Question

Thad Lutz is a 54 y.o. admitted for a deep vein thrombosis (DVT) of the left leg.Five days ago, he had surgery for a left ruptured Achilles tendon sustained during a local 10K race. He has never been hospitalized prior to his outpatient surgery. Post-operative instructions include no weight-bearing on the left leg for 4 weeks. He has crutches but admits instead to “hop-ping around at home holding onto things” on his right leg. He has an IV line via infusion pump for heparin therapy for anticoagulation. He still requires oral pain medication for post-operative pain compounded by the pain of the DVT. He is on complete bedrest with allowed use of a bedside commode (BSC).

1. As part of the routine admission assessment, a Morse Fall Scale (At end of document) is completed. Explain the variables that pertain to Mr. Lutz for this admission.

2. After reviewing the Medicare “never events,” which ones could present a risk to Mr. Lutz during this hospitalization?

3. The nurse identifies a potential diagnosis of Risk for falls related to imbalanced gait with an outcome of no episodes of falls during hospitalization. The nurse discusses the diagnosis with Mr. Lutz, but he does not view falling as a hazard. He states, “I am young and in great shape and getting around on one leg works just fine for me.” How would you approach this perspective so that a collaborative plan of care can be implemented with this patient?

Despite agreement on measures to ensure his safety, Mr. Lutz continues to “ambulate” to the bathroom without assistance instead of using the BSC. He uses the infusion pump and its rolling stand for balance and tells the nursing assistant that he does not want to bother anyone when he can figure it all out on his own. The nursing assistant tells the nurse, “That man needs to be tied down before he hurts himself.”

4. With the knowledge that Mr. Lutz still needs pain medication every 4 to 6 hours, would any kind of restraint be appropriate in this situation? Explain your rationale.

5. Recognizing that pain medications can impair cognition, discuss the interventions that you can put in place to avoid the need for restraints for this patient.

6. It is decided to implement the use of a bed exit alarm for Mr. Lutz. How will this device help decrease the incidence of falls for this patient?

7. The nursing assistant tells you, “I don’t know how to use one of those.” How would you demonstrate and instruct the assistant on how to implement a bed exit alarm?

8. What important teaching points should be communicated to Mr. Lutz?

Mr. Lutz has recovered from his DVT, is regulated on his warfarin sodium (Coumadin) therapy, an oral anticoagulant medication, and is ready for discharge. Dis-charge instructions are completed with him and his wife regarding medications, pain control, and ambulation parameters. His wife states, “I sure hope he behaves. I bet he didn’t tell you he fell several times at the house trying to hop around on his good foot.”

9. Discuss six key points with Mr. and Mrs. Lutz concerning the prevention of falls in the home.

10. In addition, Mrs. Lutz explains that her elderly father-in-law lives with them. She worries about his ability to get around safely and asks you, “How can I know if Dad is at risk for falls? He’s as stubborn as his son!” Explain the “Get Up and Go Test” to Mrs. Lutz.

Answer 1

Explain the variables that pertain to Mr. Lutz for this admission.

1) he is having left leg DVT as well as achilles tendon rupture

2) he is on iv anticoagulant

After reviewing the Medicare “never events,” which ones could present a risk to Mr. Lutz during this hospitalization?

History of fall and trauma as he is hoping on one leg.

Also nosocomial infection

How would you approach this perspective so that a collaborative plan of care can be implemented with this patient?Explain the variables that pertain to Mr. Lutz for this admission.

He is on bed rest, care plan is he should be using bed pan for toilet needs, avoid over movements as it could lead to disloadgement of the thrombus.

Or he should seek help of a nursing assistant while going to washroom.

would any kind of restraint be appropriate in this situation? Explain your rationale.

Yes, if he is adamant and going on hoping in the ward restraining will be better option according to medicare if the patient sustain a fracture or injury following fall or trauma in hospital will not be financed.

How will this device help decrease the incidence of falls for this patient

These beds put alarm once the patient on it goes of his own without assistance

Discuss six key points with Mr. and Mrs. Lutz concerning the prevention of falls in the home

1.Stay physically active

2. Wear proper shoe size

3. Avoid leaving anything on the floor carelessly

4.find out the side effects of the medication he is taking

5.take adequate sleep

Explain the “Get Up and Go Test” to Mrs. Lutz

The Up and Go test is a simple test to assess a person's mobility and balance. It measures the time Mr Lutz take to rise from a chair, walk three meters, turn around, walk back to the chair, and sit down.