Falls in hospitals represent a significant patient safety concern. They are the most frequently reported safety incidents, with a substantial percentage leading to injuries. While not all falls are preventable, a proactive approach to identifying risk factors and implementing targeted interventions can significantly reduce their occurrence, potentially by 20-30%. Diligent nurses who prioritize fall risk assessment, implement preventative measures, and clearly communicate the rationale behind these precautions to patients are instrumental in achieving optimal patient outcomes and minimizing fall-related harm.
Note on Terminology: It’s important to acknowledge 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 the term “Risk for Falls” for broader understanding and continuity with current practice, nurses should be aware of and adapt to the updated terminology as it becomes more widely adopted.
Identifying Fall Risk Factors
Accurate identification of risk factors is the cornerstone of effective fall prevention. These factors can be broadly categorized and are essential to consider when developing a Nursing Diagnosis Care Plan For Fall Risk.
Adult-Specific Risk Factors
- History of Falls: Previous falls are a strong predictor of future falls.
- Assistive Device Use: Improper or incorrect use of devices like walkers or canes can increase risk.
- Age 65 Years and Over: Age-related physiological changes increase vulnerability to falls.
- Lower Limb Prosthesis: Balance and stability can be affected with prosthesis use.
Physiological Risk Factors
- Low Visual Acuity: Impaired vision increases the risk of tripping and misjudging distances.
- Hearing Impairment: Difficulties in hearing environmental cues can contribute to falls.
- 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 Strength: Weakness, gait disturbances, and balance problems are major contributors.
- Poor Balance: Underlying neurological or musculoskeletal conditions can impair balance.
- Confusion: Altered mental status can lead to poor judgment and decreased awareness of hazards.
- Delirium: Acute confusion and disorientation significantly elevate fall risk.
Medication-Related Risk Factors
- Antihypertensive Medications: Can contribute to orthostatic hypotension.
- Sedatives: Impair alertness and coordination.
- Narcotics: Cause drowsiness, dizziness, and impaired judgment.
- Alcohol Use: Affects balance and coordination.
Environmental Risk Factors
- Restraints: Paradoxically, restraints can increase agitation and risk of injury during falls.
- Cluttered Environments: Obstacles and tripping hazards increase fall risk.
- Inadequate Footwear: Slippery or ill-fitting shoes contribute to falls.
Alt Text: Nurse attentively assists senior patient using walker, highlighting fall prevention measures in hospital environment.
Important Note: A “Risk for Falls” nursing diagnosis signifies a potential problem, not an existing one. Therefore, it is not characterized by signs and symptoms. Nursing interventions are proactively focused on prevention.
Expected Outcomes: Goals of Fall Risk Care Planning
When developing a nursing diagnosis care plan for fall risk, clear and measurable goals are essential. Common expected outcomes include:
- The patient will remain free from falls throughout their hospital stay.
- The patient will demonstrate an understanding of fall risk factors and preventative measures.
- The patient will actively participate in maintaining a safe environment, free of potential hazards.
Nursing Assessment: Identifying Patients at Risk
A comprehensive nursing assessment is the first critical step in preventing falls. It involves gathering both subjective and objective data to identify patients at risk.
1. General Health Status Assessment: Evaluate the patient’s overall health, noting any acute or chronic conditions that could impact their safety. This includes:
- Use of assistive devices like hearing aids or glasses.
- Polypharmacy (multiple medications).
- Cognitive status and presence of confusion.
2. Musculoskeletal and Mobility Assessment: Assess muscle strength, coordination, gait, balance, and any limitations due to surgery or injuries. These factors directly affect mobility and fall risk.
3. Morse Fall Scale Administration: Utilize a validated fall risk assessment tool like the Morse Fall Scale. This tool provides a rapid and objective evaluation of fall risk in hospitalized patients. Scores are interpreted as follows:
- 0: No risk.
- 25-44: Low to moderate risk.
- 45+: High risk.
4. Mental Status Evaluation: Assess cognitive function, level of sedation, and presence of hallucinations. Patients with altered mental status may have impaired judgment and be unaware of their limitations.
5. Assistive Device Evaluation: If the patient uses assistive devices, ensure they are appropriate, in good working order, and that the patient knows how to use them correctly.
Alt Text: Nurse utilizes Morse Fall Scale to evaluate patient’s fall risk in hospital room setting.
Nursing Interventions: Implementing Fall Prevention Strategies
Based on the assessment findings and identified risk factors, nurses implement targeted interventions to minimize fall risk. A nursing diagnosis care plan for fall risk should incorporate these evidence-based strategies:
1. Tailored Safety Measures: Select fall prevention interventions based on the patient’s individual risk level and condition. For example:
- An alert young adult might only need non-slip footwear and education.
- An elderly patient with confusion may require a bed alarm and more frequent monitoring.
- Severely confused patients might need restraints or continuous 1:1 supervision as a last resort when other measures fail and safety is severely compromised. Restraint use must always adhere to strict hospital policies and ethical considerations.
2. Promote Appropriate Footwear: Encourage all hospitalized patients to wear non-slip footwear. Many hospitals use color-coded socks to visually identify patients at high fall risk (e.g., yellow socks).
3. Fall Risk Identification Protocols: Utilize visual cues to alert staff to patients at high fall risk. This can include:
- Fall risk wristbands.
- Chart stickers.
- Wall signs placed outside the patient’s room.
4. Clutter Reduction: Maintain a clear and safe patient environment.
- Remove unnecessary furniture.
- Keep cords and IV lines off the floor to eliminate tripping hazards.
5. Ensure Accessibility of Essential Items: Keep the call button and personal items (water, phone, etc.) within easy reach. This minimizes the patient’s need to reach or get out of bed unassisted.
6. Encourage Assistance with Ambulation: Educate and 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 the bed.
8. Patient Education: Engage in open and direct conversations with patients about their specific fall risk factors and the implemented safety measures. This enhances patient understanding and promotes adherence to fall prevention strategies.
9. Interdisciplinary Collaboration: Collaborate with physiotherapy and occupational therapy to:
- Improve patient strength and balance.
- Instruct patients on the safe use of assistive devices (crutches, walkers, etc.).
Nursing Care Plans: Examples for Fall Risk
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 nursing diagnosis care plans for fall risk, illustrating how to apply the principles discussed.
Care Plan #1: Fall Risk related to Improper Walker Use and Orthostatic Hypotension
Diagnostic Statement:
Risk for falls as evidenced by improper use of walker and orthostatic hypotension.
Expected Outcomes:
- Patient will remain free from fall-related injuries.
- Patient will demonstrate correct and safe walker usage.
Assessments:
- Walker Use Evaluation: Observe and document the patient’s technique when using the walker to identify specific errors.
- Medication Review: Analyze the patient’s medication regimen to identify medications that could contribute to orthostatic hypotension.
- Medical History Review: Obtain a detailed medical history, noting conditions that may increase fall risk (stroke, musculoskeletal disorders, etc.).
Interventions:
- Assistive Device Education: Provide individualized instruction and supervision on proper walker use and maintenance. Ensure correct fit and adjustments.
- Exercise Promotion: In collaboration with physical therapy, encourage and assist the patient with exercises to improve gait, balance, and strength.
- Environmental Safety: Ensure adequate room lighting, especially at night, to minimize environmental hazards.
- Fall Risk Identification Band: Apply a fall risk identification wristband to alert all staff.
- Physical Therapy Consultation: Refer to physical therapy for comprehensive assessment and development of a tailored mobility and safety plan.
Care Plan #2: Fall Risk related to Vertigo and Prolonged Bed Rest
Diagnostic Statement:
Risk for falls as evidenced by vertigo and prolonged bed rest.
Expected Outcomes:
- Patient will remain free from falls.
- Patient will experience a reduction in vertigo symptoms and orthostatic hypotension.
Assessments:
- Muscle Strength Assessment: Evaluate muscle strength, recognizing that prolonged bed rest leads to muscle weakness.
- Vertigo History: Obtain a detailed history of vertigo episodes, including frequency, triggers, and associated symptoms.
- Environmental Hazard Assessment: Thoroughly assess the environment for clutter, slippery surfaces, and other potential hazards.
Interventions:
- Environmental Modifications: Implement environmental safety measures, such as lowering the bed, padding the floor if necessary, and using half-side rails for assistance.
- Assisted Transfers: Provide assistance with getting out of bed, acknowledging potential weakness from bed rest.
- Orthostatic Hypotension Precautions: Instruct the patient on slow position changes, dangling legs before standing, and standing slowly to minimize orthostatic hypotension.
- Medication Administration: Administer prescribed medications for vertigo (antihistamines, antiemetics) as ordered.
- Rehabilitation Referral: Refer to physical therapy or other rehabilitation programs focused on strength, balance, and flexibility training.
Care Plan #3: Fall Risk related to Foley Catheter and IV Lines
Diagnostic Statement:
Risk for falls as evidenced by Foley catheter and two IV lines.
Expected Outcomes:
- Patient will remain free from falls.
- Patient will not experience injury related to falls.
Assessments:
- Precipitating Risk Factor Assessment: Identify any underlying factors that increase fall risk beyond the medical devices (history of falls, altered mental status, sensory deficits).
- Environmental Safety Check: Assess the patient’s environment for hazards, paying special attention to potential entanglement with tubes and lines.
- Patient Understanding of Devices: Evaluate the patient’s awareness and understanding of the purpose and management of their Foley catheter and IV lines.
Interventions:
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Environmental Orientation and Safety Measures: Orient the patient to their room and surroundings. Implement comprehensive safety measures, including:
- Bathroom location and accessibility.
- Bed controls and call bell operation.
- Bathroom night light.
- Obstacle-free path to the toilet.
- Bed in low position.
- Non-slip footwear.
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Personal Item Placement: Position personal items and the call bell within easy reach to minimize reaching and potential falls.
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Fall Prevention Protocols: Institute comprehensive fall prevention strategies:
- Use quarter or half-length side rails.
- Maintain bed in the lowest position.
- Ensure bed and commode wheels are locked.
- Dim room lighting at night.
- Emphasize non-slip footwear.
Alt Text: Hospital bed with side rails, call button, and clear pathway, demonstrating safe environment for fall prevention.
By diligently applying these assessment strategies, interventions, and care planning principles, nurses can significantly contribute to a safer hospital environment and reduce the incidence of falls, ultimately improving patient outcomes and well-being.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Dittmer, D. K., & Teasell, R. (1993). Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Canadian family physician Medecin de famille canadien, 39, 1428–1437.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
- 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/
- 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
- Stanton, M.& Freeman, A.M. (2023). Vertigo. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482356/
