Case Study: Improving Healthcare Delivery in Nursing

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[. . .] (Kutner, et al., 1992)

There are physical deficits in the elderly that contribute to their frailty in terms of skeletal muscle strength, gait and speed, range of motion in the joints and musculoskeletal flexibility, postural stability, including balance, coordination nd reaction time as well as cardiovascular responsivity." (Kutner, et al., 1992) These conditions are reported to contribute to "significant functional limitations." (Kutner, et al., 1992) These conditions are reported to be such that contribute to significant functional limitations. (Kutner, et al., 1992)

The most prevalent type of injury among older adults is falls and it is stated that 30% of older adults 65 years of age or older fall each year. The number is highest for the oldest in this group and 5% of falls result in fractures with five percent of falls resulting in serious injuries that require medical care. Over 200,000 older adults suffer hip fractures every year as a result of osteoporosis and an increased risk of falls. Falls and other mobility-related issues are stated to be a serious health threat to the functioning of elderly adults. It is stated specifically that falls "are likely to be associated with loss of confidence in the ability to function independently, restriction of physical and social activities and eventual increased dependence." (Kutner, et al., 1992)

Some physical deficits in older adults have been shown to be preventable to some extent. Exercise programs are stated to "retard the rate of age-related bone loss and increase cardiac fitness." (Kutner, et al., 1992) It is reported that one large-scale study of fall prevention showed that "modification of home environment risks and participation in group health education sessions increased appropriate health practices and reduced the risk of falling for elderly persons." (Kutner, et al., 1992)

A clinical trial is an appropriate method for determination of the extent to which physical frailty, functional impairment nd risk of injury among elderly adults could be reduced by appropriate interventions. Such interventions would be designed for the purpose of improvement of physical functioning, such as skeletal muscle strength, mobility, flexibility, and balance, decrease of environmental hazard, and alter risky health behaviors and lifestyles." (Kutner, et al., 1992)

It is stated that a critical element in the evaluation of the effectiveness of the interventions "is being able to consistently assess the quality of life of the subjects." (Kutner, et al., 1992) Quality of life assessments are stated to be based "on a person's own opinion of his or her physical, emotional, and social well-being." (Kutner, et al., 1992) Quality of life is stated to have become a "major criterion for evaluating health and medical interventions." (Kutner, et al., 1992)

Determination of the optimal method of measuring quality of life in clinical trials is a complex issue." (Kutner, et al., 1992) Assessment of life quality among older individual is reported to be difficult and specifically among older adults who are subjects in health promotion intervention studies. (Kutner, et al., 1992) Quality of life is reported to have been viewed "from the outset of trails as an important mediator of compliance and intervention effectiveness as well as an important outcome variable." (Kutner, et al., 1992)

Masud and Morris (2001) state in their study that the most likely causes of falls in elderly persons include those stated in the following table labeled figure 1 in this study

Figure 1

Reasons for falls in elderly

Accident/Environment Related

31%

Gait or balance disorders

17%

Dizziness

13%

Drop Attacks

9%

Confusion

5%

Postural hypotension

3%

Visual Disorder

2%

Syncope

0.3%

Other specified causes

15%

Unknown

5%

Source: Masud and Morris (2001)

It is reported that primary risk factors include the following risks factors as stated in the following table labeled figure 2 in this study.

Figure 2

Primary risk factors for falls in elderly adults

Weakness

Balance Deficit

Mobility Limitation

Gait Deficit

Cognitive Impairment

Impaired ADL

Postural Hypotension

Source: Masud and Morris (2001)

It is additionally reported that there are "potentially over 400 risk factors for falling. The important impact of falls includes significant morbidity, mortality, functional deterioration, hospitalization, institutionalization and expenditure to health and social services." (Masud and Morris, 2001)

Rubenstein and Josephson (2006) state in the work entitled "Falls and Their Prevention in Elderly People: What Does the Evidence Show?" state that identification of effective interventions to prevent falls and fall-related injuries among older adults is a major area of research and policy development in geriatrics."

III. Recommendations for Action

Multifactorial interventions are those that "combine several fall prevention strategies, such as exercise, education, or environmental modification." (Rubenstein and Josephson. 2006) In residential care and nursing home facilities it is reported that "…multifactorial interventions often include prevention strategies for residents (eg, exercise, medication review, hip protectors), fall prevention education for staff, and facility-level environmental modifications On a subacute hospital ward, a multifactorial intervention included a falls risk alert card to identify high-risk patients, a fall prevention information brochure and education sessions for patients, balance exercises, and hip protectors. Fall risk assessment tools are used commonly in institutional settings to identify persons who are at greatest risk for sustaining a fall or fall-related injury, and to isolate specific risk factors that are amenable to intervention." (Rubenstein and Josephson, 2006) There are as well devices that can be used as interventions for falls among the elderly in the nursing home setting in addition to moving patients closer to the nursing station for increasing observation and periodic reassessment of patients following new illnesses which includes lowering side rails and bed height, changes in medication and increasing the nurse-to-patient ratios. (Rubenstein and Josephson, 2006, paraphrased)

Screening tools can be used to assess the risk of patients for falling and are described as "brief…administered by a nurse on admission…usually updated on a regular basis or when there is a change in health status." (Rubenstein and Josephson, 2006) It is reported that upon being identified as a high risk for falling "a nursing care plan usually is developed that includes interventions that are aimed at injury prevention. Such interventions can include indicating on the medical chart and the patient's door that the patient is at a high risk for falls…" (Rubenstein and Josephson, 2006) There is reported to have been a "…major move away from the use of physical restraints because research has shown that the adverse affects of physical restraints on functional status and quality of life outweigh any potential benefit in preventing falls. Specifically, there is evidence to suggest that physical restraints may contribute to falls, injuries, and death." (Rubenstein and Josephson, 2006) Promising strategies for reduction of falls and fall-related injuries in nursing homes is stated to include such as the use of Vitamin D and calcium supplements for enhancing bone and muscle strength and the use of special hip protectors to prevent hip fractures that are due to falling." (Rubenstein and Josephson, 2006) A meta-analysis shows that "the most effective fall prevention strategy used individualized multidimensional risk assessment combined with interventions that were directed toward reducing these risks." (Rubenstein and Josephson, 2006)

References

Clinton, Jeremiah (2011) Osteoporosis is a Major Health Concern for Seniors. Ravalli… [END OF PREVIEW]

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