Nursing diagnosis: Risk for Falls
Definition of Risk for Falls
- Increasing susceptibility to falling that may cause physical harm
Risk Factors Risk for Falls
Adult
- Age > 65 years
- Lives alone
- Environmental hazards (e.g., cluttered environment; poor lighting)
- Presence of lower limb prosthesis; use of assistive devices for walking
- Has history of falls
- Use of alcohol, diuretics, and tranquilizers
- Presence of anemias, diarrhea
- Patient verbalizes faintness when extending neck
- Difficulties with hearing or vision
- Incontinence
Child
- Age < 2 years
- Environmental hazards (e.g., bed located near window, lack of gate on stairs)
- Lack of parental supervision
- Unattended infant on elevated surface (e.g., bed/changing table)
Nursing Care Plan for Risk for Falls: Nursing Diagnosis for Risk for Falls | Assessment Focus of Risk for Falls
Nursing Care Plan for Risk for Falls: Nursing Diagnosis for Risk for Falls | Assessment Focus of Risk for Falls; Expected Outcomes
Assessment Focus of Risk for Falls (Refer To Comprehensive Assessment Parameters.)
- Activity/exercise
- Cardiac function
- Knowledge
- Neurocognition
- Sensation/perception
Expected Outcomes | Nursing Diagnosis for Risk for Falls
Patient and family will
- Identify factors that increase potential for falling.
- Assist in identifying and applying safety measures to prevent injury.
- Make necessary changes in the physical environment to ensure safety for the patient.
- Develop long-term strategies to promote safety and prevent falls.
- Optimize patient’s ability to carry out ADLs within sensor motor limitations.
Suggested NOC Outcomes | Nursing Diagnosis for Risk for Falls
Ambulation; Balance; Cognition; Neurological Status; Risk Control; Sensory Function: Vision; Sensory Function: Hearing
Nursing Care Plan for Risk for Falls: Nursing Diagnosis for Risk for Falls | Nursing Interventions of Risk for Falls
Nursing Diagnosis for Risk for Falls | Nursing Interventions of Risk for Falls and Rationales
Nursing Interventions of Risk for Falls and Rationales
- For adults, assess severity of sensory or motor deficits; environmental hazards, and inadequate lighting; medication use; improper use of assistive devices. For children, assess sensory or motor deficits, recent illnesses, unsteady balance, running at speeds beyond capability, and inadequate supervision. Assessment factors will help identify appropriate interventions.
- For older adults, make necessary changes in environment (i.e., remove throw rugs). Orient patient to environment. Post a notice that the patient is at risk for falling. Place side rails up and bed position down when the patient is in bed. Place personal items within the patient’s reach. These measures prevent injury to patient. For children, make necessary changes in environment (i.e., apply window guards); keep toys and other objects from lying around on the floor; use a gate when necessary to keep the child in a confined area; provide adequate supervision to prevent injury to the patient.
- Provide family with a list of all the things they need to do to prevent the patient from falling. Go over each item and explain the reason for each cautionary measure. Written instructions will reinforce the need for prevention.
- Teach patient with an unstable gait how to use assistive devices properly. Improper use of assistive devices can put the patient at greater risk of falling.
- Teach patient and family about the use of safe lighting. Advice patients to wear sunglasses to reduce glare. Proper lighting is always considered as a preventive measure.
- Teach patient about medications that have been prescribed for him or her. Overmedication in older adults is one of the major risk factors in falls. Understanding on the part of the patient and family can reduce the incidence of falls in the home.
- Ask frequently during hospitalization whether patient and family have questions about the modifications needed to prevent falls. Listen carefully to statement or ideas the patient and/or family may present about potential for falls in their individual home settings. Greater awareness on the part of both patient and family can markedly reduce the risk of falls.
- Encourage adult patient to express feelings about the fear of falling. Being able to express the fear will raise the nurse’s awareness of what the patient considers problem areas.
- Arrange for social service/case manager to make a home visit to help prepare the family for the patient’s return to a safe environment.
- Refer patient and family to community resources that may offer assistance to the patient when needed.
- Refer to home health nurse for a follow-up visit in the home.
Suggested NIC Interventions | Nursing Diagnosis for Risk for Falls
Environmental Management; Exercise Therapy: Balance; Fall Prevention; Medication Management; Teaching
This is a sample of Nursing Care Plan for Risk for Falls: Nursing Diagnosis for Risk for Falls.
