Question

Case Study
The current hospitalization of a 76-year-old client is the result of a fainting spell that occurred
while he was attempting to climb the stairs to his second-story apartment. The client has a
history of two myocardial infarctions and a stroke that affected the right side of his body, leaving
his leg and arm weakened. He is alert and oriented, fiercely independent, and generally
autonomous in his self-care. Although he insists on living alone, his family is close by and visits
him at least once a day to make sure he is eating and to tidy his apartment.
He was admitted to a medical unit for observation and testing. The nurses on the unit
are very concerned about the client possibly falling out of bed and so initiated the fall protection
procedures: lowering the bed, keeping the side rails up, locating the client across the hall from
the nursing station, and providing him with a built-in bed alarm that sounds when he attempts to
get up without assistance. They also talked with the client at length about turning on the call
light when he needs to get up to use the bathroom.
During the first night on the unit, the bed alarm sounded several times and the nurses
found the client attempting to climb over the side rails to get out of bed. The client was
somewhat disoriented but understood the need to use the call light when getting up. He told the
RN on the night shift that he was afraid of becoming trapped and wanted to make sure he could
get up without help when he wanted to do so.
At 3:30 a.m. the bed alarm sounded again and the nurses found the client upside down,
trapped between the side rails and the edge of the bed. After getting him back into bed, they
evaluated him for any injuries and found only a scrape on his right hand. After this incident, the
aide assigned to the unit checked on the client every 15 minutes to make sure he was not trying
to get out of bed by himself. However, the aide was unable to complete her other assigned
tasks. The following morning, the client’s daughter came to visit and told the nurse that her
Catalano Page 2 of 2 Nursing Now 8e Ch01 Case Study
father had been a construction worker. At one point on the job, he had become trapped for
several hours in a concrete building column form before being rescued. Since then, he has had
a strong fear of enclosed spaces and the inability to breathe.

Questions
• What are the key ethical principles involved in this client’s situation?
• What are the options the nurses have for maintaining the client’s safety while at the
same time dealing with his fears?
• What is the major concern regarding the position of the side rails?

• What long-term care issues need to be addressed?

Answer 1

What are the key ethical principles involved in this client’s situation?

Ethics are the moral principles (rules of conduct) that apply to professional actions or activities and guide professional decision making. They are given by professional organizations - what organizations say are right or wrong.

Ethical principles guide nurses in delivering care to their clients. Nurses must adhere to the principles of justice, beneficence, nonmaleficence, accountability, fidelity and veracity, autonomy.

The ethical principles involved in this case are :

Principle of beneficence: It mans as a nurse you are doing good to your client. Here nurse is doing good to the client by taking measures to reduce the risk of injury and falls.

Principle of nonmaleficence: It tells that you do not harm your patient intentionally or unintentionally. In this situation, unintentional harm is occurring to the patient by putting side rails up, so the client has to call nurses when he needs to get up for the bathroom. It means he has to depend on nurses for lowering side rails, while history reveals the client likes autonomous and independent life.

Principle of accountability: It means nurses take responsibility for their actions and are answerable for them. Here nurse is responsible for putting side rails up and other fall prevention measures initiated. She also has the responsibility for the safety and care of the patient. If the patient gets injured in an attempt to climb the side rails nurse is answerable for this action.

Principle of autonomy: It refers to every individual’s right of self-determination, independence and freedom to make their own choices. In this case, there is a decision taken to initiate fall protection interventions that were taken by nurses in anticipation of the risk of falling, but the patient was not asked for or involved in decision making.

What are the options the nurses have for maintaining the client’s safety while at the same time dealing with his fears?

Nurses can maintain their client’s safety and deal with their fears by using therapeutic communication skills. She can help them to remain safe and reduce or even avoid patients or family members' anxiety by carefully listening to the patients, their feelings, concerns, and doubts. Even a simple asking the patient at the onset how they are feeling could keep them from going into relief-behavior mode.

Anxiety can also be reduced by orienting the patient and caregivers to staff, facilities and equipment used for them, for example in this case about side rails, what is the purpose of using them and how they work. Familiarity with the surroundings relieves anxiety.

Another significant factor is involving the patient and caregivers (if possible) in planning the care. Involvement in care will give a sense of autonomy and self-control and patients will be more likely to adhere to the care planned.

Accurate assessment of the client for the risk of falls, including assessment of mental status (if he is afraid or fearful, confused, angry, upset or agitated?) and physical status (respiration, circulation, cleanliness, comfort, dry skin, and bed, etc) to determine the need of restraints.

Alternatives can be more frequent monitoring, reorienting the person, placing the client near an activity hub such as the nursing station, providing frequent reminders to the client to call for help before arising from the bed or chair, using a companion, sitter, etc.

In this case all these issues are especially important due to previous experience of the client caught trapped at the workplace, he is anticipating the same risk of getting trapped when side rails are up and struggling against them.

What is the major concern regarding the position of the side rails?

Bed rails, also known as side rails or cot sides, are widely used to reduce the risk of falls. Side rails sometimes don’t prevent falls and can introduce other risks.

The major concern regarding the position of side rails is that they are positioned on the upper half of the bed, and improperly fitting side rails can even cause death if a person’s neck, chest or limbs become trapped in gaps between the bed rails or between the bed rail and the bed, headboard, or mattress.

Other risks not specific to the position of rails but associated with the use of side rails are:

· rolling over the top of the rail

· climbing over the rail

· violently shaking and dislodging rails

· violent contact with bedrail parts

What long-term care issues need to be addressed?

· Long term issues in the care of clients need for assessment of fainting as he has already had two episodes of myocardial infarction and stroke. There are high chances of risk or complication. So he needs to be carefully evaluated for any cardiac issue.

· He also needs to be addressed for his fear of enclosed space and breathing difficulty. The client's fear and anxiety to side rails were out of proportion and need to be addressed.

· He was climbing upstairs when he got a fainting spell. It indicates that housing conditions also need modification according to his age to ensure a safe and protective environment.

· As he is living alone and due to his age to is more prone to the risk of complications from pre-existing illness and for risk of injuries and accidents.