Clinical Scenario Reflection: Geriatric Patient Fall
One of the clinical scenarios I was involved in the Professional Experience Placement program was a patient admitted to the unit from emergency for left pretibial laceration management that was slow to heal. The pretibial lacerations are common injuries caused by mechanical falls or traumatic blunt impacts and are often present among the elderly and infirm persons (Singh et al. 2017). According to the Australian Institute of Health and Welfare Report (2019), the rate of injuries from falls by the elderly has almost doubled in the last ten years. The World Health Organisation definition of a fall is an event that leads to an individual coming to rest accidentally on the floor, ground, or any other lower levels. The AIHW report reveals that around 125,000 persons aged 65 and over had serious head, hip, and thigh injuries due to falls in 2016–2017. The prevalence of falls among older persons and can lead to fractures, severe injuries, and death. Accordingly, this paper critically reflects the clinical scenario and its influence on future practice based on Driscoll’s reflection model that clear delineates the three reflective steps. Also, key areas will be identified to propose recommendations that can be implemented to improve and attain positive outcomes in the next PEP.
Part One: The What
This section presents an in-depth description of the clinical scenario. The 65-year-old patient, Mrs. Devon, was admitted to the unit from the emergency department for management of a left pretibial laceration. She had been referred to the hospital for further medical care to maximize the healing of her laceration. The wound assessment revealed that the wound was slow to heal as it was red and inflamed. There was also an increase in exudate that had become yellow. It was evident that the patient’s left pretibial laceration had taken on a chronic wound’s characteristics as it had become hard to heal. This would have been attributed to the patient’s age, co-existent disease processes, and the pretibial region is vascularized poorly.
I assessed the overall health of the patient to avoid focusing solely on her injury. The comprehensive assessment revealed the patient’s medical history, which consists of osteoporosis, hypertension, diabetes type two, right cerebrovascular accident, and glaucoma. The medications also give valuable clues to the health status and indicate disease processes, which could delay the healing process, such as diabetes, or increase the risks of bleeding and the formation of a hematoma. Her medication included Lisinopril 5 mg once a day morning, Vitamin D 1000 units daily, Glicazide 80 mg, and Timoptil 0.5% one drop twice daily. I treated the patient with intravenous fluids and antibiotics and referred the patient for review by the wound consultant for assessment and dressing requirements. I collaborated with the wound care center consultant, as she had substantial experience in wound care. Hence she provided technical support and advice at the hospital. Currently, Mrs. Devon has an IV insitu on her right hand and dry dressing on the left leg. Overall, it was a great experience. My actions led to the maximization of Mrs. Devon’s healing, minimization of risks of infections, and, more importantly, enhanced the cosmetic and functional outcomes.
Part Two: So What
When I encountered the patient, I was perturbed since the wound was slow to heal. It was red, inflamed, and there was an increase in exudate that had become yellow. Since the patient had presented with traumatic wounds, my initial reaction was to conduct a full assessment to determine the causes and underlying conditions to guide the treatment choices. The goal was to minimize the risks of infections, enhance the patient’s functionality, promote fast healing, and attain the best cosmetic results with minimal inconvenience to the patient. I successfully conducted a wound assessment to ascertain the maximum length, maximum width, underlying structures, level and type of exudate, the formation of hematoma, bleeding points, and the flap’s condition and viability. At the time, I also experienced a conflict with my values, but I applied locally acceptable clinical guidelines to make optimal treatment choices. My past working experience in an aged care facility played a pivotal role during the situation. But, I need to improve my knowledge on different types of skin closure. After the event, my views changed after collaborating with the wound care center consultant as she has ample experience and expertise in managing traumatic wounds. The main effects of my actions are the review of the extensive treatment options and guidelines needed to make well-informed decisions on managing traumatic injuries.
Part 3: Now What?
Falls among older adults are among the leading causes of mortality and morbidity worldwide. They are ranked as one of the top reasons for unintentional deaths (Alshammari et al. 2018). One of the lessons from reflecting on this situation are the risks of falling tends to increase with age for numerous reasons, comprising overall weakness, frailty, cognitive problems, medications, balance problems, environmental hazards, vision problems, and acute illness (Jin 2018). Several measures can be implemented to prevent the adverse outcomes that arise from falls in the elderly population. Based on the clinical scenario, two main areas have been identified to propose recommendations that can be implemented to improve and attain positive outcomes in subsequent PEPs. They are a patient assessment applicable in the hospital setting and patient and caregiver education that applies to the mitigation of risks at home.
There is a need to avert falls in hospitals, and serious falls resultant in injury. At present, there are clinical guidelines that have been developed to address the identified risk factors among elderly patients. In subsequent PEPs, some aspects need to be considered when assessing risks for falls: age, medical conditions, history, time, reasons, location of falls, and the history of previous falls. For instance, patients with higher risks of falling have a medical history of delirium and confusion, diabetes, disability, muscle weakness, visual impairment, urinary frequency, and postural hypotension (Vieira et al. 2016). The best approaches for preventing falls in the hospital setting are implementing standardized falls prevention policies, identifying risks, implementing interventions targeting patients at more significant risks, and preventing injuries to the patients who fall (Bolding & Corman, 2019).
Besides, the Falls Risk Assessment Tool can be used in future practice. FRAT is a validated tool developed as a multidisciplinary intervention to lessen the occurrence of falls and allied injury. The FRAT screening tool has three main sections: falls risk status, the checklist for the risk factors, and the action plan (Stapleton et al., 2009). In Australia, there is no standardized risk assessment for falls since policies are trust-specific. After reflecting on my personal experience, before and after the clinical scenario, it is imperative the FRAT model can be used to conduct assessments in the next PEPs. Moreover, discussions with other healthcare professionals revealed that about 2 out of 3 falls tend to happen at home due to household hazards such as low lighting, slippery surfaces, unsafe footwear, and trip hazards. Falls can be minimized through lifestyle changes, group exercise, modification of the home environment, home exercise, and multi-factorial interventions that include individual risk assessment (Lee et al., 2013). Accordingly, the implementation of the prevention strategies can reduce the occurrence and risks of falls at home and in the community.
Reference List
- Alshammari, SA Alhassan, AM Aldawsari, MA Bazuhair, FO Alotaibi, FK Aldakhil, AA, & Abdulfattah, FW 2018, ‘Falls among elderly and its relation with their health problems and surrounding environmental factors in Riyadh’. Journal of family & community medicine, vol. 25 pp. 29–34. https://doi.org/10.4103/jfcm.JFCM_48_17
- Australian Institute of Health and Welfare 2019, Trends in hospitalised injury due to falls in older people 2007–08 to 2016–17. AIHW Media Release. Available from https://www.aihw.gov.au/reports/injury/trends-in-hospitalised-injury-due-to-falls/contents/table-of-contents. [29 September 2009].
- Australian Institute of Health and Welfare 2018, Older Australia at a glance. Available from https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance [29 September 2009].
- Bolding, DJ & Corman, E 2019, ‘Falls in the Geriatric Patient’. Clinics in Geriatric Medicine, vol. 35, no.1, pp. 115-126.
- Jin, J 2018, Prevention of Falls in Older Adults. Jama, vol. 319, no. 16, pp. 1734.
- Lee, A Lee, KW & Khang, P 2013, ‘Preventing falls in the geriatric population’. The Permanente journal, vol. 17, no. 4 pp. 37–39. https://doi.org/10.7812/TPP/12-119
- Singh, P Khatib, M Elfaki, A Hachach-Haram, N Singh, E & Wallace, D 2017, ‘The management of pretibial lacerations’. Annals of the Royal College of Surgeons of England, vol. 99, no. 8 pp., 637–640. https://doi.org/10.1308/rcsann.2017.0137
- Vieira, ER Palmer, RC & Chaves, PHM 2016, ‘Prevention of falls in older people living in the community’. Bmj, vol. 353, pp. 1-13.
- World Health Organization 2018, Violence and Injury Prevention. Available from from http://www.who.int/violence_injury_prevention/other_injury/falls/en/index.html [29 September 2009].
- Stapleton, C Hough, P Oldmeadow, L Bull, K Hill, K & Greenwood, K 2009, ‘Four-item fall risk screening tool for subacute and residential aged care: The first step in fall prevention’. Australasian Journal on Ageing, vol. 28, no. 3, pp.139-43.