Complete the Fall Risk and Cognition Assessments Case Study, including the Hendrich II Fall Risk Assessment available in the Resources folder.

Complete the Mini-Cog screening (see Borson, n.d., in the Resources section) and the Pittsburgh Sleep Quality Index (PSQI; see Buysse, Reynolds, Monk, Berman, & Kupfer, 1989, in the Resources section) to develop a comprehensive assessment for Mrs. L.’s risk of falling.

Develop a one-paragraph summary describing Mrs. L.’s risk for falls.

Create one goal for each category.

Resources:

Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals. Tool 4B: Staff roles. Retrieved from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool4b.html

Agency for Healthcare Research and Quality. (2017). Recent research findings suggest practice recommendations for preventing falls in hospitalized patients. Retrieved from https://www.ahrq.gov/chain/practice-tools/practice-guidelines/recent-research-findings.html

Borson, S. (n.d.) Mini-Cog screening for cognitive impairment in older adults. Retrieved from https://mini-cog.com/

Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index (PSQI). Retrieved from https://www.sleep.pitt.edu/instruments/ (Links to an external site.)

Hendrich, A. (2016). Fall risk assessment for older adults: The Hendrich II Fall Risk model. Try This, 8. Retrieved from https://hign.org/consultgeri/try-this-series/fall-risk-assessment-older-adults-hendrich-ii-fall-risk-model (Links to an external site.)

The Joint Commission. (n.d.). Joint Commission requirements relevant to falls. Retrieved from https://www.jointcommission.org/assets/1/6/SEA_55add_falls_requirements.pdf

The Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_55.pdf

Panel on Prevention of Falls in Older Persons, American Geriatrics Society, & British Geriatrics Society. (2010). Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons and recommendations. Retrieved from geriatricscareonline.org/ProductAbstract/updated-american-geriatrics-societybritish-geriatrics-society-clinical-practice-guideline-for-prevention-of-falls-in-older-persons-and-recommendations/CL014

Quigley, P., Lunsford, B., Wilson, L. D., Wexler, S. S., D’Amico, C. O., & Hester, A. L. (2015). Focus on falls prevention [Supplemental material]. American Nurse Today, 10(7), 27–39. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2015/07/ant7-Falls-630_FULL.pdf

SAMPLE SOLUTION

PITTSBURGH SLEEP QUALITY INDEX (PSQI)

INSTRUCTIONS: The following questions relate to your usual sleep habits during the past month only.

Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.

1. During the past month, when have you usually gone to bed at night?

USUAL BED TIME _  _2300h  _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _

• During the past month, how long (in minutes) has it usually take you to fall asleep each night? NUMBER OF MINUTES 90                                                                                                                          _

• During the past month, when have you usually gotten up in the morning?

USUAL GETTING UP TIME _   _  _0330h   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _

• During the past month, how many hours of actual sleep did you get at night? {This may be different than the number of hours you spend in bed.)

HOURS OF SLEEP PER NIGHT 3 hours                                                                                      _

INSTRUCTIONS: For each of the remaining questions, check the one best response.

Please answer all questions.

• During the past month, how often have you had trouble sleeping because you…

Not during the       Less than           Once or        Three or more past month       once a week      twice a week      times a week

• …cannot get to sleep within 30 minutes            □       □        □        □

{b)… wake up in the middle of the night or

early morning

□        □        □        □

(c)  …have to get up to use the bathroom               □       □        □        □

{d   …cannot breathe comfortably                           □        □        □        □

• …cough or snore loudly                                  □        □        □        □
• …feel too cold                                                □        □        □        □
• …feel too hot                                                  □        □        □        □

{h) …had bad dreams                                           □        □        □        □

• …have pain                                                    □        □        □        □
• Other reason(s), please describe

□        □        □        □

How often during the past month have you had trouble sleeping because of this?

Very good   6. During the past month, how would you rate your sleep quality overall?                             □	Fairly good   □	Fairly bad   □	very bad   □
Not during the	Less than	Once or	Three or more
past month	once a week	twice a week	times a week
7. During the past month, how often have
you taken medicine (prescribed or “over the counter”) to help you sleep?                   □ 8. During the past month, how often have	□	□	□
you had trouble staying awake while driving, eating meals, or engaging in social activity?          □	□	□	□
No problem	Only a very	Somewhat of	Avery
at all	slight problem	a problem	big problem
9. During the past month, how much of a
problem has it been for you to keep up enough enthusiasm to get things done?                □	□	□	□
No bed	Partner/	Partner in same
partner or	roommate in	room, but not	Partner in
roommate	other room	same bed	same bed

1. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

□         □         D                □

If you have a roommate or bed partner, ask him/her how often in the past month you have had…

Not during the	Less than	Once or	Three or more
past month	once a week	twice a week	times a week

• …loud snoring                                                □         □         □         □
  • …long pauses between breaths while asleep     □         □         □         □
  • …legs twitching or jerking while you sleep         [J                □         □         □
  • …episodes of disorientation or confusion

during sleep

• Other restlessness while you sleep;

□         □         □         □

please describe

□         □         □         □

SCORING INSTRUCTIONS FOR  THE PITTSBURGH SLEEP QUALITY INDEX:

The Pittsburgh Sleep Quality Index (PSQI) contains 19 self-rated questions and 5 questions rated by the bed partner or roommate (if one is available). Only self-rated questions are included in the scoring. The 19 self-rated items are combined to form seven “component” scores, each of which has a range of 0-3 points. In all cases, a score of “O” indicates no difficulty, while a score of “3” indicates severe difficulty. The seven component scores are then added to yield one “global” score, with a range of

0-21 points, “O” indicating no difficulty and “21 ” indicating severe difficulties in all areas. Scoring proceeds as follows:

Component 1: Subjective sleep quality

Examine question #6, and assign scores as follows:

Component 1

Response “Very good” “Fairly good” “Fairly bad” “Very bad”

score

0

1

2

3

Component 1 score: 2            _

Component 2: Sleep latency

1. Examine question #2, and assign scores as follows:

Respo\nse

:::15 minutes

16-30 minutes

31-60 minutes

> 60 minutes

Score

0

1

2

3

Question #2 score:            3              

• Examine question #5a, and assign scores as follows:

Response                                  Score

Not during the past month            0

Less than once a week                1

Once or twice a week                  2

Three or more times a week         3

Question #Sa score :          3              

• Add #2 score and #5a score

Sum of #2 and #Sa:           6              

• Assign component 2 score as follows:

Sum of #2 and #5a             Component 2 score

0                     0

1-2

3-4

5-6

PSOI Page 3

1

2

3

Component 2 score: _ 3_ _ _

Component 3: Sleep duration

Examine question #4, and assign scores as follows:

Component 3

Response

> 7 hours 6-7 hours 5-6 hours

< 5 hours

score

0

1

2

3

Component 3 score:        3      _

Component 4: Habitual sleep efficiency

1. Write the number of hours slept (question #4) here:        3      _
   1. Calculate the number of hours spent in bed:

Getting up time (question #3):        0330h    _

Bedtime (question #1):       2300h   _

Number of hours spent in bed:       4.5 hours   _

• Calculate habitual sleep efficiency as follows:

(Number of hours slept/Number of hours spent in bed) X 100 = Habitual sleep efficiency (%)

                 3/4.5       ) X 100= 66%

• Assign component 4 score as follows:

Habitual sleep efficiency %

>85%

75-84%

65-74%

< 65%

Component 4 score

0

1

2

3

Component 4 score:        2      _

Component 5: Step disturbances

1 . Examine questions #5b-5j, and assign scores for each question as follows :

Response                                  Score

Not during the past month           O

Less than once a week                1

Once or twice a week                  2

Three or more times a week        3

5b score:                           3              

5c score:                           3              

5d score:                           2             

5e score:                           2             

5f score :                            1             

5g score :                            0             

5h score:                           0             

5i score :                            0             

5j score:                            0              

• Add the scores for questions #5b-5j:

Sum of #5b-5j:                  12           

• Assign component 5 score as follows:

Sum of #5b-5j                   Component 5 score

0                     0

1-9

10-18-4

19-27

1

2

3

Component 5 score:        2      _

Component 6: Use of sleeping medication

Examine question #7 and assign scores as follows:

Component 6

Response                                  score

Not during the past month            0

Less than once a week                1

Once or twice a week                   2

Three or more times a week         3

Component 6 score:        0      _

Component 7: Daytime dysfunction

1. Examine question #8, and assign scores as follows:

Response                                        Score

Never                                                0

Once or twice                                    1

Once or twice each week                   2

Three or more times each week          3

Question#B score:                   2              

• Examine question #9, and assign scores as follows:

Response                                        Score

No problem at all                               0

Only a very slight problem                  1

Somewhat of a problem                     2

A very big problem                             3

Question #9 score :                  3              

• Add the scores for question #8 and #9:

Sum of #8 and #9:                   5              

• Assign component 7 score as follows:

Sum of #8 and #9                    Component 7 score

0                        0

1-2                                                    1

3-4                                                    2

5-6                                                    3

Component 7 score:        3   _

Global PSQI Score

Add the seven component scores together:

Global PSOI Score:        15   _