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

Falls represent a significant safety concern within healthcare settings, notably hospitals, and are the most frequently reported safety incidents. Alarmingly, between 30% and 50% of patient falls result in injuries, ranging from minor to severe. While it’s acknowledged that not all falls are preventable, implementing robust safety measures is crucial to mitigate the risk and ensure patient well-being. Studies indicate that a proactive approach, involving the identification of risk factors and the application of tailored interventions, can reduce falls by 20-30%.

Diligent nurses who prioritize comprehensive risk assessment, integrate effective fall prevention strategies, and clearly communicate the rationale behind these precautions to patients are instrumental in achieving optimal patient outcomes and minimizing fall-related incidents. This article delves into the “risk for falls” nursing diagnosis, providing an in-depth understanding of risk factors, assessment techniques, and evidence-based interventions to develop effective care plans focused on patient safety.

Risk Factors Associated with Falls

Identifying patients at risk for falls is the cornerstone of prevention. Numerous factors can contribute to an increased risk, and these can be broadly categorized to facilitate comprehensive assessment and targeted interventions.

Adult-Specific Risk Factors

Certain factors are particularly relevant when assessing fall risk in adult patients:

History of Falls: A prior fall is a significant predictor of future falls. Patients with a history of falls should be considered at higher risk.
Assistive Device Use: While intended to aid mobility, improper or inconsistent use of assistive devices like walkers or canes can paradoxically increase fall risk.
Age 65 Years and Over: Advanced age is independently associated with increased fall risk due to age-related physiological changes.
Lower Limb Prosthesis: Patients using lower limb prostheses may experience balance and gait instability, elevating their risk of falls, especially during the adaptation period or if the prosthesis is ill-fitting.

Physiological Risk Factors

Physiological impairments can significantly compromise balance and stability, contributing to fall risk:

Low Visual Acuity: Impaired vision reduces environmental awareness and obstacle detection, increasing the likelihood of trips and falls.
Hearing Impairment: Hearing deficits can affect spatial orientation and balance, particularly in noisy environments.
Orthostatic Hypotension: A sudden drop in blood pressure upon standing can cause dizziness and lightheadedness, leading to falls.
Incontinence: Urgency and frequency associated with incontinence can lead to rushed movements and falls, especially when navigating to the bathroom.
Impaired Mobility and Strength: Muscle weakness, joint stiffness, and overall reduced mobility directly impact balance and gait stability, increasing fall risk.
Poor Balance: Underlying balance disorders or age-related balance decline are primary fall risk factors.
Confusion: Altered mental status, including confusion, disorientation, and impaired judgment, can lead to unsafe behaviors and increased fall risk.
Delirium: An acute state of confusion and fluctuating awareness significantly impairs safety judgment and increases the likelihood of falls.

Medication-Related Risk Factors

Certain medications can induce side effects that increase the risk of falls:

Antihypertensive Medications: While managing blood pressure, these medications can sometimes cause orthostatic hypotension, a key fall risk factor.
Sedatives: Medications with sedative effects can impair alertness, coordination, and reaction time, significantly increasing fall risk.
Narcotics: Opioid pain medications can cause drowsiness, dizziness, and confusion, all of which contribute to an elevated fall risk.
Alcohol Use: Alcohol consumption impairs balance, coordination, and judgment, substantially increasing the risk of falls.

Environmental Risk Factors

The immediate environment plays a crucial role in patient safety and fall prevention:

Restraints: While intended for safety, restraints can paradoxically increase fall risk if patients attempt to overcome them or experience complications from immobility. Note: Restraints should be a last resort and used with strict protocols.
Cluttered Environments: Obstacles such as equipment, furniture, and spills create tripping hazards and increase the risk of falls.
Inadequate Footwear: Slippery or ill-fitting footwear can compromise stability and increase the likelihood of falls.

Important Note: The “risk for falls” nursing diagnosis is a risk diagnosis. This means that the problem (a fall) has not yet occurred. Therefore, it is not evidenced by signs and symptoms but by the presence of risk factors. Nursing interventions are proactively focused on prevention.

Expected Outcomes for Fall Prevention

When developing a nursing care plan for “risk for falls,” clearly defined and measurable expected outcomes are essential. These outcomes guide interventions and provide a framework for evaluating the effectiveness of the care plan. Common expected outcomes include:

Patient Will Remain Free of Falls: This is the primary and overarching goal.
Patient Will Demonstrate a Safe Environment Free From Potential Hazards: This outcome focuses on patient and staff actions to maintain a safe environment.
Patient Will Verbalize Understanding of Risk Factors for Falls: Patient education and engagement are crucial for adherence to fall prevention strategies.

Nursing Assessment for Fall Risk

A thorough nursing assessment is the foundation of effective fall prevention. It involves gathering both subjective and objective data to identify individual risk factors and tailor interventions.

1. Assess the Patient’s General Health Status: Evaluate the patient for acute and chronic conditions that may impact safety. This includes:

Sensory Aids: Note the use of and need for hearing aids or eyeglasses and whether they are used consistently and are effective.
Polypharmacy: Identify the number and types of medications the patient is taking, paying attention to medications known to increase fall risk (sedatives, antihypertensives, etc.).
Cognitive Status: Assess for confusion, disorientation, or memory deficits, which can impair safety judgment.

2. Assess Muscle Strength, Coordination, and Use of Devices: Evaluate the patient’s physical capabilities:

Strength and Mobility: Assess muscle strength in upper and lower extremities, range of motion, gait, and balance. Note any weakness, paralysis, or mobility limitations.
Recent Surgery or Injuries: Consider the impact of recent surgeries or physical injuries on coordination, gait, and balance.

3. Utilize the Morse Fall Scale: Implement a standardized fall risk assessment tool like the Morse Fall Scale. This widely used scale provides a rapid and reliable method to identify fall risk in hospitalized patients.

Morse Fall Scale Scoring: Understand the scoring system:
- 0: No risk
- 1-24: Low risk
- 25-44: Moderate risk
- 45+: High risk

4. Evaluate Mental Status: Assess the patient’s cognitive function and level of consciousness:

Orientation and Alertness: Determine if the patient is oriented to person, place, and time. Assess their level of alertness and identify any sedation or lethargy.
Hallucinations or Delusions: Note any presence of hallucinations or delusions, which can significantly impair safety awareness and judgment.

5. Evaluate the Use of Assistive Devices: If the patient uses assistive devices:

Device Appropriateness: Ensure the patient has the necessary devices (walker, cane, bedside commode) and that they are appropriate for their needs.
Proper Use: Assess the patient’s understanding and ability to use devices correctly and safely.

Nursing Interventions for Fall Prevention

Nursing interventions are crucial in mitigating identified fall risks and creating a safer environment for patients. Interventions should be individualized based on the patient’s specific risk factors and needs.

1. Incorporate Appropriate Safety Measures: Select and implement fall prevention interventions tailored to the patient’s condition and risk level.

Risk-Stratified Interventions: Match the intensity of interventions to the level of risk. For example, a young, alert patient may only need non-slip footwear and education, while an elderly, confused patient may require bed alarms and more intensive supervision.
Bed Alarms: Utilize bed alarms for patients at moderate to high risk, particularly those with confusion or mobility limitations.
Restraints (Last Resort): Use restraints only as a last resort for severely confused patients who pose an immediate safety risk to themselves and cannot be safely managed with less restrictive measures. Adhere to strict institutional policies and ethical considerations regarding restraint use. Continuous reassessment and appropriate documentation are essential.
1:1 Supervision: In cases of extreme risk, continuous 1:1 supervision may be necessary to ensure patient safety.

2. Provide Footwear and Encourage Use: Promote the consistent use of non-slip footwear for all hospitalized patients.

Non-Slip Socks: Utilize hospital-provided non-slip socks, often color-coded (e.g., yellow for high fall risk) to visually alert staff.
Patient Education: Educate patients and families about the importance of wearing non-slip footwear at all times while ambulating in the hospital.

3. Utilize Fall Risk Identification: Employ visual cues to communicate fall risk to all staff members.

Fall Risk Identifiers: Use patient wristbands (color-coded), chart stickers, and door/wall signs to clearly indicate patients at high risk for falls.
Staff Communication: Ensure all staff members are aware of and understand the meaning of fall risk identifiers.

4. Keep the Patient’s Room Free of Clutter: Maintain a safe and organized patient environment.

Remove Hazards: Eliminate excess furniture, equipment, and clutter from the patient’s room.
Cord Management: Keep electrical cords and IV lines off the floor and safely routed to prevent tripping hazards.
Spill Management: Promptly clean up any spills to prevent slippery surfaces.

5. Keep the Call Button and Personal Items Within Reach: Ensure patient accessibility to essential items.

Proximity of Items: Before leaving the room, always verify that the call button, water, phone, and other personal items are within easy reach of the patient.
Education on Call Button Use: Instruct the patient on how to use the call button to request assistance and emphasize its importance for safety.

6. Encourage Assistance When Getting Out of Bed: Promote safe patient transfers.

Requesting Assistance: Encourage patients to use the call button and request staff assistance when needing to get out of bed or chair, especially for toileting or ambulation.
Education on Safe Transfers: Educate patients on the risks of attempting to get up unassisted, particularly if they are weak, dizzy, or taking medications that affect balance.

7. Keep the Bed in the Lowest Position: Maintain bed safety.

Low Bed Height: Except when actively providing care at the bedside that requires raising the bed for ergonomic reasons, keep the bed consistently in the lowest position.
Rationale for Low Bed: Explain to patients and families that keeping the bed low minimizes injury risk in case of an accidental fall from the bed.

8. Educate the Patient on Their Fall Risk Factors: Engage patients in their care through education.

Individualized Education: Have open and direct conversations with patients about their specific risk factors that contribute to their fall risk.
Explanation of Safety Measures: Explain the fall prevention strategies being implemented and the rationale behind them to enhance patient understanding and cooperation.
Active Participation: Encourage patients to actively participate in their fall prevention plan by following safety instructions and communicating any concerns.

9. Coordinate with Physiotherapy and Occupational Therapy: Utilize interprofessional collaboration.

Therapy Consults: Request physiotherapy (PT) and occupational therapy (OT) consultations to assess and address mobility, strength, balance, and functional limitations.
Rehabilitation and Equipment: PT and OT can develop individualized exercise programs to improve strength and balance, instruct patients on the proper use of assistive devices (crutches, walkers), and recommend environmental modifications as needed.

Nursing Care Plan Examples for Risk for Falls

Nursing care plans provide a structured framework for organizing assessments and interventions to achieve patient-centered goals. Here are two examples of care plans for the “risk for falls” nursing diagnosis:

Care Plan #1

Diagnostic Statement: Risk for falls as evidenced by improper use of walker and orthostatic hypotension.

Expected Outcomes:

Patient will be free of injury related to falls.
Patient will demonstrate the proper use of a walker by [specific date/discharge].

Assessment:

Evaluate Walker Use: Observe and document how the patient uses their walker. Identify specific errors in technique (e.g., improper height adjustment, incorrect gait pattern, not using it consistently). Rationale: Identifying specific errors is crucial for developing targeted health teaching and skills training.
Review Medication Regimen: Obtain a detailed medication history, noting all prescribed and over-the-counter medications, dosages, and administration times. Pay particular attention to medications known to cause orthostatic hypotension (e.g., antihypertensives, diuretics). Rationale: Polypharmacy and specific medication classes can contribute to orthostatic hypotension and fall risk.
Obtain Complete Medical History: Gather information about past medical conditions, including history of stroke, brain injury, musculoskeletal disorders, and cardiovascular conditions. Rationale: Certain medical conditions can predispose patients to balance problems, weakness, and increased fall risk.

Interventions:

Assist with Assistive Device Use and Maintenance:
- Provide individualized instruction and demonstration on the correct use of the patient’s walker.
- Ensure the walker is properly adjusted to the patient’s height.
- Educate the patient on the importance of using the walker consistently as recommended.
- Provide written instructions and visual aids if appropriate.
- Rationale: Correct use and maintenance of assistive devices are essential for safety and fall prevention.
Engage in Exercise Routines:
- Collaborate with physiotherapy to develop an individualized exercise program focusing on gait, balance, and lower extremity strengthening exercises.
- Encourage participation in prescribed exercises at least [frequency, e.g., twice daily].
- Rationale: Exercise can improve strength, balance, and coordination, reducing fall risk.
Provide Proper Room Lighting:
- Ensure adequate lighting in the patient’s room, especially during nighttime hours.
- Provide a night light to illuminate the path to the bathroom.
- Rationale: Adequate lighting reduces environmental hazards and improves visibility, especially for patients with visual impairments or nocturnal disorientation.
Provide Fall Risk ID Wristband:
- Apply a fall risk identification wristband (e.g., yellow) to the patient’s wrist per hospital protocol.
- Rationale: Wristbands provide a visual cue to all healthcare staff that the patient is at increased fall risk.
Collaborate with Physical Therapy:
- Initiate a physical therapy referral for a comprehensive mobility and balance assessment.
- Actively communicate with the physical therapist regarding the patient’s progress and any challenges.
- Rationale: Physical therapists are experts in mobility and balance rehabilitation and can provide specialized interventions and recommendations.

Care Plan #2

Diagnostic Statement: Risk for falls as evidenced by vertigo and prolonged bed rest.