Nursing Diagnosis: Risk for Falls – Comprehensive Care Plan Sample

Falls are a significant concern in healthcare settings, particularly for hospitalized patients. They represent the most frequently reported safety incident, with a substantial percentage leading to injuries. While not all falls are preventable, implementing robust safety measures is crucial to minimize risk. Studies show that identifying risk factors and applying targeted interventions can reduce falls by 20-30%. Nurses play a pivotal role in this by diligently assessing patient risk, implementing preventive strategies, and educating patients about fall precautions.

It’s important to note that the nursing diagnosis “Risk for Falls” has been updated by NANDA International to “Risk for Adult Falls” and “Risk for Child Falls.” While this article primarily uses “Risk for Falls” for broader accessibility, healthcare professionals should be aware of these updated diagnostic labels.

Risk Factors for Falls

Identifying risk factors is the cornerstone of fall prevention. These factors can be broadly categorized:

Adult-Specific Risk Factors

• History of Falls: A previous fall significantly increases the likelihood of future falls.
• Assistive Device Use: Improper use or reliance on devices like walkers or canes can paradoxically increase fall risk.
• Age 65 Years and Over: Age-related physiological changes increase susceptibility to falls.
• Lower Limb Prosthesis: Adjusting to and managing a prosthesis can impact balance and coordination.

Physiological Risk Factors

• Reduced Visual Acuity: Poor vision impairs environmental awareness and hazard detection.
• Hearing Impairment: Difficulties hearing instructions or environmental cues can increase fall risk.
• Orthostatic Hypotension: Sudden drops in blood pressure upon standing can cause dizziness and falls.
• Incontinence: Urgency and frequency can lead to rushed movements and falls, especially at night.
• Impaired Mobility and Weakness: Muscle weakness, balance issues, and gait disturbances directly contribute to fall risk.
• Poor Balance: Compromised balance makes maintaining stability challenging.
• Confusion: Disorientation and impaired judgment increase the likelihood of unsafe actions.
• Delirium: Acute confusional states significantly elevate fall risk due to altered perception and behavior.

Medication-Related Risk Factors

• Antihypertensive Medications: These can contribute to orthostatic hypotension.
• Sedatives: Impair alertness, coordination, and reaction time.
• Narcotics: Similar to sedatives, narcotics can cause drowsiness and impaired balance.
• Alcohol Use: Alcohol intoxication significantly impairs balance and judgment.

Environmental Risk Factors

• Restraints: Paradoxically, restraints can increase agitation and injury risk, including falls, when patients attempt to move.
• Cluttered Environments: Obstacles and clutter create tripping hazards.
• Inadequate Footwear: Slippery or ill-fitting shoes increase the risk of slips and falls.

Important Note: “Risk for Falls” is a risk diagnosis. This means there are no existing signs or symptoms because the problem (a fall) has not yet occurred. Nursing interventions are therefore focused on proactive prevention.

Expected Outcomes for Fall Prevention

Effective nursing care planning aims to achieve the following outcomes:

• The patient will remain free from falls throughout their care.
• The patient will demonstrate an understanding of a safe environment and potential hazards.
• The patient will verbalize awareness of their individual risk factors for falls.

Nursing Assessment for Fall Risk

A thorough nursing assessment is crucial for identifying individual patient risks and tailoring interventions. This involves gathering both subjective and objective data.

1. General Health Status Assessment:

• Evaluate acute and chronic conditions that could impact safety. This includes assessing for sensory deficits (vision, hearing), polypharmacy (multiple medications), and cognitive status (confusion, alertness).

2. Musculoskeletal and Mobility Assessment:

• Assess muscle strength, coordination, gait, and balance. Note any recent surgeries, injuries, or conditions that may impair mobility. Observe the patient’s use of any assistive devices.

3. Utilize the Morse Fall Scale:

• The Morse Fall Scale is a validated tool for rapid fall risk assessment in hospitalized patients. It assigns scores based on various risk factors to categorize patients as no risk (0), low to moderate risk, or high risk (45+).

4. Mental Status Evaluation:

• Assess cognitive function, level of sedation, and presence of hallucinations. Patients with altered mental status may overestimate their abilities or forget limitations.

5. Assistive Device Assessment:

• Verify the patient has necessary assistive devices (walker, bedside commode, etc.) and can use them correctly and safely.

Nursing Interventions for Fall Prevention

Nursing interventions are tailored to the patient’s identified risk factors and level of risk.

1. Implement Personalized Safety Measures:

• Select interventions based on the patient’s specific needs. A young, alert patient might only require a walker, while an elderly, confused patient may need a bed alarm. For severely confused patients, consider restraints or 1:1 supervision as a last resort, always prioritizing less restrictive measures first.

2. Ensure and Encourage Appropriate Footwear:

• Promote the use of non-slip footwear for all hospitalized patients. Color-coded socks (e.g., yellow for high fall risk) can visually alert staff.

3. Utilize Fall Risk Identification Protocols:

• Employ visual cues like patient wristbands, chart stickers, and door signs to communicate fall risk status to all staff involved in the patient’s care.

4. Maintain a Clutter-Free Environment:

• Remove unnecessary furniture, clear pathways, and ensure cords and IV lines are not on the floor.

5. Keep Essential Items Within Reach:

• Before leaving the room, ensure the call button, water, and personal items are easily accessible to prevent patients from reaching and potentially falling.

6. Promote Assisted Ambulation:

• Encourage patients to use the call button and request assistance when getting out of bed or going to the bathroom.

7. Bed Positioning:

• Keep the bed in the lowest position at all times, except when actively providing care that requires raising it.

8. Patient Education on Fall Risk:

• Engage in open conversations with patients about their specific fall risk factors and the implemented safety measures. This enhances understanding and adherence to precautions.

9. Interdisciplinary Collaboration:

• Consult with physiotherapy and occupational therapy for strength and balance training, gait retraining, and proper use of assistive devices.

Nursing Care Plan Samples for Risk for Falls

The following are sample nursing care plans illustrating how to apply the “Risk for Falls” nursing diagnosis in practice.

Care Plan #1

Diagnostic Statement: Risk for falls related to improper walker use and orthostatic hypotension.

Expected Outcomes:

• Patient will remain free from injury.
• Patient will demonstrate correct walker usage.

Assessment:

1. Walker Use Evaluation: Assess and document specific errors in walker technique to guide targeted education.
2. Medication Review: Identify medications, particularly those known to cause orthostatic hypotension, to determine contributing factors.
3. Medical History Review: Explore pre-existing conditions (stroke, brain injury, musculoskeletal disorders) that increase fall susceptibility.

Interventions:

1. Assistive Device Education and Support: Provide individualized instruction on proper walker use and maintenance. Ensure correct device fitting.
2. Exercise Promotion: Collaborate with the patient to establish appropriate exercise goals to improve gait, balance, and strength, if medically suitable.
3. Environmental Safety: Lighting: Ensure adequate room lighting, especially at night, to minimize environmental hazards.
4. Fall Risk Identification Wristband: Apply a fall risk identification wristband to alert all staff to the patient’s increased risk.
5. Physical Therapy Consultation: Refer to physical therapy for expert guidance on exercises, assistive devices, and mobility strategies.

Care Plan #2

Diagnostic Statement: Risk for falls related to vertigo and prolonged bed rest.

Expected Outcomes:

• Patient will remain free from falls.
• Patient will experience a reduction in dizziness, visual disturbances, and orthostatic hypotension.

Assessment:

1. Muscle Strength Assessment: Evaluate muscle strength to determine the extent of mobility impairment due to bed rest.
2. Vertigo History: Obtain a detailed history of vertigo episodes, including triggers, frequency, and associated symptoms (dizziness, unsteadiness, visual disturbances).
3. Environmental Hazard Assessment: Inspect the environment for clutter, slippery surfaces, and loose rugs.

Interventions:

1. Environmental Hazard Mitigation: Implement environmental modifications such as lowering the bed, using a raised edge mattress, padding the floor, or placing the mattress on the floor. Consider half-side rails for bed mobility assistance.
2. Assisted Bed Mobility: Provide assistance when the patient gets out of bed due to potential weakness from bed rest.
3. Orthostatic Hypotension Precautions: Instruct the patient to change positions slowly, dangle legs before standing, and stand briefly by the bed before ambulating.
4. Medication Administration: Administer prescribed medications for vertigo (antihistamines, benzodiazepines, antiemetics) as ordered.
5. Physical Therapy Referral: Refer to physical therapy for programs targeting strength, balance, flexibility, and endurance to improve mobility and reduce fall risk.

Care Plan #3

Diagnostic Statement: Risk for falls related to presence of Foley catheter and two IV lines.

Expected Outcomes:

• Patient will not experience a fall.
• Patient will remain free from injury.

Assessment:

1. Precipitating Fall Risk Factors: Assess for other contributing factors beyond medical devices, such as history of falls, altered mental status, sensory deficits, and disease-related symptoms.
2. Environmental Risk Factor Surveillance: Conduct a thorough environmental assessment to identify and address any potential hazards.
3. Patient Understanding of Medical Devices: Evaluate the patient’s understanding of the purpose and management of their IV lines and Foley catheter to prevent accidental or intentional removal.

Interventions:

1. Environmental Orientation and Safety Measures: Orient the patient to their surroundings and safety features. Provide clear instructions on bathroom location, bed controls, and call bell use. Ensure bathroom lighting, remove obstacles, assess side rail safety, maintain low bed position, and encourage non-slip footwear.
2. Personal Items Within Reach: Position personal items, call bell, and necessities within easy reach to minimize the need for the patient to get out of bed unassisted.
3. Implement Fall Precautions: Utilize strategies such as quarter or half-length side rails, maintaining a low bed position, locking bed and commode wheels, and using dim lighting at night.

References

1. Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
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7. Morris, R. (2017). Prevention of falls in hospital. Royal College of Physicians, 17(4), 360-362. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297656/
8. Preventing Falls in Hospitals. (2013, January). Agency for Healthcare Research and Quality. Retrieved October 13th, 2021, from https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html
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