NANDA-I Definition of nursing care plans fall risk “Increased susceptibility to falls that can cause physical injury”.
Falls are a major safety risk for older adults. “According to the Centers for Disease Control and Prevention (CDC), approximately one in three community-dwelling adults over the age of 65 falls each year, and women fall more than men in this age group”
Fall-related injuries are the most common cause of death in people over the age of 65.
Injuries sustained as a result of a fall include soft tissue injuries, fractures (hip, spine and wrist) and traumatic brain injuries. Fall-related injuries are associated with prolonged hospitalization of older adults. For those who survive a fall, quality of life changes significantly after a fall-related injury.
The morbidity, mortality, and economic burden resulting from patient falls pose serious risk management challenges facing the healthcare industry.
Patient falls are caused by multiple factors. Nurses also have an important role in educating patients, families and caregivers about fall prevention throughout the continuum of care. Nurses also have a major role in educating patients, families, and caregivers about the prevention of fall risk.
Desired Outcomes for nursing care plans fall risk
- The client will report controlled falls or non-falls according to the following indicators:
- Relate intent to use safety measures to prevent falls.
- Demonstrate selective prevention measures.
Common risk factors for fall risk
- History of falls
- Wheelchair use
- Lives alone
- Use of assistive devices for mobility
- Orthostatic hypotension
- Impaired physical mobility
- Diminished mental status
- Environmental condition
- Impaired balance
- Decreased lower extremity strength
- Urinary or bowel incontinence
- Presence of acute illness
- Wheelchair use
- Cluttered environment
- Visual difficulties
- History of falls
- Desired Outcomes
Some important Nursing Interventions to prevent fall risk
- Orient the client to the environment and safety measures.
- Advise the client about the location of the restroom.
- Educate the client about bed controls and call bell.
- Leave the bathroom light on.
- Remove obstacles from the bathroom.
- Assess whether side rails are dangerous.
- Keep bed position low.
- Instruct client to wear slip-resistant shoes or socks with grips.
- Identify clients at high risk of falling for all staff.
- Sticker on the headboard of the bed.
- Brightly colored armband.
- Sign on door.
- “Red Slipper Program”
- Specific programs to alert staff to high-risk clients are more effective.
- Implement safety measures for cognitively impaired clients.
- Place an alarm pad on the bed.
- Clients can be placed in small groups with intense and focused supervision.
- Intense supervision is effective in preventing falls.
- Ensure proper use of assistive devices.
- Consult with a physical therapist.
- Involve the client in exercise routines.
- Assess the client’s fear of falls.
- Encourage group classes
- Provide opportunities for walking exercise.
- Perform specific exercises to improve gait, balance and ankle strength.
- Initiate health teaching and referrals as needed.
- Refer the client to the Home Nursing Agency for a home evaluation.
- Ensure that the family is aware of issues related to safety and the risk of falls.
Nursing care plans fall risk with nursing intervention and rationale in below table
|Assess factors known to increase the level of fall risk at admission, after any change in patients’ physical or cognitive status, whenever a fall occurs, periodically during the hospital stay, or at defined times in the long-term care setting.|
The level of risk and subsequent precautions against falls can be determined using standard risk assessment tools that incorporate these intrinsic and extrinsic factors.
|Know the patient’s history of falls||Previous evidence suggests that a patient who has fallen in the past 6 months is more likely to fall a|
|Changes in mental status ||Normal edge-associated changes increase a patient’s risk of falling. Changes include decreased visual ability, impaired color perception, change in center of gravity, decreased muscle strength, decreased endurance, altered depth perception, and delayed response and reaction time.|
|Sensory deficit||Impaired vision and hearing limit the patient’s ability to recognize hazards in the environment.|
|Use of a mobility aid||Inadequate use and maintenance of mobility aids, such as canes, walkers, and wheelchairs, increase the patient’s fall risk.|
|Disease-related symptoms||A higher incidence of falls has been demonstrated in people with symptoms such as orthostatic hypotension, urinary incontinence, reduced cerebral blood flow, edema, weakness, fatigue, and confusion.|
|Assess the patient’s environment for factors known to increase the risk of falls, such as age and family environment, inadequate lighting, wet surfaces, waxed floors, catcher and objects on the floor.||Patients who are unfamiliar with the placement of furniture and equipment in their room are more likely to fall. Anything that blocks or limits a clear straight path for ambulation can contribute to a person’s risk of falling.|
|Refer the patient with musculoskeletal system problems for diagnostic evaluation and assessment.||Patients with musculoskeletal problems, such as osteoporosis of aging, are at increased risk for serious injury from falls. Bone mineral density testing will help identify the risk of fracture from falls, and physical therapy evaluation can identify balance and gait problems that may increase a person’s risk of falls.|
|Post signs or use identification bracelets to identify those present at risk for falls and to remind health care professionals to implement fall precautionary behaviour||All healthcare providers should recognize the patient at risk of falling. All healthcare providers are responsible for implementing activities to promote patient safety and prevent falls.|
|Move the patient to a room near the nursing station.||Proximity allows for more frequent observation and quicker response to call needs.|
|Place items used by the patient within easy reach, such as the urinal call light, water and telephone.||Reaching for items on bedside tables that are out of reach can disrupt the patient’s balance and contribute to falls.|
|Use bed side rails as needed. For beds with split side rails, leave at least one of the rails at the foot of the bed lowered.||Patients who are disoriented or confused have been known to climb over the side rails and fall. Research shows that when one of the four rails is down, the patient is less likely to fall.|
|Ensure adequate room lighting, especially at night.||Older adults with reduced visual ability will benefit from adequate lighting, especially in an unfamiliar environment. The use of a night light helps increase visibility if the patient must get up at night.|
|Encourage the patient to wear slip-resistant soled shoes when walking.|
Slip-resistant footwear provides a secure footing for the patient with the impaired foot and elevation of the toy when walking.
Collaborate with other members of the healthcare team to assess the patient’s medication that contributes to the fall considering the maximal effects of prescribed medications that affect the level of consciousness.
|The more medications a patient takes, the greater the risk of side effects and interactions such as dizziness, orthostatic hypotension, drowsiness, and incontinence.|
|Encourage the patient to participate in a regular exercise and gait training program.||Evidence suggests that people who engage in regular exercise and activity strengthen muscles, improve balance and increase bone density. Increased fitness reduces the risk of falls and limits injuries that occur when a failure occurs.|
|Encourage those present to wear glasses and hearing aids and have them routinely checked.||The risk of falls can be reduced if the patient uses appropriate announcements to promote visual and auditory orientation to the environment. Pure vision can significantly increase the risk of falls.|
|Collaborate with physical and occupational therapy to assist with gait techniques and provide the patient with transfer and ambulation aids. Initiate a home safety assessment if necessary.||The use of gait belts by all healthcare professionals can promote safety by helping patients transfer from bed to chair. Canes, walkers, and wheelchairs can provide the patient with greater stability and balance when ambulating.|
|Provide high-risk patients with a hip pad.||These pads, when properly fitted, can reduce the hip factor in the event of a fall.|
|Educate the patient and family caregivers about the risk factor of four falls in the home. Suggest taking medication to increase safety.||Approximately 40% of community-dwelling older adults experience at least one fall per year. Falls are the leading cause of accidental death in the home environment. Falls are often caused by hazards that are easy to fix.|
|Refer the family to community e-resources for assistance with home safety modifications.||The Maine Community Services Organization offers financial assistance to help older adults make safety improvements to their homes.|
|Educate patient and family caregivers on the proper use and maintenance of mobility aids.||Correct use or improper maintenance of canes, walkers, and wheelchairs can increase the risk of falls. The device must be properly fitted to the patient. Falls can occur if wheelchair brakes are not used correctly.|
|Suggest that the patient wear an alarm device in case of a fall.||Various devices are available to alert providers to come to the scene to assist a patient who falls and is unable to get up.|
|Instruct the patient and family members on what to do after a fall.|
If the patient has an obvious injury, notify medical assistance immediately.
If the patient has a major blow to the head or any loss of consciousness, initiate immediate medical assistance.
If the patient is on anticoagulant therapy but shows no signs of active bleeding, notify medical assistance.
If the patient is on anticoagulant therapy and there is active bleeding after a fall, call for emergency assistance.
|Rapid assessment of the consequences of a fall will facilitate early treatment.|