The patient’s presenting problem is the risk of falls, which has already occurred recently. Unfortunately, multiple persons over 65 are at risk of a similar problem. The chance of falling, as well as fall-related issues, increases with age. Many older adults are afraid of falling, even if they have never fallen. This dread may cause individuals to avoid activities like walking, shopping, or participating in social events. A fall can be caused by a variety of factors. For example, diabetes, cardiovascular disease, or issues with your thyroid, neurotransmitters, feet, or arteries can all influence your balance and cause you to fall. Falling risk factors include age-related muscle loss, balance and gait issues, and blood pressure that drops too low when you get up from lying down or sitting, which is called postural hypotension.
In the present case, the patient is a 73-year-old male who used to get his care at Medical Center in Stroke Rehabilitation in Singapore. For some time, the patient experienced chest discomfort, breathing difficulty, fatigue, and pain in his leg while walking, which caused cramping in the buttocks. The patient has a history of atherosclerosis, which caused an ischemic stroke two years ago and led to muscle strength loss. In the first three months following a stroke, the patient was provided rehabilitation and when experienced the most significant improvement. Moreover, the patient attended and finished an inpatient rehabilitation program during this period. Physical therapy was the most common kind of activity during rehabilitation. The goal of physical therapy is for the stroke patient to relearn simple motor functions, including walking, sitting, standing, and lying down, as well as the process of transitioning from one kind of movement to another. After the therapy, the patient fully recovered the ability to move independently. Regarding the social history, the patient does not intake alcohol and has a supporting family.
However, five days ago, in the morning, the patient fell when looking upward to do repairs in the house. Before the accident, the patient felt dizziness and disorientation. During the fall, the patient became pale and injured his right arm (a strain). After the fall, the patient could not get himself up off the floor, and his wife helped him after she discovered him lying, although the patient could not return to normal activities due to the arm strain. Although it was the first accident of such kind, there is a risk that the patient will fall again.
The pathophysiology of the patient’s condition is primarily related to his atherosclerosis. According to Casolo et al. (2020), poor musculoskeletal health is linked to atherosclerotic vascular disorders. Coronary atherosclerosis is the most frequent coronary artery disease. Its occurrence, as well as the pathophysiological processes by which the illness advances and finally manifests clinically, have been widely researched in the recent and preceding decades. Although not the primary cause of ischemic heart disease, coronary atherosclerosis is the most common. For prognostic reasons, coronary artery disease is regarded as the most crucial symptom of atherosclerosis, being the primary source of ischemia.
Atherosclerosis is now thought to be inflammatory in nature. Several pathways implicated in both adaptive and innate immunity, as well as the breakdown of regulatory processes involved in cell proliferation and differentiation, have been linked to atherosclerosis (Casolo et al., 2020). Thus, a mixture of mechanisms involving the immune system, inflammation, cell differentiation, and proliferation all play a substantial role in the formation, progression, and clinical symptoms of atherosclerosis. The atherosclerotic plaque develops in the vessel’s intima layer. Low-density lipoprotein molecules rapidly aggregate in the vascular endothelium, generating inflammatory and immunogenic stimulation (Casolo et al., 2020). The ensuing immunological response occurs within the artery wall, involving a variety of cells. Thus, atherosclerotic plaques of the patient are caused by competing mechanisms that involve both inflammatory and regenerative activities.
Cardiovascular illness is linked to an increased risk of falling. However, the frequency and particular hazards of falls in individuals with the cardiovascular disease remain unknown, and falls are potentially underdiagnosed in clinical practice. Falls might be are caused by a variety of factors, including muscular weakness, decreased physical function during transition phases (sitting to standing, moving), and imbalance while standing. The cardiovascular system is accountable for heart rate acceleration with changes in posture, peripheral blood supply, and blood pressure stability against gravity variations when standing, all of which are required for processes of balance aided by the central nervous system. Thus, deficiencies in functional pathways that lead to falls may result from cardiac problems before they emerge as chronic cardiovascular disease.
Moreover, the fact that the patient fell while looking upward signifies that he might have vertebrobasilar insufficiency. When circulation of blood to the back of the brain decreases or stops, this is referred to as vertebrobasilar insufficiency. Vertebrobasilar insufficiency can cause trouble swallowing, dizziness, and numbness since this portion of the brain regulates movement and balance. In terms of the pathogenesis of falling, insufficient blood supply to the balance center in the brain can produce postural hypotension and vertigo, which can lead to falling (Aydın, 2021). Vertebrobasilar insufficiency is a common cause of vertigo in the geriatric population. Vertigo caused by vertebrobasilar insufficiency has a sudden onset, can last several minutes and is typically accompanied by vomiting and dizziness. Multiple symptoms, such as headache, loss of sight, disorientation, numbness, paralysis, or oropharyngeal malfunction, are common. The root cause of vertebrobasilar insufficiency is generally atherosclerosis of the subclavian, spinal, or basilar arteries.
Finally, the paleness during and after the fall can indicate a vasovagal attack. The most frequent type of reflex fainting is a vasovagal episode or vasovagal syncope. Reflex syncope refers to any kind of syncopal episode induced by a breakdown in blood pressure autoregulation, resulting in a reduction in arterial pressure and a brief loss of consciousness (Poothrikovil & Al Mashaikhi, 2021). The processes behind this are complicated, and they can cause both a drop in cardiac output and a fall in vascular tone. In other terms, vasovagal syncope occurs when the body overreacts to particular stimuli, such as seeing blood or experiencing significant emotional distress. The vasovagal syncope trigger produces an abrupt dip in both heart rate and blood pressure. The possible connection between cardiovascular disease and increased risk of falls and fractures might be related to the same pathophysiological signaling systems.
The findings regarding the patient include vital signs as follows: the temperature is 36.8 degrees; respiration is 16 per minute; the pulse is 110 per minute; blood pressure is 90/60 mm Hg. As was mentioned, the patient history includes atherosclerosis and ischemic stroke, while the investigation demonstrated no problems except for the difference in blood pressure during lying and standing, which could be explained by vertebrobasilar insufficiency and poor cardiovascular health.
The findings could be considered abnormal since a high heart rate and low blood pressure indicate hypotension causing falling. Namely, the optimal blood pressure for seniors is currently 120/80 (systolic/diastolic), which is also the optimal blood pressure for younger persons (Cremer et al., 2020; Shaw et al., 2019). In turn, 90/60 mm Hg or below is deemed inadequate (hypotension). Exceedingly low blood pressure can induce dizziness or fainting, as well as an increased risk of falling, which is the case of the patient. For persons above the age of 15, a healthy resting heart rate is between 60 and 100 beats per minute, while the patient’s rate is 110. Low blood pressure and a rapid pulse indicate that the organism is not receiving enough oxygen. When the blood pressure lowers, the heart rate rises, and blood flow in other regions of the body contract to help continue to keep stable. Blood pressure will decline if the heart rate does not rise sufficiently or the blood vessels do not contract sufficiently to maintain blood pressure.
Furthermore, the patient’s changing blood pressure is related to vertebrobasilar insufficiency. Poor blood flow through the back circulation of the brain, which is fed by the two vascular systems that join to create the basilar artery, is referred to as vertebrobasilar insufficiency. The vertebrobasilar vasculature, also known as the posterior circulation, nourishes the brainstem, thalamus, hippocampus, cerebellum, occipital, and medial temporal lobes, among other locations (Pirau & Lui, 2022). The major cause of vertebrobasilar illness is atherosclerosis, sometimes known as artery stiffening. A stroke can develop as a result of a vertebral or basilar artery obstruction or an embolization that settles closer to the brain.
Furthermore, several therapeutic interventions seem to be necessary in the case of the patient. Since the patient has vertebrobasilar insufficiency and a history of stroke, he should try to reduce their cholesterol levels through diet and exercise on a regular basis. Medication may also be prescribed to improve blood pressure, lower cholesterol levels, and inhibit platelet activity. Moreover, the site of the plaque generating the vertebrobasilar insufficiency will define whether the artery can be repaired.
Next, further fall prevention implies maintaining a secure living environment. The nurses in elder care should instruct on the following recommendations for avoiding falls at home. The family of the patient should remove any debris from hallways and staircases, especially stacks of old papers and magazines. Next, falls can be caused by house fittings, which can lead to back discomfort and other ailments. The family should examine each room and hallway for loose carpeting, slippery rubber matting, or wood planks that stick alert. Then, they must repair, eliminate, or replace such objects for more successful fall prevention. Furthermore, it is helpful to install railings and grab bars since these safety gadgets can help the patient to travel up and down stairs, get on and off the toilet, and step in and out of the bath without harming himself.
The latest evidence-based nursing management for the risk of falls provides several insights. As such, most fall prevention programs prefer clinically driven plan formulation and execution. However, according to new research, patient fall evaluations must transition from clinician-centric to patient-centric (Dykes et al., 2020). The authors highlight that nurses who connect with patients understand their needs better and propose better inpatient care. Hence, to prioritize the patient’s care needs, it is necessary to communicate during the visits to the hospital. When patients are older, it is critical to acquire a good history, which includes information on social situations and lifestyle, in addition to family and medical history. Such an interview was included in the treatment plan, which addresses the prioritization of the client’s needs. Due to the varying demands of elderly patients, different interviewing strategies may be required. The program suggests obtaining an entire history of current and previous issues, family history, medicines, and socioeconomic conditions.
There is additional evidence that inpatient falls prevention treatments that include patient education can minimize falls and accompanying injuries, including bruises, puncture wounds, or fractures. The design, style of delivery, and level of educational design all have an impact on the outcomes (Dykes et al., 2020). As a result, the treatment plan includes several essential recommendations that the family can make to make the patient’s house safer and avoid falls. For example, removing tripping risks and adding grab bars in the bathroom to make the home safer. Moreover, research suggests that better outcomes and less stress for patients can be achieved through patient education instead of hospitalization (Heng et al., 2020). This aspect is especially significant for the case of the patient. Keeping the body and mind busy might help the patient stay awake when on the move. The more the patient can sustain an active and well-balanced lifestyle, the less these hazards will affect him.
The knowledge of the nursing management of falls will help me recognize patients at risk and prevent accidents and injuries in my healthcare unit. Falls are prevalent among the elderly and are associated with significant morbidity and death. Falls result in injuries, fractures, a loss of self-esteem and independence, despair, and even death. Due to nursing’s growing role in caring for older persons, embracing fall prevention knowledge for me is valuable for spreading awareness of the importance of fall prevention. As a result, I will apply this information to community-dwelling older individuals and try to expand access to fall risk analysis for older adults, as well as manage the issue better in my unit.
References
Aydın, E. (2021, January 1). Vertebrobasilar blood flow in geriatric patients with hip fractures. MNJ (Malang Neurology Journal), 7(1), 20–23.
Casolo, G., Del Meglio, J., & Tessa, C. (2020). Epidemiology and pathophysiologic insights of coronary atherosclerosis relevant for contemporary non-invasive imaging. Cardiovascular Diagnosis and Therapy, 10(6).
Cremer, A., Boutouyrie, P., Laurent, S., Gosse, P., & Tzourio, C. (2020). Orthostatic hypotension: A marker of blood pressure variability and arterial stiffness: A cross-sectional study on an elderly population: The 3-City study. J Hypertens, 38(6). Web.
Dykes, P. C., Burns, Z., Adelman, J., Benneyan, J., Bogaisky, M., Carter, E., Ergai, A., Lindros, M. E., Lipsitz, S. R., Scanlan, M., Shaykevich, S., & Bates, D. W. (2020). Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries. JAMA Network Open, 3(11), e2025889. Web.
Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2020). Hospital falls prevention with patient education: a scoping review. BMC Geriatrics, 20(1).
Pirau, L., & Lui, F. (2022). Vertebrobasilar insufficiency. NIH. Web.
Poothrikovil, R. P., & Al Mashaikhi, T. (2021). Vasovagal syncope in epilepsy monitoring unit: A case report and review. The Neurodiagnostic Journal, 61(3), 132–143.
Shaw, B. H., Borrel, D., Sabbaghan, K., Kum, C., Yang, Y., Robinovitch, S. N., & Claydon, V. E. (2019). Relationships between orthostatic hypotension, frailty, falling and mortality in elderly care home residents. BMC Geriatrics, 19(1).
