Purpose
To provide students with the opportunity to assess, plan, prioritize, and implement
nursing care for a patient at high risk for falls and pressure ulcer development.
Overview
Lisa Rae, a 78-year-old Caucasian female, was admitted through the emergency
department Monday at 0900 with complaints of continued dizziness following a fall at
her assisted living facility. Mrs. Rae has a history of falls and hypertension, and takes
medication to control her blood pressure. While in the emergency department, Mrs. Rae
was found to be hypotensive and IV fluids were initiated. She has experienced urinary
incontinence since admission. The scenario takes place on Monday at 1200. During this
scenario, students will have the opportunity to assess, plan, prioritize, and implement
nursing care for a patient at high risk for falls and pressure ulcer development.
Recommended scenario time limit: 20-30 minutes
The identifiable actions that the student is expected to perform during this scenario are based on
the nursing process and have been organized according to the Quality and Safety Education for
Nurses (QSEN) quality and safety competencies.
The student will:
Provide individualized patient-centered care by:
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Conducting a fall risk assessment
Conducting a pressure ulcer risk assessment
Utilizing therapeutic communication
Providing individualized teaching
Developing an individualized plan of care
Function competently as a member of the health care team by:
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Independently initiating care within nursing scope of practice
Implement best clinical practices by:
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Recognizing abnormal findings:
 High fall risk
 Moderate pressure ulcer development risk
 Wet urinary incontinence pad
Prioritizing and implementing appropriate interventions:
 Developing and implementing a fall prevention plan
 Developing and implementing a pressure ulcer prevention plan
 Providing incontinence care
Integrating current evidence-based research into clinical decision making
Promote safety for patient, self, and others by:
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Ensuring patient safety
Assessing and maintaining a safe environment
Identify factors that influence quality of care by:
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Evaluating patient's response to interventions
Evaluating effectiveness of communication and teaching
Utilize information technology to support patient care by:
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Accessing patient data including prior care
Documenting care in the electronic medical record
Physiologic State
T = 98.2 F (36.8 C)
BP = 92/74
P = 86
RR = 18
O2 Sat = 98% (room air)
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Heart sounds: Regular
Lung sounds: Clear
Abdominal sounds: Present
Pulses: Normal (2+)
Pain: 3/10
Mrs. Rae asks, "Sweetie, can you put these
side rails down so that I can get out of bed
when I need to go to the bathroom?"
Situation/Transition
Mrs. Rae is supine in bed with the head of bed at 60 degrees. She requests that the side rails be
lowered so that she can get up to go to the bathroom independently and expresses embarrassment
related to her current urinary incontinence.
Recommended time to advance to Phase II: 10-15 minutes
Expected Student Performance
1.
2.
3.
4.
Conducts initial and focused assessments.
Conducts a fall risk assessment using the Morse Fall Scale.
Conducts a pressure ulcer risk assessment using the Braden Scale.
Recognizes abnormal findings:
o High fall risk
o Moderate pressure ulcer development risk
o Wet urinary incontinence pad
5. Treats patient with dignity and respects her independence.
6. Utilizes therapeutic communication to provide education and address patient concerns.
Physiologic State
T = 98.4 F (36.9 C)
BP = 96/72
P = 82
RR = 18
O2 Sat = 97% (room air)
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Mrs. Rae states, "I really can take care of
myself pretty well. I'm strong and able to
get around. I don't want to bother you. You
have plenty to do already."
Situation/Transition
Until a fall prevention plan is developed and implemented, Mrs. Rae continues to insist that she
is able to get out of bed and ambulate independently.
Recommended time to advance to Phase III: 10-15 minutes
Expected Student Performance
1.
2.
3.
4.
5.
Provides incontinence care.
Develops fall prevention plan with patient.
Initiates fall prevention measures.
Develops pressure ulcer prevention plan with patient.
Initiates pressure ulcer prevention measures.
Physiologic State
If fall and pressure ulcer prevention measures (including incontinence care) are initiated:
T = 98.2 F (36.8 C)
BP = 94/72
P = 82
RR = 16
O2 Sat = 98% (room air)
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Mrs. Rae states, "Thank you for watching
out for me. I suppose everyone needs a little
help sometimes."
If pressure ulcer prevention measures (including incontinence care) are NOT initiated:
T = 98.4 F (36.9 C)
BP = 96/78

Mrs. Rae states, "My bottom is sore. I hope
that being wet has not caused a rash down
P = 88
RR = 20
O2 Sat = 97% (room air)
there."
If fall prevention measures are NOT initiated:
T = 98.4 F (36.9 C)
BP = 96/78
P = 88
RR = 20
O2 Sat = 97% (room air)

A loud crashing noise, signaling that Mrs.
Rae has fallen, occurs when the student
leaves the room.
Situation/Transition
If fall and pressure ulcer prevention measures are initiated, Mrs. Rae will demonstrate
understanding and will agree to cooperate with the plan of care.
If pressure ulcer prevention measures are not initiated, Mrs. Rae will complain of skin irritation
in the sacral area.
If fall prevention measures are not initiated, a loud crashing noise, signaling that Mrs. Rae has
fallen, occurs when the student leaves the room.
Expected Student Performance
1. Evaluates patient's response to interventions.
2. Documents all findings, interventions, and patient responses.
Debriefing is an integral part of every quality simulation. The best debriefing experience allows
the students to discuss, digest, and discover. The facilitator's role in debriefing is to guide the
discussion and to keep the conversation on topic. However, the facilitator's comments about the
simulation should be kept to a minimum. The student participants should provide the majority of
the discussion.
Phase 1: Student Reaction
Simulation experiences can be very emotional. The reaction phase allows the students to vent
their feelings so that further discussion and learning can occur.
Examples of appropriate facilitator comments include:
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"Tell us about what you experienced during the simulation."
"Please share some initial thoughts about the case."
Phase 2: Student Reflection
During the reflection phase, the facilitator asks the students to reflect on their decision-making
process and on the actions taken during the simulation. Observers can comment using the
Observer Evaluation Rubric.
Examples of appropriate facilitator comments include:
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"Describe your thought process as you made decisions about _______."
"What patient response (or assessment) led you to _______?"
"Did the patient respond the way you thought he/she would?"
Phase 3: Responsive Inquiry
Facilitators can use the Performance Checklist to identify and guide areas for inquiry.
Examples of appropriate facilitator comments include:
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"I noticed _______. What did you think about that?"
"I am wondering why _______. Would you describe more about this?"
Phase 4: Integration
During the integration phase, the facilitator assists the students to apply theoretical content to the
simulation as well as to anticipate the transfer of knowledge to the clinical setting.
Linking Theory to Practice:
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Use the debriefing questions designed for the specific scenario.
Assimilation:
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"How will this experience influence your patient care?"
"What will you now do differently to prepare for clinical?"
Phase 5: Closure
With 1-2 minutes left, ask for any final thoughts on the scenario or the simulation experience.
End with positive comments, such as:
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"I really appreciate how you _______."
"It seems like this was a really good learning experience."
"I really appreciate everyone's participation."
1. Mrs. Rae is at high risk for falls. Identify the appropriate fall risk measures that should be
implemented for this patient.
Possible Answers
Fall prevention measures that should be implemented include:
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Call light within reach
Side rails up (2 or 3, but not 4)
Bed brakes on
Bed alarm
Reorientation to environment and situation
Relocate to room closer to nursing station
Frequent visual checks
Scheduled toileting routine
Request family or friend to stay with patient
Place bedside tables and belongings close to patient
Remove clutter from area
Rationale
p. 816: Assessment of a patient's fall risk is essential in determining specific needs and
developing targeted interventions to prevent falls. The nurse begins by asking if the patient has a
history of falls. Fall risk is a nurse-sensitive outcome, meaning that there will most likely not be
an order in the medical record by the provider to complete fall risk assessment and implement
interventions. Fall prevention is under the nursing domain and is based on nursing-specific
interventions.
2. How is evidence-based practice applied to fall risk prevention?
Possible Answers
Reducing the risk of patient harm resulting from falls is a National Patient Safety Goal.
Rationale
p. 820: In January 2003, The Joint Commission (TJC) established National Patient Safety Goals
in an effort to reduce the risk of medical errors. These evidence-based recommendations require
health care facilities to focus their attention on a series of specific actions. Data on the
achievement of the goals will be made public each year. TJC announces new goals each year in
July.
Remediation Reading Assignment
3. What is Mrs. Rae's Braden risk score? Identify the appropriate safety precautions that
should be implemented for this patient.
Possible Answers
Mrs. Rae's Braden risk score:
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Sensory perception = 3
Moisture = 2
Activity = 3
Mobility = 2
Nutrition = 2
Friction and shear = 2
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Total Score = 14
Safety precautions that should be implemented:
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Use support surface (pressure redistribution surface)
Schedule a toileting routine
Apply barrier ointment after each episode of incontinence
Reposition patient using a drawsheet and lifting off surface
Position patient at a 30-degree lateral turn and limit head elevation to 30 degrees
Establish individualized turning schedule
Provide adequate nutritional and fluid intake
Consult dietician for nutritional evaluation
Rationale
pp. 1288, 1301: A variety of factors predispose a patient to pressure ulcer formation. These
factors are often directly related to disease. Similarly to prevention of falls, skin breakdown
prevention is a nurse-sensitive outcome. Skin assessment and prevention of pressure ulcer
formation is under the nursing domain and is based on nursing-specific interventions.
4. How is evidence-based practice applied to skin breakdown prevention?
Possible Answers
Prevention of health care-associated pressure ulcers is a National Patient Safety Goal.
Rationale
p. 820: In January 2003, The Joint Commission (TJC) established National Patient Safety Goals
in an effort to reduce the risk of medical errors. These evidence-based recommendations require
health care facilities to focus their attention on a series of specific actions. Data on the
achievement of the goals will be made public each year. TJC announces new goals each year in
July.
5. How might the health care team best work together to prevent Mrs. Rae from
experiencing another fall?
Possible Answers
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The nurse can delegate safety-related interventions to assistive personnel, such as
certified nursing assistants.
The plan is developed by the registered nurse and communicated to other care providers
for assistance in implementation.
o Develop a plan for frequent visualization of patient
o Develop a repositioning schedule
o Develop a toileting schedule
The patient's risk assessment, nutritional intake needs, and need for barrier ointment
should be communicated to all team members.
1. Risk for injury related to impaired mobility and medication side effects
Patient Goal
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The patient will not experience another fall or injury during her hospitalization.
The patient will use call light to obtain assistance when getting out of bed.
Text Reference:pp. 824-830
2. Risk for impaired skin integrity related to impaired mobility and incontinence
Patient Goal
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The patient's skin will remain without redness or breakdown over pressure points during
her hospitalization.
The patient will verbalize understanding of the importance of maintaining dry skin and
linens.
The patient will notify nursing staff immediately if her skin becomes wet.
Text Reference:pp. 1288-1291
1. Fall prevention measures
Key Points
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Use of call light
Importance of calling for help when getting out of bed
Time and frequency of nursing rounds
Time and frequency of toileting schedule
Importance of non-skid socks
Removal of clutter from room
Location of patient care items within close proximity
Text Reference:pp. 816-820, 830
1. Developmental Stage
Old age
Erickson psychosocial development stage: Integrity versus despair
Key Points
Older adults often:
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Experience physical and social losses
Engage in retrospective life appraisal
Mrs. Rae has articulated that autonomy is very important to her. This hospitalization may
interrupt her desired autonomous state and may affect her self-concept.
Text Reference:p. 140
2. Gerontologic Considerations
Older adults and falls
Key Points
Physiologic changes in the older adult can increase the risk for falls and injury from falls.
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Muscle strength and function decrease, joints become less mobile, bones are brittle due to
osteoporosis, postural changes are common, and range of motion is limited.
Voluntary and automatic reflexes slow, the ability to respond to multiple stimuli
decreases, and sensitivity to touch is decreased.
Text Reference:pp. 816, 828
Reference
Edelman and Mandle: Health Promotion Throughout the Life Span, 7th Edition, St. Louis, 2010,
Mosby
1. Family life cycle: Family in later life
Key Points
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Accepting shift of generational roles
Making room for wisdom and experience of older adults
Dealing with loss of spouse, siblings, and other peers
Preparing for own death
Reviewing life
Maintaining functioning in the face of physiological decline
1. A nurse is caring for a patient who has recently fallen at home. What interventions can the
nurse incorporate into the plan of care to reduce the potential for falls while the patient is
hospitalized?
Correct answer(s):
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Place disoriented patients in rooms near the nurses' station
Maintain close supervision of confused patients
Keep call light within reach and ensure that the patient understands how to use it
Remove clutter from bedside tables, hallways, bathrooms, and grooming areas
Leave one side rail up and one down to provide a source of support
Place bath mats or nonskid strips on bathtub or shower stall floors
Encourage use of properly fitting shoes or slippers with a nonskid surface
2. A patient's family has asked the nursing staff if the use of restraints is a consideration for their
family member who has been trying to get out of bed without assistance and is at high risk for
falls. List the potential complications associated with the use of restraints.
Correct answer(s):
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Pressure ulcers
Constipation
Pneumonia
Urinary and fecal incontinence
Urinary retention
Contractures
Nerve damage
Circulatory impairment
Reduced self-esteem
Humiliation
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Fear
Anger
3. Older adult patients who are hospitalized are at risk for falls. List the issues associated with
hospitalization that may result in a patient's fall.
Correct answer(s):
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Confusion
Multiple medical problems
Medications
Immobility
Urinary urgency
Age-related sensory changes
Postural instability
Unfamiliar environment
Lisa Rae was found to be hypotensive in the emergency department. List some factors that may
influence blood pressure.
Correct answer(s):
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Age
Stress
Ethnicity
Gender
Daily variation
Medications
Activity
Weight
Smoking
2. Lisa Rae experienced a fall prior to coming to the hospital. She is 78 years old. What changes
in the body associated with aging may increase an older adult's risk for having an accident?
Correct answer(s):
Musculoskeletal changes
Decreased strength
o
o
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Decreased flexibility
Decreased range of motion
Nervous system changes
o Slowed reaction time
o Reduced ability to respond to multiple stimuli
Sensory changes
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o Alterations in vision and hearing
Genitourinary changes
o Increased incidence in nocturia
o Increased episodes of incontinence
3. Nocturia and incontinence may place the older adult patient at risk for falls. Describe the
interventions that may be implemented to manage these problems in the older adult patient.
Correct answer(s):
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Providing toileting at least every 3 hours
Scheduling diuretics to be administered in the morning
Offering assistance as needed
Providing adequate lighting to patients when ambulating