Nursing Diagnosis: Risk for Falls – Comprehensive Care Plan for Patient Safety

Falls in hospitals are a significant concern, being the most frequently reported safety incident among patients. Alarmingly, 30-50% of these falls lead to injuries, ranging from minor to severe. While not all falls can be prevented, implementing robust safety measures is crucial to minimize the risk. In fact, fall rates can be reduced by 20-30% when risk factors are accurately identified and addressed with targeted interventions.

Diligent nurses play a pivotal role in patient safety by proactively assessing fall risk factors, implementing preventive strategies, and clearly communicating these precautions to patients. This comprehensive approach is essential for achieving the best possible patient outcomes.

Risk Factors for Falls

Identifying risk factors is the first critical step in preventing falls. These factors can be broadly categorized:

Adult Risk Factors

• History of Falls: Patients with a previous fall are at significantly higher risk.
• Assistive Device Use: Reliance on devices like walkers or canes can indicate underlying mobility issues.
• Age 65 or Over: Older adults are more susceptible to falls due to age-related physiological changes.
• Lower Limb Prosthesis: Prosthesis use can affect balance and coordination, increasing fall risk.

Physiological Risk Factors

• Low Visual Acuity: Impaired vision hinders environmental awareness and obstacle avoidance.
• Hearing Impairment: Difficulty hearing may reduce awareness of verbal cues and environmental sounds.
• 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, paralysis, or pain can significantly compromise balance and gait.
• Poor Balance: Underlying neurological or musculoskeletal conditions can impair balance control.
• Confusion: Altered mental status reduces awareness of surroundings and safety precautions.
• Delirium: Acute confusional states are strongly associated with increased fall risk.

Medication-Related Risk Factors

• Antihypertensive Medications: Can contribute to orthostatic hypotension.
• Sedatives: Impair alertness and coordination.
• Narcotics: Cause drowsiness, dizziness, and reduced reaction time.
• Alcohol Use: Impairs balance, coordination, and judgment.

Environmental Risk Factors

• Restraints: Paradoxically, restraints can increase fall risk during attempts to escape them.
• Cluttered Environments: Obstacles in the patient’s path increase tripping hazards.
• Inadequate Footwear: Slippery or ill-fitting shoes contribute to falls.

Note: A “risk for” diagnosis indicates a potential problem that hasn’t yet occurred. Nursing interventions are therefore focused on proactive prevention.

Expected Outcomes: Goals of Fall Prevention Care

Effective nursing care planning aims to achieve the following outcomes:

• Patient will remain free from falls during hospitalization.
• Patient will demonstrate a safe environment, free of potential fall hazards.
• Patient will verbalize understanding of their individual risk factors for falls and preventive measures.

Nursing Assessment: Identifying Patients at Risk

A thorough nursing assessment is the foundation of fall prevention. It involves gathering comprehensive data:

1. General Health Status Evaluation:

• Assess for acute and chronic conditions that may impact safety, such as visual or hearing impairments, polypharmacy (multiple medications), and cognitive status.
• For example, note if the patient uses hearing aids or glasses, which are crucial for sensory perception and environmental awareness. Polypharmacy increases the risk of drug interactions and side effects like dizziness. Confusion can significantly impair judgment and safety awareness.

2. Muscle Strength, Coordination, and Device Use Assessment:

• Evaluate muscle strength in all extremities, coordination, gait, and balance. Note any limitations or abnormalities.
• Assess for recent surgeries, injuries, or conditions that may impair mobility and balance.
• Determine if the patient uses any assistive devices (walkers, canes, etc.) and their proficiency in using them. Decreased strength, post-surgical weakness, and physical injuries directly affect coordination and balance, increasing fall risk.

3. Morse Fall Scale Administration:

• Utilize the Morse Fall Scale, a validated tool for rapid fall risk assessment in hospitalized patients.
• Calculate the score based on the scale’s parameters. A score of 0 indicates no risk, 25-44 indicates low to moderate risk, and 45 or greater signifies high risk. This standardized tool provides a quantifiable measure of fall risk, guiding the intensity of preventive interventions.

4. Mental Status Evaluation:

• Assess cognitive function, orientation, and level of sedation.
• Note any presence of confusion, delirium, or hallucinations. Patients with altered mental status may overestimate their abilities or forget their limitations, leading to unsafe actions.

5. Assistive Device Evaluation:

• Confirm the patient has necessary assistive devices readily available, such as walkers, bedside commodes, or grab bars.
• Ensure the patient knows how to use each device correctly and safely. Proper use of assistive devices is paramount for safe mobility.

Nursing Interventions: Implementing Fall Prevention Strategies

Based on the assessment, nurses implement targeted interventions to mitigate fall risks:

1. Implement Appropriate Safety Measures:

• Select fall prevention interventions tailored to the patient’s specific condition and risk level.
• A young, alert patient may only require a walker, while an elderly, confused patient might need a bed alarm and closer supervision.
• For severely confused patients unable to follow directions, consider restraints or 1:1 supervision as a last resort, always prioritizing safety while minimizing restrictions. Restraints should only be used when less restrictive measures have failed and patient safety is severely compromised.

2. Provide and Encourage Proper Footwear:

• Advise all hospitalized patients to wear non-slip footwear at all times.
• Utilize hospital-provided, color-coded socks, often yellow, to visually identify patients at high fall risk. Non-slip footwear significantly improves traction and stability.

3. Utilize Fall Risk Identification:

• Employ visible fall risk alerts such as patient wristbands, chart stickers, and room signage.
• These identifiers immediately communicate the patient’s high fall risk to all staff members involved in their care.

4. Maintain a Clutter-Free Environment:

• Remove unnecessary furniture and equipment from the patient’s room.
• Ensure clear pathways by keeping cords, tubes, and IV lines off the floor. A tidy environment minimizes tripping hazards and allows for safer ambulation.

5. Keep Call Button and Personal Items Within Reach:

• Before leaving the room, always position the call button, water, phone, and other personal items within easy reach of the patient.
• This reduces the patient’s need to reach or get out of bed unassisted, preventing potential falls when attempting to access necessities.

6. Encourage Assistance with Ambulation:

• Educate and encourage patients to use their call button and request assistance whenever they need to get out of bed, especially for toileting.
• Promote a “call, don’t fall” approach to ensure safe mobility.

7. Keep Bed in Lowest Position:

• Maintain the bed in the lowest position at all times, except when actively providing care that necessitates raising it.
• Lower beds minimize the distance of a potential fall from the bed, reducing injury severity.

8. Patient Education on Fall Risk Factors:

• Engage in open and direct conversations with patients about their individual fall risk factors and the specific safety measures in place.
• Explain the rationale behind fall precautions to enhance patient understanding and compliance. Informed patients are more likely to actively participate in fall prevention.

9. Coordinate with Therapy Services:

• Collaborate with physiotherapy and occupational therapy to address underlying mobility and balance deficits.
• Therapists can provide tailored exercises to improve strength and balance, and instruct patients on the correct use of assistive equipment like crutches or walkers.

Nursing Care Plans: Examples for Risk for Falls

Nursing care plans provide structured frameworks for individualized patient care. Here are examples:

Care Plan #1

Diagnostic Statement:

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

Expected Outcomes:

• Patient will remain free from injury during hospitalization.
• Patient will demonstrate correct and safe use of a walker.

Assessment:

1. Walker Use Evaluation:

• Assess the patient’s technique when using the walker, noting any deviations from correct usage. Identifying specific errors allows for targeted teaching and skill refinement.

2. Medication Regimen Review:

• Review all current medications, noting dosages, frequency, and classes, particularly antihypertensives or diuretics. This helps identify potential medication-related causes of orthostatic hypotension.

3. Medical History Review:

• Obtain a comprehensive medical history, including past and present conditions. Conditions such as stroke, brain injury, or musculoskeletal disorders can predispose patients to falls.

Interventions:

1. Assistive Device Education and Support:

• Provide thorough education and hands-on training on the proper use and maintenance of the walker.
• Ensure the walker is correctly sized and adjusted for the patient. Correct device fit and usage are crucial for safety and stability.

2. Implement Exercise Program:

• Collaborate with the patient to establish a safe and appropriate exercise routine, focusing on balance and strengthening exercises.
• Exercise can improve gait, balance, and lower extremity strength, reducing fall risk.

3. Optimize Room Lighting:

• Ensure adequate room lighting, especially during nighttime hours.
• Provide a nightlight to improve visibility during nighttime ambulation. Good lighting reduces environmental hazards and improves safety, especially for patients with visual impairments.

4. Fall Risk Identification Wristband:

• Apply a fall risk identification wristband to the patient.
• This visual cue alerts all healthcare staff to the patient’s increased fall risk, prompting consistent fall precautions.

5. Physical Therapy Consultation:

• Consult with physical therapy for a comprehensive mobility assessment and tailored exercise plan.
• Physical therapists are experts in mobility and can recommend specific exercises and assistive devices to optimize patient safety and independence.

Care Plan #2

Diagnostic Statement:

Risk for falls related to vertigo and prolonged bed rest.

Expected Outcomes:

• Patient will remain free of falls during hospitalization.
• Patient will experience a reduction in vertigo symptoms, visual disturbances, and orthostatic hypotension.

Assessment:

1. Muscle Strength Assessment:

• Evaluate muscle strength in upper and lower extremities. Prolonged bed rest leads to muscle deconditioning and weakness, increasing fall risk.

2. Vertigo History:

• Obtain a detailed history of vertigo episodes, including frequency, duration, triggers, and associated symptoms like dizziness or visual disturbances. Understanding the nature of vertigo is crucial for targeted interventions.

3. Environmental Hazard Assessment:

• Assess the patient’s immediate environment for potential hazards such as clutter, spills, slippery floors, and unsecured rugs. Removing environmental obstacles minimizes tripping risks.

Interventions:

1. Environmental Risk Factor Modification:

• Keep the bed in the lowest position. Consider using a raised edge mattress or padding the floor if indicated for high-risk patients.
• Use half-side rails to assist with bed mobility rather than full rails, which can paradoxically increase fall risk for some patients attempting to climb over them. These modifications minimize injury risk should a fall occur.

2. Assisted Transfers and Mobility:

• Provide assistance with all transfers, particularly getting out of bed, due to potential weakness from bed rest.
• Gradual mobilization is crucial to prevent orthostatic hypotension and falls in deconditioned patients.

3. Implement Gradual Position Changes:

• Instruct the patient to change positions slowly, sit on the edge of the bed for a few minutes before standing, and stand beside the bed momentarily before walking.
• These techniques help mitigate orthostatic hypotension by allowing the body to adjust to positional changes.

4. Medication Administration for Vertigo:

• Administer prescribed medications for vertigo, such as antihistamines or antiemetics, as ordered by the physician.
• Medications can help manage vestibular symptoms and reduce vertigo-related fall risk.

5. Physical Therapy Referral for Rehabilitation:

• Refer the patient to physical therapy for vestibular rehabilitation and exercises focused on strength, balance, flexibility, and endurance.
• Targeted exercise programs are proven to reduce fall rates and improve overall stability.

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.
2. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
3. 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.
4. 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.
5. Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
6. 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/
7. 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
8. Stanton, M.& Freeman, A.M. (2023). Vertigo. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482356/