Falls Nursing Diagnosis: A Comprehensive Guide for Nurses

Falls in hospitals represent a significant patient safety concern. They are the most frequently reported safety incidents affecting hospitalized individuals, with a substantial portion leading to injuries. While complete prevention is not always achievable, implementing robust safety protocols is crucial to minimize the risk and enhance patient outcomes. Research indicates that a proactive approach, involving the identification of patient-specific risk factors coupled with tailored interventions, can effectively reduce falls by 20-30%.

Nurses play a pivotal role in fall prevention. Their diligence in conducting thorough risk assessments, consistently applying preventative measures, and clearly communicating fall precautions to patients and their families are paramount to ensuring patient safety and well-being.

It’s important to note a recent update in terminology: the nursing diagnosis previously known as “Risk for Falls” has been refined by the NANDA International Diagnosis Development Committee (DDC). The updated labels are now “Risk for Adult Falls” and “Risk for Child Falls,” reflecting a move towards greater precision in nursing language. While this article acknowledges this change, it will continue to use the more broadly recognized term “Risk for Falls” to ensure clarity and accessibility for all nurses, until the updated terminology gains widespread adoption.

Risk Factors for Falls: Identifying Vulnerable Patients

Understanding the factors that increase a patient’s susceptibility to falls is the cornerstone of effective prevention. These risk factors can be broadly categorized and are crucial to consider during patient assessment.

Adult-Specific Risk Factors

• History of Falls: A prior fall is a strong predictor of future falls.
• Assistive Device Use: While intended to aid mobility, improper or inconsistent use of devices like walkers or canes can paradoxically increase fall risk.
• Age 65 and Over: Physiological changes associated with aging naturally elevate fall risk.
• Lower Limb Prosthesis: Adjusting to and managing a prosthesis can impact balance and coordination, posing a fall risk.

Physiological Risk Factors

• Low Visual Acuity: Impaired vision hinders environmental awareness and obstacle avoidance.
• Hearing Impairment: Reduced auditory cues can affect spatial orientation and awareness of surroundings.
• 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, particularly at night.
• Impaired Mobility and Strength: Weakness, balance issues, and gait disturbances directly increase fall risk.
• Poor Balance: Underlying conditions or age-related changes can compromise balance.
• Confusion: Disorientation and impaired judgment increase the likelihood of unsafe actions.
• Delirium: An acute state of confusion significantly elevates fall risk due to altered perception and cognition.

Medication-Related Risk Factors

• Antihypertensive Medications: These can contribute to orthostatic hypotension and dizziness.
• Sedatives: Impaired alertness and coordination are common side effects.
• Narcotics: Similar to sedatives, narcotics can cause drowsiness, confusion, and impaired motor skills.
• Alcohol Use: Intoxication significantly impairs balance and judgment.

Environmental Risk Factors

• Restraints: Paradoxically, restraints can sometimes increase agitation and the risk of injury from falls when patients attempt to free themselves. Restraints should be used as a last resort and carefully monitored.
• Cluttered Environments: Obstacles like equipment, personal items, and spills increase tripping hazards.
• Inadequate Footwear: Slippery or ill-fitting footwear contributes to instability.

It is crucial to remember that a “Risk for Falls” diagnosis is based on the presence of these risk factors, not on the occurrence of a fall itself. Nursing interventions are therefore focused on proactive prevention.

Expected Outcomes: Goals of Fall Prevention

Effective nursing care planning for fall risk centers on clear, measurable goals. Common expected outcomes include:

• Patient Remains Fall-Free: The primary goal is to prevent falls during hospitalization.
• Safe Environment Demonstrated: Ensuring the patient’s immediate surroundings are free of hazards.
• Verbalizes Understanding of Risk Factors: Patient education is key to empowering patients to participate in their own safety.

Nursing Assessment: Gathering Crucial Data

A thorough nursing assessment is the foundation of individualized fall prevention strategies. This involves collecting both subjective and objective data.

1. General Health Status Assessment: Evaluate the patient’s overall health, noting acute and chronic conditions that might impact safety. This includes:

• Use of assistive devices like hearing aids or glasses.
• Polypharmacy (multiple medications), and potential drug interactions.
• Cognitive status, including any confusion or memory issues.

2. Musculoskeletal Assessment: Assess muscle strength, coordination, gait, and balance. Note any:

• Decreased strength, particularly in lower extremities.
• Recent surgeries or injuries affecting mobility.
• Pre-existing physical limitations.

3. Morse Fall Scale Administration: Utilize a validated fall risk assessment tool like the Morse Fall Scale. This tool provides a standardized method to quantify fall risk based on several factors.

• A score of 0 indicates no apparent risk.
• Scores between 25-44 indicate low to moderate risk.
• Scores of 45 or higher signify high risk.

Alt text: The Morse Fall Scale assessment tool, a scoring system used by nurses to evaluate patient fall risk based on factors like history of falls, secondary diagnosis, ambulatory aid, IV/Heparin lock, gait, and mental status.

4. Mental Status Evaluation: Assess cognitive function and awareness. Consider:

• Level of consciousness and orientation.
• Presence of confusion, sedation, or hallucinations.
• Patient’s understanding of their physical limitations.

5. Assistive Device Evaluation: If the patient uses assistive devices, verify:

• Availability and proper fit of devices (walkers, canes, bedside commodes).
• Patient’s understanding and correct usage of these devices.

Nursing Interventions: Implementing Preventative Measures

Based on the assessment, nurses implement tailored interventions to mitigate fall risk.

1. Implement Patient-Specific Safety Measures: Select interventions based on the individual patient’s risk factors and condition.

• For an alert and mobile young adult, non-slip footwear and a clear environment might suffice.
• An elderly patient with confusion may require a bed alarm, frequent monitoring, or sitter.
• Severely confused patients who cannot follow directions may require restraints or continuous 1:1 supervision as a last resort to ensure safety. Restraint use must always adhere to hospital policy and ethical guidelines.

2. Ensure and Encourage Appropriate Footwear: Promote the use of non-slip footwear for all hospitalized patients.

• Many hospitals utilize color-coded socks to visually identify patients at high fall risk, such as yellow socks.

Alt text: Close-up of yellow non-slip hospital socks with rubber grips on the bottom, used as a visual identifier for patients at high risk of falls.

3. Utilize Fall Risk Identification Protocols: Employ visual cues to alert staff to patients at high risk.

• Fall risk wristbands, chart stickers, and door signs effectively communicate risk status to all healthcare providers.

4. Maintain a Clutter-Free Patient Environment: Reduce environmental hazards.

• Remove unnecessary furniture and equipment from the room.
• Ensure cords, tubing (IV lines, catheter tubing), and personal items are not on the floor and are safely managed.

5. Keep Call Button and Personal Items Within Reach: Promote patient independence and safety.

• Before leaving the room, always ensure the call button, water, phone, and other essential personal items are within easy reach from the bed or chair. This minimizes the need for the patient to reach or attempt to get up unassisted.

6. Encourage Assistance with Ambulation: Promote safe mobility practices.

• Educate and encourage patients to use the call button and request assistance whenever getting out of bed, especially for toileting or ambulating.

7. Maintain Bed in the Lowest Position: Minimize injury severity should a fall occur from the bed.

• Keep the bed in the lowest position at all times, except when actively providing care that necessitates raising the bed. Remember to lower the bed immediately after care is completed.

8. Patient Education on Fall Risk Factors and Prevention: Empower patients through knowledge.

• Engage in open and direct conversations with patients and families about their individual fall risk factors and the specific safety measures being implemented. This enhances understanding and promotes patient adherence to the plan of care.

9. Coordinate with Therapy Services: Collaborate with Physical Therapy (PT) and Occupational Therapy (OT).

• PT can assess and address strength, balance, and gait deficits, and provide exercise programs.
• OT can assess functional abilities and recommend adaptive equipment and strategies for safe performance of daily activities.
• Both can instruct patients on the proper use of assistive devices and recommend home modifications if needed.

Nursing Care Plans: Examples for “Risk for Falls”

Nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Here are examples of care plans for “Risk for Falls”:

Care Plan #1

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

Expected Outcomes:

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

Assessments:

1. Walker Use Evaluation: Observe and document how the patient uses their walker, noting any deviations from correct technique. This informs targeted teaching.
2. Medication Review: Analyze the patient’s medication list, paying attention to medications known to cause orthostatic hypotension.
3. Medical History Review: Obtain a comprehensive medical history to identify predisposing conditions like stroke, brain injury, or musculoskeletal disorders that may increase fall risk.

Interventions:

1. Assistive Device Education and Support: Provide detailed instruction and supervised practice on proper walker use and maintenance. Ensure the walker is correctly sized and adjusted for the patient.
2. Exercise Promotion: Collaborate with the patient (and PT if appropriate) to establish a safe exercise regimen to improve gait, balance, and strength.
3. Environmental Safety: Ensure adequate room lighting, especially at night, to minimize environmental hazards.
4. Fall Risk Identification Band: Apply a fall risk identification wristband to alert all staff.
5. Physical Therapy Consultation: Consult PT for specialized exercises and recommendations for 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 report a reduction in vertigo symptoms and absence of orthostatic hypotension.

Assessments:

1. Muscle Strength Assessment: Evaluate muscle strength, recognizing that prolonged bed rest leads to muscle weakness and deconditioning.
2. Vertigo History: Gather a detailed history of vertigo, including triggers, frequency, and associated symptoms like dizziness and visual disturbances.
3. Environmental Hazard Assessment: Scrutinize the environment for clutter, slippery surfaces, and loose rugs, addressing any identified hazards.

Interventions:

1. Environmental Hazard Mitigation: Implement environmental modifications like lowering the bed, using a raised edge mattress, padding the floor if necessary, and ensuring clear pathways. Consider half-side rails for bed mobility assistance, avoiding full rails which can increase risk of climbing over.
2. Assisted Bed Mobility: Provide assistance when the patient gets out of bed, especially initially after prolonged bed rest, due to potential weakness and orthostatic hypotension.
3. Orthostatic Hypotension Precautions: Instruct the patient on slow position changes: sit up slowly, dangle legs at the bedside, and stand gradually before walking to minimize dizziness.
4. Medication Administration: Administer prescribed medications for vertigo, such as antihistamines or antiemetics, as ordered.
5. Rehabilitation Referral: Refer to physical therapy or balance rehabilitation programs to address vertigo and improve strength, balance, and flexibility.

Care Plan #3

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

Expected Outcomes:

• Patient will remain free from falls.
• Patient will remain free from injury.

Assessments:

1. Precipitating Fall Risk Factors: Identify underlying factors that compound the risk from medical devices, such as history of falls, altered mental status, sensory deficits, or disease-related symptoms.
2. Environmental Risk Assessment: Thoroughly assess the patient’s environment for hazards, considering the limitations imposed by the medical devices.
3. Device Understanding Assessment: Evaluate the patient’s understanding of the purpose and management of their Foley catheter and IV lines to minimize accidental or intentional disruption.

Interventions:

1. Environmental Orientation and Safety Measures: Orient the patient to their surroundings, especially bathroom location. Educate on bed controls and call bell use. Ensure bathroom is well-lit and free of obstacles. Consider bed height and side rail use carefully – low bed is key, side rails may be hazardous for some. Encourage non-slip footwear.
2. Personal Items Within Reach: Position personal items, call bell, and necessities within easy reach to minimize reaching and maneuvering with devices.
3. Fall Prevention Protocols: Implement standard fall precautions: use quarter or half-length side rails if needed, maintain low bed position, lock bed and commode wheels, and ensure dim lighting at night. Educate staff and family on precautions. Avoid full side rails if possible, as they can increase risk of climbing over.

References

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