A fall is an event that occurs when a person at rest accidentally comes to the ground or a lower area.
A patient’s fall risk is highly associated with serious injuries including death. According to the World Health Organization (WHO), falls are a high risk major public health problem, and is considered as the second leading cause of accidental deaths.
The rates are recorded to be higher in the older population with the age of 60 years and above.
Risk Factors
The following are the known fall risk factors that can affect the severity of injuries:
- Age
- Gender. A fall can occur in both genders. However, it is noted that men are more likely to die from it than women.
- Other known risk factors for patient falls include:
- Occupational hazards
- Altered Mental Status
- Alcohol and/or substance use
- Socioeconomic factors such as overcrowded housing
- Underlying medical conditions affecting physical, neurologic, and cardiac wellbeing
- Poor mobility, cognition, and vision
- Unsafe environment
Expected Outcomes & Goals for Fall Risk
- The patient will understand the importance of using assistive devices and extra measures for preventing falls.
- The patient will maintain the ability to perform activities of daily living without having a fall.
- Patient will maintain safety by having no falls and fall-related injuries.
- The patient will be able to prevent a fall by means doing activities that can be done within the parameters of visual limitation and by modifying environment to adapt to current vision capacity.
Nursing Assessment for Fall Risk
History of falls: Inquire about any previous falls the patient has experienced.
Medication review: Assess the patient’s current medications, including prescription drugs, over-the-counter medications, and supplements.
Mobility and gait assessment: Observe the patient’s ability to move and walk independently. Evaluate their balance, coordination, and any difficulties they may have while walking or transferring.
Vision assessment: Assess the patient’s visual acuity and any visual impairments.
Environmental assessment: Evaluate the patient’s living environment, including their home or healthcare setting.
Cognitive assessment: Assess the patient’s cognitive function, including memory, attention, and decision-making abilities.
Orthostatic hypotension evaluation: Check the patient’s blood pressure and heart rate in different positions (lying, sitting, and standing).
Assess for urinary incontinence: Inquire about any issues related to urinary incontinence.
Use of assistive devices: Determine if the patient requires assistive devices such as canes, walkers, or wheelchairs for mobility.
Nursing Interventions for Fall Risk
Below you will find nursing interventions for risk for falls along with rationales
Implement fall prevention protocols: Adhere to established fall prevention protocols within the healthcare facility. Rationale: These protocols are designed to identify patients at risk for falls and guide the implementation of preventive measures based on evidence-based practices.
Ensure adequate supervision: Provide close supervision and frequent checks for patients who are at high risk for falls. Rationales: This ensures that assistance is readily available and helps prevent accidents or falls during unsupervised activities.
Assist with mobility and transfers: Help patients with mobility and transfers, especially those who have impaired balance or mobility difficulties. Rationale: Offering assistance during activities such as walking, getting in and out of bed, or moving from sitting to standing can minimize the risk of falls.
Educate patients and family members: Provide education to patients and their families about fall prevention strategies. Rationale: This includes teaching patients how to use assistive devices properly, raising awareness about potential hazards in the environment, and encouraging them to report any changes in their condition that may increase fall risk.
Promote a safe environment: Identify and eliminate potential hazards in the patient’s environment, both in healthcare settings and at home. Rationale: This may involve removing clutter, ensuring good lighting, maintaining clear pathways, and using safety equipment such as grab bars or non-slip mats.
Review and adjust medication regimens: Collaborate with the healthcare provider to review the patient’s medication regimen and identify any drugs that may contribute to fall risk. Rationale: Adjustments can be made, such as reducing dosages, changing medications, or scheduling doses at times that minimize the impact on balance and coordination.
Encourage regular exercise and physical therapy: Promote regular exercise programs and physical therapy for patients at risk of falls. Rationale: These interventions help improve strength, balance, and mobility, reducing the likelihood of falls.
Implement a call light system: Ensure that patients have access to call bells or call buttons within easy reach. Rationale: This allows them to request assistance promptly when needed, reducing the likelihood of falls during attempts to move or perform activities independently.
Encourage appropriate footwear: Educate patients about the importance of wearing proper footwear, such as non-slip shoes or slippers with good traction. Rationale: This helps maintain stability and reduces the risk of slipping or tripping.
Risk for Falls Nursing Care Plan & Nursing Diagnoses
When writing a risk for fall nursing nursing care plan, several nursing diagnosis at risk for falls can be applied.
Osteoporosis
Nursing Diagnosis: Risk for falls related to major bone loss secondary to osteoporosis.
Parkinson’s Disease (PD)
Falls Nursing Diagnosis: Risk of falls related to cognitive impairment secondary to the disease process of Parkinson’s Disease
Orthostatic Hypotension
Nursing Diagnosis: Risk for falls related to previous fainting secondary to orthostatic hypotension
Glaucoma
Nursing Diagnosis: Risk for Fall related to loss of vision and/or reduced visual acuity secondary to glaucoma.
Epilepsy
Nursing Diagnosis: Risk for Fall related to loss of sensory coordination and muscular control. (Epilepsy)
Sample NCLEX Nursing Test Questions for Risk for Falls
Question 1: Which of the following medications is most likely to contribute to an increased risk of falls in an elderly patient?
A) Antihypertensive medication
B) Analgesic medication
C) Anticoagulant medication
D) Antidepressant medication
Answer: D) Antidepressant medication
Rationale: Antidepressant medications, especially those with sedating effects such as tricyclic antidepressants (TCAs) or benzodiazepines, can cause drowsiness, dizziness, and impaired balance, increasing the risk of falls in elderly patients.
Question 2: A patient with a history of falls is at risk for injury due to impaired mobility. Which of the following interventions should the nurse prioritize to minimize the risk of falls?
A) Encouraging the use of a cane or walker
B) Ensuring proper lighting in the patient’s room
C) Providing a medication review
D) Implementing a call bell system
Answer: A) Encouraging the use of a cane or walker
Rationale: Encouraging the use of assistive devices, such as a cane or walker, can provide stability and support during mobility, reducing the risk of falls in a patient with impaired mobility.
Question 3: A nurse is performing a fall risk assessment for an elderly patient. Which of the following factors should the nurse prioritize in the assessment?
A) The patient’s visual acuity
B) The patient’s cognitive function
C) The patient’s blood pressure in different positions
D) The patient’s history of falls
Answer: D) The patient’s history of falls
Rationale: The patient’s history of falls is an essential factor to assess as it helps identify their previous fall experiences and provides insights into potential risk factors or causes, helping to determine the likelihood of future falls.
Question 4: Which of the following interventions is most effective in reducing the risk of falls related to orthostatic hypotension?
A) Implementing a medication review
B) Assisting the patient with transfers
C) Encouraging regular exercise
D) Monitoring the patient’s blood pressure
Answer: A) Implementing a medication review
Rationale: Orthostatic hypotension, a drop in blood pressure upon standing, can contribute to falls. Reviewing the patient’s medication regimen can help identify medications that may exacerbate this condition and contribute to falls, allowing for adjustments or alternative treatment options to be considered.
Question 5: Which of the following factors should the nurse prioritize when conducting an environmental assessment to prevent falls?
A) Clutter in the patient’s room
B) The patient’s level of mobility
C) The patient’s blood pressure
D) The patient’s history of falls
Answer: A) Clutter in the patient’s room
Rationale: Clutter in the patient’s room can increase the risk of falls by creating obstacles or tripping hazards. Prioritizing the removal of clutter and maintaining clear pathways helps create a safer environment and reduces the likelihood of falls.
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
Disclaimer:
Please follow your facility’s guidelines and policies and procedures.
The medical information on this site is provided as an information resource only and should not be used or relied on for diagnostic or treatment purposes.
This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.
