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Mrs Mary Tonin is a 77 years old female living alone in a suburb near Adelaide. She is living alone in her house for the past 10 years when her husband died. She has three sons from which two lives in Queensland and one son lives nearby her with his wife and three grandsons. The patient has a history of a heart attack I 2016 with recent recovery from a right-sided vascular accident in 2018. Her overall health is deteriorating with recent incidents of dementia-like symptoms where she forgets important things and is unable to do routine work on her own due to breathlessness. She spent her last is days recovering from atrial fibrillation in a hospital and is very adamant of not going to care home or aged care for her remaining life and wants to stay at her own house only. Her son Sam received the caring authorization for her and is eligible to care for her now but his responsibility towards his wife and children is forcing him to place her mother in an aged care home and he is aware of his mother's wishes to not to go there. This assignment is a written report that will highlight the care needs of Mary as well as plan appropriate nursing interventions for the patient. It will also focus on explaining the role of a nurse in the scenario and how the patient can be provided patient-centred with planning better fall prevention strategies.
Mary is 77 years old that makes her in the age group that has various limitations and health issues associated with it. Old age brings together a variety of issues and health concerns and as the patient has a history of Trans ischemic attack and cerebral accident the vulnerability of the patient to get ill is higher in such an age (Cherry and Jacob., 2016). Various care needs are identified in this particular patient involving assessment of her care requirement with the help of different assessment aids. The five care requirements identified for this patient are an assessment for fall, transition into the aged care home, management of diabetes and hypertension, cardiac monitoring and requirements, and complementary therapies to enhance the quality of life. The major requirement that is identified here and will be discussed is the fall assessment and prevention strategies and convincing Mary to transit to an aged care home for reduced risk of falling and hurting herself due to a variety of health issues she has. Foremost need indicates the fall assessment by the nurse. Fall assessment should be done by using an appropriate fall assessment tool. Hopkins’s fall assessment tool is a credible tool in order to be used in this scenario. It was developed for evidence-based fall safety initiative to assess the risk of the patient towards falls and slips (Klinkenber and Potter., 2017). Using this tool to assess the degree of risk associated with the patient's health towards the probability of fall is essential. It will allow the care professional to assess the related risks with the patient and able to incorporate those risks in further care planning. As a patient here already has a history of falling the risks for fall in future is high and presents the need to place Mary in an aged care home for better care and quality of life. Fall prevention can be carried out by assessing the risk and then educating and informing the patient regarding that risk. Communication according to NMC code of conduct is the key to build a therapeutic relationship with the patient. Communicating the information related to the health and associated risks with the patient will help the healthcare professional to convince the patient, in this case, to accept the aged care services and be transited to it (Bloomfield and Pegram., 2015). One of the major factors associated with fall probability is the hypoglycemia and diabetes mellitus the patient is suffering from increases the complication of diabetic retinopathy or an episode of dizziness that will hamper the eyesight of the patient and make her more prone to falls. 
Firstly the role of a care provider here is to convince and communicate the benefits of aged care home to Mary so that she is able to understand and correlate the entire situation and accept the aged care services as an option for her care. In order to do so, the care provider has to work effectively under the nursing standards of care to communicate the benefits and information regarding health and social care of the patient so that the patient can accept and take reasonable decisions for own care planning. Involving patient in care planning with her family is an essential way of addressing patient centred care (Bloomfield and Pegram., 2015). In order to do so, a nurse or healthcare worker has to build trust and therapeutic relationship with Mary and involve her and Sam in all the decisions of her care during her stay in the hospital and post-transition care. Educating the patient and her family regarding the benefits of aged care home that sates the need of aged care services in this case, receiving support for day to day tasks, be socially active, receive appropriate pharmacological and non-pharmacological therapy as per the health issues associated, achievement of help with activities of daily living, regular monitoring of the health condition and prevention of progress of any health issues, and assistance for routine tasks and medical and social services  (Brownie and Nancarrow., 2013). These benefits of the aged care home were presented in front of Mary and her family that were evaluated to be the best deal for her to consider. As Mary was suffering from the severe cardiac issue and old age made her more prone to falls and getting hurt if she dwells alone and her son cannot stay with her always it is necessary for them to place her in an aged care home (Fairhall et l., 2013). 

Different resources and procedures will be involved in promoting these requirements to the patient in this case. Use of appropriate referrals and multitasking team containing all the professionals like doctors, physiotherapist, occupational therapist, nurses and care providers who would visit regularly for routine checks and follow up (Gough., 2017). As per NICE guidelines, the multispecialty team will be delivering services that involve routine screening and follow up of the heart condition as well as fall prevention and assessments (Mazurek et al., 2017). 
Fall prevention will highly be focused on aged care home and can be also managed by framing a plan that will include the use of sensory mats and table bells that will be provided additional safety to the patient and in case of any dysfunction or fall incidence the patient can perceive help as soon as possible using these technical aids (Sherrington et al., 2017). The fall prevention plan would also include the education promoted by the nurse to the patient regarding the use of the bell in need of anything and taking care of movements and infrastructure while moving to prevent falls. Environmental factor plays a role in fall prevention as the infrastructure and placement of the floors, furniture and other equipment in the aged care home is done according to the risks associated with fall. The placement of chairs as well other furniture should be appropriately planned that it never gets in the way of the patient while using the routine pathways to walk as well as the floors should be adequately lined and gripped for preventing any slips, as well as the rooms, should be adequately lighted to avoid any vision issues. These factors can be considered to provide better care to the individual reducing their potential risk towards falls (Sherrington et al., 2017). 
These duties of a registered nurse are to be followed under the NMC code of ethical conduct that enables the nurse to promote dignity and respect while caring as well as provide care including empathy and patient-centred principles. Here the nurse will be taking care of Mary’s routine as well as her daily dose of medication and follow up for recording her progress and recovery. Other than this the patient-centred care concept includes nurse to provide care including the spiritual and ethical requirements of the patient as well. As seen Mary is in her late 70s and old age is a risk factor associated with falls as she recently has a history of fracture due to a fall (Ferguson et al., 2015). Having a registered home nurse caring for her will empower her by providing better opportunities and quality of life for remaining life. Dutcher and Kathryn (2014) examined in their study the transition of the patient from community care setting to hospitals after atrial fibrillation was somewhere correlated with the pharmacological therapy provided to them. The findings revealed that transition planning involving high-quality pharmacotherapeutic care is supported by the majority of the health care professionals as it promotes better health and care to the individual (Gough., 2017). It is also beneficial to place the patient in this case in an aged care home with a registered nurse that will provide the patient with the basic requirements and promote better recovery. According to the study by Shepperd et al (2016) that was aimed at examining the quality of life and recovery of patient transited to home care health setting. The research showed that the end of life care at home can provide patient satisfaction as well as better health outcomes but for short term and long term results indicates deterioration of patient’s health rather placing them into aged car facility promotes better quality life and (Seow et al., 2016).
In a given case the care plan should involve the transition of the patient to aged care home that will provide patient-centred care as well the multispecialty team care to provide better quality care and services. Hence it can be concluded that the role of a registered nurse, in this case, is crucial and it will help in the achievement of better health outcomes for the patient. Also, the fall preventions strategies are to be planned and applied in a given case as the patient is associated with a high risk of falling. Also, the staff should be more adequately trained in order to provide better fall prevention services and care. 
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