Hendrich II Fall Risk Model

Fall Risk Assessment
Student’s Name
Institutional Affiliation
The Hendrich II Fall Risk Model Assessment
Hendrich II falls Risk Model RISK POINTS SCORE
Confusion/Disorientation/Impulsiveness 4 4
Depression (Nursing staff assesses patient or patient states “depressed”) 2 1
Altered Elimination (leakage of urine or stool, “can’t wait” or gets up 4 or more times/night) 1 1
Dizziness/Vertigo (reported by patient) 1 0
Gender (Male) 1 1
Any antiepileptics Carbamazepine (Tegretol, Carbatrol), divalproex (Depakote), fosphenytoin (Cerebryx injection) gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), mephobarbital, (Mebaral) oxcarbazepine (Trileptal), Phenobarbital, (phenytoin), (Dilantin), topiramate (Topamax) and valproic acid (Depakene) 2 2
Any benzodiazepines: (Alprazolam (Xanax), chlordiazepoxide (Librium, Librax) clonazepam (Klonopin), diazepam (Valium), flurazepam (Dalmane), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion) 1 1
Get-Up-And-Go Test (Choose One): Rises in a single movement 0 Pushes up in one attempt 1 Multiple Attempts, successful 3 3
Unable to rise without assist 4 ADD TOTAL POINTS (>5 points = High Risk): 12
Hendrich II Fall Risk Model (AHI, 2013)
Mr. T.J.’s total score is 12 indicating that he has a high risk of falling as noted by Han at al. (2017). Reducing the risk requires adjusting the care plan. From the assessment, it is evident that his impulsiveness and anxiety are intermittent. The patient also presents gait and mobility challenges.

Because of the mobility challenges, the care plan should include increased observation. The facility should schedule toileting rounds based on his elimination pattern and install a bed-exit alarm to alert the practitioners whenever the individual leaves his bed. Because of T.J.’ high risk of falling, the nurses should wrap a yellow band round his arm to reflect his risk of falling and serve as a reminder to himself and other staffs. The nurses should not allow T.J. to get up without assistance or get into the bathroom alone. In order to stabilize the patient and reduce his risk of falling, the nurse practitioners should keep Mr. T.J. mobile by helping him to get up and seating him in a chair or bedside. They should also allow him to go for short walks under supervision and reduce the pain medication gradually.
Most important, the nurse practitioners should discuss with the patient the need to accept assistance in order to reduce the risk of falling. It is also necessary to inquire into the preferences of the patient to determine whether he would prefer a male or female practitioner to provide assistance while using the toilet and bathroom. Personally, I think that the score from the Fall Risk Tool is accurate and that the tool is worth the effort to develop since it addresses the six key aspects of a fall risk reduction program noted by Hempel et al. (2013). These include evaluating and reevaluating the risk of falling among patients, maintaining a safe environment, monitoring mobility and gait, enabling safe toileting, educating the patient and family, and finally, using an interdisciplinary team to manage the condition.
References
AHI of Indiana. (2013). Hendrich II Fall Risk Model TM. 
Han, J., Xu, L., Zhou, C., Wang, J., Li, J., Hao, X., … & Yang, N. (2017). Stratify, Hendrich II fall risk model and Morse fall scale used in predicting the risk of falling for elderly in-patients. Biomedical Research.
Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., … & Ganz, D. A. (2013). Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483-494.