Elderly Patient with Polypharmacy and Fall Risk
Mrs. L is an 82-year-old female admitted to the medical unit after a fall at home. She has a history of atrial fibrillation, heart failure, hypertension, and osteoarthritis. Her medications include warfarin 5 mg daily, furosemide 40 mg daily, metoprolol 25 mg twice daily, lisinopril 10 mg daily, and acetaminophen 650 mg every 6 hours as needed. She lives alone and admits to occasional dizziness when standing up. Her vital signs are: BP 102/58 mmHg, HR 88 bpm and irregular, RR 18, Temp 36.8°C, SpO2 96% on room air. Labs: INR 4.2, potassium 3.2 mEq/L, sodium 134 mEq/L, BUN 28 mg/dL, creatinine 1.4 mg/dL. She has a bruise on her right hip and complains of pain when moving. The nurse notes that she is slightly confused and has dry mucous membranes.
1. Identify the factors contributing to Mrs. L's fall risk and explain how each increases her risk.
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Factors contributing to Mrs. L's fall risk include: 1) Orthostatic hypotension likely due to furosemide, lisinopril, and metoprolol, as evidenced by low BP (102/58) and dizziness on standing. 2) Electrolyte imbalance (hypokalemia K 3.2) which can cause muscle weakness and cardiac arrhythmias. 3) Anemia or bleeding risk from warfarin with elevated INR (4.2), increasing risk of bleeding and potential dizziness. 4) Cognitive impairment (slight confusion) possibly due to electrolyte imbalance, infection, or medication effects. 5) Dehydration (dry mucous membranes, elevated BUN/creatinine ratio) which can cause weakness and orthostasis. 6) Pain and mobility issues from osteoarthritis and the recent fall. 7) Polypharmacy with multiple medications that can cause dizziness or hypotension. Each factor impairs her ability to maintain balance and increases the likelihood of another fall.
2. What are the priority nursing interventions to ensure Mrs. L's safety and manage her medications?
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Priority interventions include: 1) Implement fall precautions: keep bed low, use bed alarm, assist with ambulation, provide non-skid footwear, and ensure call light within reach. 2) Monitor vital signs including orthostatic BP (lying, sitting, standing) and heart rate. 3) Monitor INR and assess for bleeding (bruising, gums, urine, stool). 4) Administer medications cautiously: hold warfarin and notify provider due to INR 4.2; monitor potassium and replace as ordered; assess for digoxin toxicity (though not on digoxin, monitor for signs of heart failure). 5) Encourage hydration if not contraindicated, and monitor intake/output. 6) Assess pain and provide acetaminophen as needed. 7) Orient patient to surroundings and reorient as needed. 8) Collaborate with physical therapy for gait and balance training. Rationale: These interventions address the multifactorial causes of falls and prevent injury, while managing medication safety.