Risk for Falls Nursing Diagnosis & Care Plan


The words risk for falls surrounded by health care related vector images

Risk Factors 

  • Intrinsic: (risk factors that arise within the patient)
    • History of previous falls 
    • Age 65 and older 
    • Musculoskeletal disorders (muscle weakness, osteoporosis, spontaneous fracture) 
    • Impaired gait/ balance problems (neurologic disorder)
    • Impaired vision 
    • Mental changes 
    • Incontinence/urgency
    • Acute illness 
    • Neurological disease (stroke, multiple sclerosis, Parkinson disease) 
    • Orthostatic hypotension 
    • Deformities 
    • Limited physical activity 
    • Alcohol use
  • Extrinsic: (risk factors that arise outside of the patient) 
    • Slippery floors/ showers 
    • Cluttered pathways 
    • Poor lighting 
    • Use of assistive devices 
    • Malfunctioning sensory aids/ dirty glasses 
    • Medications/Polypharmacy 
    • Medical equipment (IVs, tubes, drains)

Expected Outcome 

  • The patient will remain free from falls during the hospital stay 
  • The patient will verbalize strategies to prevent from harming self 
  • The patient will demonstrate how to manipulate the environment to make it safer. 

Assessment 

Perform a fall risk assessment any time a patient’s condition changes, the environment changes, after a fall, and at designated times. 

Admission assessment should include a fall risk assessment so that appropriate safety measures can be implemented from the moment of admission. In addition, certain events such as stroke alerts, cardiac events, deterioration in health condition, and environmental changes such as transfers to other units require a new fall risk assessment because such events cause the patient to have a new baseline and require more safety interventions.

Screen the patient for risk factors (see risk factors above) upon admission. 

Previous conditions increase the risk for falls. Being aware of these risk factors right away helps initiate appropriate fall risk measures from the start.

Record patient medications and determine which ones can increase the risk for falls. 

Medications that affect mental status and blood pressure can significantly increase the risk for falls. Also, patients using multiple pharmacies and doctors are at a higher risk for falls due to the risk of drug interactions and increased dosing. Medications associated with falls are anticonvulsants, antidepressants, antipsychotics, benzodiazepines, sedatives, hypnotics, opioids, anticholinergics, antihistamines, muscle relaxers, antihypertensives, and diuretics. 

Assess the patient’s mobility and use of mobility aids. 

Some patients’ ability to walk, stand, and sit might be so compromised that it is safer to use mobility aids such as machines to lift and transfer patients. Using appropriate methods to mobilize patients decreases the risk for falls and injury. 

Use a fall risk tool such as the Morse Fall Scale to determine a fall risk as a numeric value and implement the appropriate safety measures. 

The Morse Fall Score addresses the history of falls, a secondary diagnosis, the use of ambulatory aids, the presence of IVs, the ability to walk and transfer, and the patient’s mental status. Each factor is assigned a numeric score, which accumulates to a score total that determines if the patient is a low, medium, or high fall risk.

Assess the patient’s new environment and review the findings from the home hazard assessment.

Medical equipment, furniture, lighting, unfamiliarity with a new environment, and clutter in the pathway can all increase a patient’s fall risk.

Nursing Interventions for Risk for Falls 

Instruct the patient to use the call button and to wait for assistance before getting up. 

The patient is less likely to fall with assistance. In addition, medical personnel can help assist with safe transfers and ambulation by keeping eyes on medical equipment attached to the patient and being familiar with the room set up. 

Place signs on doors, ceilings, and walls instructing the patient to call before getting up. 

Signs in prominent colors, if possible, can serve as a constant reminder to wait for assistance before getting up and help reinforce instructions from staff. 

Place the patient in a room close to the nurses’ station. 

Having the patient close provides for increased observation and a better ability to respond more quickly if necessary. 

Answer calls promptly. 

Waiting times for assistance in urgent situations (bathroom, repositioning, pain) can become distorted and seem longer, causing the patient to act before help is available. These situations can significantly increase the risk for falls. 

Activate the bed alarm and chair alarm at all times. 

Even with frequent instruction and reminders about waiting for assistance, patients often act alone without waiting. Alarm systems can help with alerting staff that an attempt was made to get up from the chair or bed. 

Place a fall risk armband on the patient. 

A fall risk armband informs all facility personnel that the patient is at a high risk of falling even when away from the room. For example, If the patient is transported to other areas of the facility, such as procedural areas, the staff of that area will be aware of the patient’s fall risk status.

Place the bed in the lowest position possible and a mattress on the floor next to the bed, if appropriate. 

Patients might still climb out of bed despite all fall precautions being implemented. Therefore, these measures might not prevent falls; however, they might reduce the risk for injury. 

Lock bed and chair wheels. 

Having furniture move while sitting down may cause patients to lose their balance. 

Place personal items within close reach. 

Trying to reach items on the table or items placed somewhere else in the room may cause the patient to lose balance and cause him or her to fall. 

Frequently orient the patient to the room arrangement and keep furniture placement the same throughout the hospital stay. 

The patient is less likely to hit or trip over furniture the more familiar he or she is with the room set up. 

Consider OT(Occupational therapy)/PT(Physical consultation). 

Frequent exercises and gait training with PT and OT may help improve muscle strength and balance, decreasing the risk for falls. Furthermore, using canes, walkers, and wheelchairs, if necessary, will add more stability during ambulation and transfers. 

Maintain a toileting schedule throughout the day.

In urgent situations, patients are likely not to wait for assistance. Frequent toileting reduces these situations. 

Remind the patient to use sensory aids such as glasses and hearing aids. 

These devices help the patient be more aware of his or her surroundings reducing the risk for falls. 

Encourage wearing sturdy shoes with non-skid soles. 

Flip-flops, sandals, or socks can have slippery soles that can make the patient fall. Solid shoes provide more stability and help with uneven surfaces. 

Consider having a sitter or 1:1 personnel for high fall risk patients. 

Sitters are with the patient at all times where needs can be addressed immediately. 

Patient Education on Risk for Falls 

Educate the patient and family on using assistive devices correctly and the importance of checking their condition and integrity routinely.

Knowledge about the appropriate use of the devices keeps the patient and family members safer. Ill-fitted and defective mobility devices can increase fall risk.

Instruct the patient and family on how to maintain safety at home. 

Keep walkways free from boxes, electrical cords, and phone cords.
Use tape to secure rugs and remove loose rugs altogether.
Store food, clothes, and toiletries within easy reach.
Adopt the habit to clean up spills right away.
Use non-slip mats in bathtubs and showers.
Use night lights in all rooms and hallways.
Install glow-in-the-dark light switches or motion-sensitive lighting.
Turn on the lights before moving up and down the stairs.
Consider installing these assistive devices: 
Handrails for stairs on both sides from top to bottom 
Raised toilet seat 
Grab bars for showers and bathtubs
A bathtub or shower with a seating area  

Removing fall hazards, keeping the home brightly lit, and using assistive devices help reduce the risk for falls. 

Offer information about resources to aid in improving safety at home. 

Community resources can offer financial assistance to make home modifications to enhance safety. 

Emphasize the importance of continuing mobility. 

Continued exercise can help improve balance, gait, and muscle strength, reducing the risk for falls. 

Encourage the patient to wear an alarm bracelet. 

Emergency response systems will dispatch providers to the scene to assist a person who has fallen and cannot get up independently. 

More Care Plans

Head Injury Nursing Diagnosis & Care Plan

Risk for Bleeding Nursing Diagnosis & Care Plan

Acute Pain Nursing Diagnosis & Care Plan

Knowledge Deficit [Care Plan]

Impaired Physical Mobility Nursing Diagnosis & Care Plan

Impaired Home Maintenance [Care Plan]

Self-Care Deficit [Care Plan]

Ineffective Health Maintenance [Care Plan]

References:

https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf

https://www.the-hospitalist.org/hospitalist/article/123384/fall-risk

https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-MedsLinkedtoFalls-508.pdf

Potter, P., & Perry, A. (2013). Fundamentals of nursing (8th ed.). Elsevier.

Recent Posts