Nursing diagnosis – RISK FOR FALLS

RISK  FOR  FALLS

DEFINITION

Increasing susceptibility to falling that may cause physical harm

RISK FACTORS

Adult

• Patient verbalizes faintness

• Age   65 years

when extending neck

• Lives alone

• Difficulties with hearing or

• Environmental hazards (e.g.,

vision

cluttered environment; poor
lighting)

• Incontinence
Child

• Presence of lower limb pros-

• Age   2 years

thesis; use of assistive devices
for walking

• Environmental hazards (e.g.,
bed located near window, lack

• Has history of falls

of gate on stairs)

• Use of alcohol, diuretics, and

• Lack of parental supervision

tranquilizers

• Unattended infant on elevated

• Presence of anemias, diarrhea

surface (e.g., bed/changing table)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Sensation/perception

• Knowledge

EXPECTED OUTCOMES

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

Ambulation; Balance; Cognition; Neurological Status; Risk Control;

Sensory Function: Vision; Sensory Function: Hearing

INTERVENTIONS AND RATIONALES

Determine: 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 appro-

priate interventions.

Perform: For older adults, make necessary changes in environment

(i.e., remove throw rugs). Orient patient to environment. Post a

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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.

Inform: 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. Advise

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.

Attend: 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.

Manage: 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

Environmental Management; Exercise Therapy: Balance; Fall Preven-

tion; Medication Management; Teaching

Reference

Bright, L. (2005, January). Strategies to improve the patient safety outcome

indicator: Preventing or reducing falls. Home Healthcare Nurse, 23(1), 29–36.

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