer ✔✔measures pt's gait + balance
• Max score for gait component = 12 points; balance component = 16 points
• Score below 19 @ high risk for falls
• 19-24 indicates pt has risk for falls
Why do we use the same assessment tool over time? - correct answer ✔✔we can see if patients risk
assesment has changed over time
What are we assessing in the assessment? - correct answer ✔✔- intrinsic factors
-extrinsic factors
-preform PFA ( post fall assessment)
, Intrinsic Factors - correct answer ✔✔inside body
-Physiological changes associated w/ age: acute + chronic dxs, effect of meds
-Incontinence, age > 75, cog. impairment, vision probs, orthostatic changes, history of falls
Extrinsic Factors - correct answer ✔✔-Environment around OA
-Lighting, floor treatments, furniture, footwear, IV's, foleys, loose rugs, socks
Study in 2008 - 3 factors affect when falls occur: - correct answer ✔✔1) During lack of supervision during
toileting
2) During 10 am - 2 pm
3) During day shift - more activities going on
PFA (post fall assessment) following pt fall includes: - correct answer ✔✔-Perform physical assessment of
pt @ time of fall
-Vital signs, ROM, mental status, any symptoms (lightheaded, dyspnea, pain) before they fell?
-After fall: vital signs 4x q15 minutes; to 30 mins; to hour
-Obtain history of fall
-Note circumstances of fall - did pt slip on something? was floor wet?
-Pt's say they turned around too quick, lost balance + fell
-Review of underlying illness + problems
-Check for baseline vitamin D level - risk for fracture
-Review medications + risk factors for falling
-Assess functional, sensory + psychological status
General safety precaution + fall prevention measures
(nursing care strategies) - correct answer ✔✔-Assess pt care environment routinely for extrinsic risk
factors
-Assess/screen OA pt for risk factors to fall, on admission, following change in condition, transfer to new
unit, following a fall
-Institute general safety precautions according to facility protocol (note what they are)
graded A+ passed
fall definition - correct answer ✔✔unintentional coming to rest on a lower area (ground); considered
geriatric syndrome specific to OA
1 out of ___ OA's (65+) falls each year - correct answer ✔✔3
Highest fall incidence occurs in - correct answer ✔✔in institutional LTC setting -> have more co-
morbidities than those living in community
___ fall more (almost 2x) than men - correct answer ✔✔women
Why OA's fall: - correct answer ✔✔In hurry, not careful, don't look where they are going, step over pets,
stand on something unsafe, no lights on, no footwear
Consequences of falls: ___ end in hospitals and ___ end in nursing home - correct answer ✔✔Hospital
(20%) + nursing home admissions (50%)
Other consequences of falls - correct answer ✔✔Physical injury + fear of falling again: (cascade to
dependency)
cascade to dependency - correct answer ✔✔Reduce activities (-> loss of muscle strength), unnecessary
dependency, loss of function, less socialization, poor quality of life (a cycle of falling)
Risk factors for fall - correct answer ✔✔-Age-related factors, improper use of mobility aids
-Medication :
Benzodiazepines (Valium + Ativan), antipsychotics, sedatives, hypnotics, antidepressants, sleep aids
o Unsafe clothing (poor fitting socks, shoes)
,o Dx-related symptoms, environmental hazards, caregiver-related factors
Fall risk assessment completed when: - correct answer ✔✔patient is admitted, transferred to new unit,
level of care changes, change in condition, after a fall
Fall risk assessment usually addresses issues such as - correct answer ✔✔• History of falls - pt w/ history
of fall in last 3 mo. biggest predictor of having another fall
• LOC, elimination, BP, orthostatic changes, co-morbidities, vision
Patient with a history of fall within the last three months: - correct answer ✔✔biggest predictor of
another fall
Two fall assessments: - correct answer ✔✔-Hendrich II Fall Risk Model
-Tinetti Assessment Tool
Hendrich II Fall Risk Model - correct answer ✔✔looks @ risk factors for falls; used in acute care setting
-If pt confused, depressed, problems w/ elimination - risk factors for HII
Tinetti Assessment Tool - correct answer ✔✔measures pt's gait + balance
• Max score for gait component = 12 points; balance component = 16 points
• Score below 19 @ high risk for falls
• 19-24 indicates pt has risk for falls
Why do we use the same assessment tool over time? - correct answer ✔✔we can see if patients risk
assesment has changed over time
What are we assessing in the assessment? - correct answer ✔✔- intrinsic factors
-extrinsic factors
-preform PFA ( post fall assessment)
, Intrinsic Factors - correct answer ✔✔inside body
-Physiological changes associated w/ age: acute + chronic dxs, effect of meds
-Incontinence, age > 75, cog. impairment, vision probs, orthostatic changes, history of falls
Extrinsic Factors - correct answer ✔✔-Environment around OA
-Lighting, floor treatments, furniture, footwear, IV's, foleys, loose rugs, socks
Study in 2008 - 3 factors affect when falls occur: - correct answer ✔✔1) During lack of supervision during
toileting
2) During 10 am - 2 pm
3) During day shift - more activities going on
PFA (post fall assessment) following pt fall includes: - correct answer ✔✔-Perform physical assessment of
pt @ time of fall
-Vital signs, ROM, mental status, any symptoms (lightheaded, dyspnea, pain) before they fell?
-After fall: vital signs 4x q15 minutes; to 30 mins; to hour
-Obtain history of fall
-Note circumstances of fall - did pt slip on something? was floor wet?
-Pt's say they turned around too quick, lost balance + fell
-Review of underlying illness + problems
-Check for baseline vitamin D level - risk for fracture
-Review medications + risk factors for falling
-Assess functional, sensory + psychological status
General safety precaution + fall prevention measures
(nursing care strategies) - correct answer ✔✔-Assess pt care environment routinely for extrinsic risk
factors
-Assess/screen OA pt for risk factors to fall, on admission, following change in condition, transfer to new
unit, following a fall
-Institute general safety precautions according to facility protocol (note what they are)
