RISK FOR FALLS
Increasing susceptibility to falling that may cause physical harm
• Patient verbalizes faintness
• Age 65 years
when extending neck
• Lives alone
• Difﬁculties with hearing or
• Environmental hazards (e.g.,
cluttered environment; poor
• Presence of lower limb pros-
• Age 2 years
thesis; use of assistive devices
• 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
• Unattended infant on elevated
• Presence of anemias, diarrhea
surface (e.g., bed/changing table)
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
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
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-
Perform: 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.
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
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
Bright, L. (2005, January). Strategies to improve the patient safety outcome
indicator: Preventing or reducing falls. Home Healthcare Nurse, 23(1), 29–36.