13.5 Falls, Mobility Impairment, Pressure Injury Prevention & Palliative Care Transitions
Key Takeaways
- Fall risk assessment requires the CDC STEADI framework; a Timed Up and Go (TUG) score of ≥12 seconds or inability to hold a tandem stance for 10 seconds indicates high fall risk requiring multifactorial intervention.
- Pressure injuries develop from prolonged pressure, shear, friction, and moisture over bony prominences; the Braden Scale stratifies risk (score ≤12 indicates high risk).
- The NPIAP Pressure Injury Staging System defines 6 distinct stages; stable, intact, dry eschar on heels must never be debrided, as it acts as the body's natural biological cover.
- Palliative care is specialized medical care for serious illness focusing on symptom relief and goal alignment, delivered concurrently with curative therapy at any disease stage; hospice requires a certified prognosis of ≤6 months and election of comfort-focused care.
- In advanced dementia, artificial nutrition and hydration via percutaneous endoscopic gastrostomy (PEG) tubes does not prolong survival, prevent aspiration, or improve pressure injury healing, while increasing agitation and physical restraint use; assisted oral hand-feeding is gold-standard care.
Falls, Mobility Impairment, Pressure Injury Prevention & Palliative Care Transitions
Maintaining functional mobility, preserving skin integrity, and navigating serious illness transitions represent core responsibilities of the Adult-Gerontology Primary Care Nurse Practitioner. Falls and pressure injuries are hallmark geriatric syndromes resulting from multifactorial physiological vulnerability. When multimorbidity and chronic illnesses advance toward end-stage disease, the AGPCNP must expertly transition patients from disease-directed interventions to goal-concordant palliative and hospice care, expertly managing distressing end-of-life symptoms.
1. Falls & Mobility Impairment: The CDC STEADI Protocol
Falls are the leading cause of fatal and non-fatal injury in adults aged 65 and older. More than one in four older adults falls each year, resulting in hip fractures, subdural hematomas, traumatic brain injuries, loss of independence, and fear-induced functional decline.
+---------------------------------------------------------------------------------------------------+
| CDC STEADI FALL RISK ALGORITHM & WORKUP |
| |
| [STEP 1: SCREEN ALL OLDER ADULTS ANNUALLY] |
| Ask 3 Key Screening Questions: |
| 1. Have you fallen in the past year? (If yes, how many times? Were you injured?) |
| 2. Do you feel unsteady when standing or walking? |
| 3. Do you worry about falling? |
| | |
| +---------------------------+---------------------------+ |
| | (Screen Negative) | (Screen Positive: Any 'Yes') |
| v v |
| [LOW RISK] [ASSESS FUNCTIONAL MOBILITY] |
| - Educate on fall prevention - Timed Up and Go (TUG) Test |
| - Recommend community Tai Chi / balance exercise - 30-Second Chair Stand Test |
| - Re-evaluate annually - 4-Stage Balance Test |
| | |
| +---------------------------+ |
| v |
| [HIGH RISK MOBILITY CRITERIA] |
| • TUG Test $\ge 12\text{ seconds}$ |
| • Inability to maintain Tandem Stance for 10 seconds |
| • $\ge 2$ falls in past year or 1 fall with traumatic injury |
| | |
| v |
| [EXECUTE MULTIFACTORIAL CLINICAL INTERVENTIONS] |
| 1. Orthostatic Vital Signs & 12-lead ECG (evaluate bradycardia, arrhythmias, postural drops) |
| 2. Medication Reconciliation (deprescribe Beers sedatives, anticholinergics, antihypertensives) |
| 3. Visual Acuity & Cataract Screening |
| 4. Feet & Footwear Inspection (neuropathy, arthritic deformities, non-skid supportive shoes) |
| 5. Vitamin D level (supplement 800-1000 IU/day if deficient) |
| 6. Physical Therapy Referral (gait training, assistive device prescription: cane vs rollator) |
| 7. Occupational Therapy Home Safety Assessment (remove throw rugs, install grab bars/lighting) |
+---------------------------------------------------------------------------------------------------+
The Post-Fall Clinical Evaluation: The "SPLATT" Mnemonic
When an older adult experiences a fall, the AGPCNP must systematically reconstruct the event to prevent recurrence:
+---------------------------------------------------------------------------------------------------+
| SPLATT POST-FALL INVESTIGATION |
| |
| - S: Symptoms Experienced Prior to Fall (Lightheadedness, palpitations, aura, chest pain, vertigo)|
| - P: Previous Falls (Frequency, trajectory, underlying patterns over preceding 12 months) |
| - L: Location of Fall (Bathroom, stairs, outdoors, poorly lit hallway, uneven pavement) |
| - A: Activity at Time of Fall (Rising rapidly from bed, reaching overhead, rushing to bathroom) |
| - T: Time of Fall (Nocturnal during bathroom transit, postprandial, following morning doses) |
| - T: Trauma Sustained (Head strike, loss of consciousness, lacerations, hip pain, fractures) |
+---------------------------------------------------------------------------------------------------+
Critical Post-Fall Rule: In any patient on anticoagulation (DOACs, Warfarin) or antiplatelet therapy who experiences a fall with head trauma or unexplained mechanical fall, the AGPCNP must immediately obtain a non-contrast Head CT to rule out an acute or subacute subdural hematoma, even if baseline neurological exam is currently intact.
2. Pressure Injury Pathophysiology, Staging & Wound Care
Pressure injuries (pressure ulcers) result from unrelieved mechanical pressure, shearing forces, friction, and moisture (microclimate) over bony prominences, leading to microvascular occlusion, tissue ischemia, cellular necrosis, and deep ulceration.
Risk Assessment: The Braden Scale
The Braden Scale assesses 6 clinical subscales (Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction/Shear), each scored 1 to 4 (Friction/Shear scored 1 to 3). Total score ranges from 6 to 23:
- $\le 9$: Very High Risk
- 10–12: High Risk
- 13–14: Moderate Risk
- 15–18: Mild Risk
- 19–23: No Risk / Normal
NPIAP Pressure Injury Staging System
+---------------------------------------------------------------------------------------------------+
| NPIAP PRESSURE INJURY STAGING CROSS-SECTION |
| |
| [STAGE 1] |
| - Intact skin with localized area of NON-BLANCHABLE ERYTHEMA. |
| - Darkly pigmented skin may show discoloration, warmth, edema, or induration rather than red. |
| |
| [STAGE 2] |
| - Partial-thickness skin loss with exposed DERMIS. |
| - Wound bed is viable, pink or red, moist. May present as an intact or ruptured serum BLISTER. |
| - Adipose, granulation tissue, slough, and eschar are NOT visible. |
| |
| [STAGE 3] |
| - Full-thickness skin loss. ADIPOSE (subcutaneous fat) is visible in the ulcer. |
| - Granulation tissue and epibole (rolled wound edges) often present. |
| - Slough and/or eschar may be visible. Undermining and tunneling may occur. |
| - Fascia, muscle, tendon, ligament, cartilage, and bone are NOT exposed. |
| |
| [STAGE 4] |
| - Full-thickness skin and tissue loss with EXPOSED or DIRECTLY PALPABLE FASCIA, MUSCLE, TENDON, |
| LIGAMENT, CARTILAGE, or BONE. |
| - Slough/eschar, epibole, undermining, and tunneling common. Osteomyelitis risk is high. |
| |
| [UNSTAGEABLE] |
| - Full-thickness skin and tissue loss in which the extent of tissue damage CANNOT BE CONFIRMED |
| because the wound base is completely obscured by SLOUGH (yellow/tan) or ESCHAR (brown/black). |
| - *Clinical Rule:* If eschar is debrided, Stage 3 or Stage 4 is revealed. |
| - *CRITICAL HEEL EXCEPTION:* Stable, intact, dry, adherent eschar on HEELS must NOT be debrided!|
| |
| [DEEP TISSUE PRESSURE INJURY (DTPI)] |
| - Intact or non-intact skin with localized area of persistent, non-blanchable DEEP RED, MAROON, |
| or PURPLE discoloration, or epidermal separation revealing a dark wound bed or blood blister. |
+---------------------------------------------------------------------------------------------------+
Evidence-Based Dressing Selection Matrix
| Dressing Class | Mechanism & Properties | Clinical Indications | Precautions / Contraindications |
|---|---|---|---|
| Transparent Film (Tegaderm) | Semi-permeable, waterproof, non-absorptive; allows visual inspection. | Stage 1 pressure injuries; minor superficial abrasions; catheter dressing securement. | Avoid in draining, exudative wounds or infected ulcers. |
| Hydrocolloid (DuoDERM) | Occlusive/semi-occlusive wafer; forms gel upon exudate contact; promotes autolytic debridement. | Stage 2 and shallow Stage 3 pressure injuries with low-to-moderate exudate. | Contraindicated in heavily draining or clinically infected wounds (anaerobic environment). |
| Foam Dressings (Mepilex, Allevyn) | Highly absorbent polyurethane foam; cushions bony prominences; maintains moist thermal wound bed. | Stage 2, 3, and 4 pressure injuries with moderate-to-heavy exudate; periwound skin protection. | Ineffective for dry, desiccated eschar (requires moisture donor). |
| Alginate / Hydrofiber (Aquacel, Kaltostat) | Derived from seaweed/calcium fibers; absorbs up to 20x its weight in exudate; forms soft gel; provides hemostasis. | Heavily exudative Stage 3 and 4 pressure injuries; tunneling and undermining packing. | Contraindicated in dry wounds (causes tissue desiccation and pain). |
| Hydrogel (Curafil, Intrasite) | High water content; donates moisture to dry wound beds; softens dry necrotic slough/eschar. | Dry Stage 2, 3, and 4 ulcers; promotes autolytic debridement of dry necrotic tissue. | Ineffective in heavily exudative wounds (causes periwound maceration). |
3. Palliative Care vs. Hospice Care Transitions
Understanding the distinct regulatory, operational, and clinical boundaries between Palliative Care and Hospice Care is a high-yield board competency:
+---------------------------------------------------------------------------------------------------+
| PALLIATIVE CARE vs. HOSPICE CARE ARCHITECTURE |
| |
| [PALLIATIVE CARE] |
| - Definition: Specialized medical care for serious, life-limiting illnesses focusing on symptom |
| burden, functional quality of life, and alignment of treatment goals. |
| - Timing: Initiated at ANY STAGE of serious illness (from the moment of diagnosis onward). |
| - Curative Therapies: ALLOWED concurrently alongside disease-modifying, life-prolonging care |
| (e.g., chemotherapy, radiation, hemodialysis, heart failure therapies). |
| - Prognosis Requirement: NO PROGNOSTIC LIMITATION (patient may have years to live). |
| - Location: Inpatient hospital, outpatient clinic, long-term care facility, home. |
| |
| [HOSPICE CARE (A Subset of Palliative Care)] |
| - Definition: Comprehensive comfort-focused care for patients entering terminal illness phase. |
| - Timing: Initiated when life expectancy is estimated at $\le 6\text{ months}$. |
| - Curative Therapies: WAIVED / FORGONE; patient elects comfort-directed symptom management. |
| - Regulatory Certification: Two licensed physicians (Attending + Hospice Medical Director) must|
| certify terminal prognosis of $\le 6\text{ months}$ if disease runs normal course. |
| - Medicare Hospice Benefit: 100% coverage for hospice team, medications for symptom control, |
| medical equipment, and respite care for family caregivers. |
+---------------------------------------------------------------------------------------------------+
Advance Care Planning Instruments
- Living Will: Legal document detailing specific medical interventions a patient desires or refuses in end-stage conditions or persistent vegetative state (e.g., CPR, mechanical ventilation, tube feeding).
- Durable Power of Attorney for Healthcare (DPOA-HC / Healthcare Proxy): Legal designation of a surrogate decision-maker who speaks on behalf of the patient only when the patient loses decision-making capacity.
- POLST / MOLST (Provider/Medical Orders for Life-Sustaining Treatment): Actionable, immediately executable medical orders signed by a clinician (NP or MD) that translate patient goals into specific medical instructions across all settings (home, EMS, hospital). Covers CPR status (DNR vs Attempt CPR), Level of Medical Intervention (Comfort-Focused, Selective Treatment, Full Treatment), and Artificially Administered Nutrition.
4. End-of-Life Symptom Management Protocols
+---------------------------------------------------------------------------------------------------+
| HIGH-YIELD END-OF-LIFE PHARMACOTHERAPY MATRIX |
| |
| SYMPTOM FIRST-LINE PHARMACOTHERAPY MECHANISM & CLINICAL PEARLS |
| ======= ========================== =========================== |
| Severe Pain Morphine, Hydromorphone, Titrate short-acting opioids for |
| Oxycodone, Fentanyl patch breakthrough pain. ALWAYS co-prescribe|
| a STIMULANT LAXATIVE (Senna) for OIC.|
| |
| Terminal Dyspnea Low-dose Oral / Sublingual Decreases central perception of air |
| ("Air Hunger") Morphine (2.5-5 mg q2-4h PRN) hunger; lowers respiratory drive work|
| + Cool Fan blowing on face Trigeminal V2/V3 sensory stimulation.|
| |
| Terminal Secretions Glycopyrrolate (0.2 mg SC/IV q4h) Antimuscarinic; Glycopyrrolate DOES |
| ("Death Rattle") or Sublingual Atropine 1% drops NOT cross blood-brain barrier (avoids|
| or Scopolamine transdermal patch central delirium/agitation). Reposition|
| |
| Terminal Delirium / Haloperidol (0.5-2 mg SC/IV/oral) D2 receptor antagonism; manage acute |
| Agitation or Quetiapine (12.5-25 mg) hallucinations/restlessness. Avoid |
| benzodiazepines (worsens disinhibit.)|
| |
| Nausea / Vomiting Haloperidol, Metoclopramide, Target CTZ dopamine/serotonin or |
| Ondansetron, Prochlorperazine vestibular pathways based on etiology|
+---------------------------------------------------------------------------------------------------+
The Artificial Nutrition and Hydration (ANH) Dilemma in Advanced Dementia
One of the most heavily tested ethical and clinical scenarios on the AGPCNP exam involves feeding tube (Percutaneous Endoscopic Gastrostomy - PEG) placement in severe, end-stage dementia:
- Evidence-Based Reality (AGS / AAN Position Guidelines): Multiple large-scale prospective studies confirm that tube feeding in advanced dementia:
- Does NOT prolong survival or reduce mortality.
- Does NOT prevent aspiration pneumonia (oral secretions and gastric regurgitation still occur).
- Does NOT improve pressure ulcer healing or nutritional markers.
- Does NOT reduce infection rates.
- Significantly INCREASES agitation, emergency department visits, fluid overload, diarrhea, and the use of physical and chemical restraints to prevent tube extubation.
- Gold-Standard Clinical Recommendation: Recommend careful, assisted oral hand-feeding (comfort feeding) prioritizing patient pleasure, tactile contact, and dignity.
5. Board-Yield Summary & Clinical Pearls
+---------------------------------------------------------------------------------------------------+
| ANCC AGPCNP CLINICAL EXAM PEARLS |
| |
| - A Timed Up and Go (TUG) score ≥12 seconds establishes high fall risk and mandates a full |
| multifactorial assessment (orthostatics, medication deprescribing, PT gait training, OT home).|
| |
| - On board exams, never debride stable, intact, dry, non-tender eschar on the heels. It serves |
| as a physiological biological shield. Debridement exposes underlying bone to osteomyelitis. |
| |
| - For terminal respiratory secretions ('death rattle'), Glycopyrrolate is the board-preferred |
| anticholinergic because its quaternary structure prevents blood-brain barrier penetration, |
| effectively drying secretions without triggering or worsening central delirium. |
| |
| - Low-dose oral/sublingual morphine is the gold standard for terminal dyspnea ('air hunger') |
| in hospice care. It safely relieves respiratory distress without accelerating death when |
| properly titrated according to comfort-directed guidelines. |
+---------------------------------------------------------------------------------------------------+
An 82-year-old male with Stage 4 chronic kidney disease and severe diabetic peripheral neuropathy presents to the primary care clinic for a routine health maintenance exam. During the CDC STEADI mobility screening, his Timed Up and Go (TUG) test is timed at 17 seconds, and he is unable to hold a tandem balance stance for longer than 4 seconds. He reports one near-fall in his kitchen last month. Which of the following represents the most comprehensive, evidence-based management plan by the AGPCNP?
The AGPCNP is conducting rounds at a long-term care facility and evaluates an 88-year-old non-ambulatory female resident who is bedbound following a severe ischemic stroke. On physical examination of the sacral area, the NP observes a 4 cm × 3 cm full-thickness ulcer where subcutaneous adipose tissue is clearly visible throughout the wound bed. Granulation tissue is present with rolled wound edges (epibole). There is no exposed bone, tendon, ligament, or muscle tissue, and no undermining is detected. How should the AGPCNP accurately stage this pressure injury according to NPIAP criteria?
A 79-year-old female with advanced, end-stage Alzheimer's disease (FAST Stage 7c, non-verbal, bedbound, total dependence for all ADLs) is admitted to the hospital with her third episode of aspiration pneumonia in 5 months. The patient's surrogate healthcare proxy (her son) is extremely distressed and asks the AGPCNP whether a percutaneous endoscopic gastrostomy (PEG) feeding tube should be placed to prevent future aspiration pneumonia, ensure adequate nutrition, and prolong his mother's life. Based on American Geriatrics Society (AGS) guidelines and clinical evidence, what is the most appropriate response by the AGPCNP?