Falls and injuries resulting from them are significant problems in older people. Taylor et al. (2018) note that fall-related injuries can lead to such severe consequences as serious illness, disability, or even death. Falls in old age are multifactorial, resulting from a complex interplay of internal and external causes. Internal causes are personality-based and include muscle weakness, gait and balance disorders, decreased vision and hearing, postural hypotension, fear of falling, and such chronic conditions as arthritis, stroke, diabetes, dementia, urinary incontinence, and Parkinson’s disease (Taylor et al., 2018, p. 758). In turn, external causes include environments not adapted for an aging population, including narrow steps, slippery floors, lack of handrails, and inadequate lighting, as well as the use of psychoactive drugs and the misuse of assistive devices such as canes and walkers. These causes can lead to falls and fractures, adversely affecting an older adult’s health and quality of life. It is vital to be aware of this and take preventive measures in time.
One of the areas of interaction of the staff of a medical institution, including a nurse, with elderly patients, is the assessment of the risk of falls. Hendrich II fall risk model is an appropriate tool for assessing the risk of falls among the elderly. It involves assessing risk factors and conducting a get up and go test: “Rising from a chair.” During estimating risk factors, such aspects as confusion, disorientation, impulsivity, symptomatic depression, dizziness, as well as the use of antiepileptic drugs and benzodiazepines are evaluated (Hendrich et al., 2020, p. 2). Notably, the male gender is also a risk factor. In turn, the test evaluates a person’s ability to get up from a chair and walk. The patient’s ability to get up from a chair and go is rated from 0 to 4 points. There may be such results that the patient can rise in one movement without losing balance, with one push-up attempt, multiple successful attempts, or cannot rise without assistance. Patients receiving a score of 5 or higher have a high risk of falling. Thus, the Hendrich II fall risk model is an effective tool for determining the risk of falling in adult patients, which nurses should use.
Hendrich, A. L., Bufalino, A., & Groves, C. (2020). Validation of the Hendrich II Fall Risk Model: The imperative to reduce modifiable risk factors. Applied Nursing Research, 53, 151243.
Taylor, C., Lynn, P., & Bartlett, J. (2018). Fundamentals of nursing: The art and science of person-centered nursing care (9th ed.). Wolters Kluwer.