Risk for Falls Nursing Diagnosis and Nursing Care Plans

Risk for Falls Nursing Care Plans Diagnosis and Interventions

Risk for Falls NCLEX Review and 5 Nursing Care Plans

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.

The injuries related to falls may vary depending on the situations involved and the age, gender, and health of the individual who sustained the fall.

The following are the known fall risk factors that can affect the severity of injuries:

  • Age. Age is one of the key risk factors for falls. Older people are known to be at an increased risk for falls and fall-related injuries. This may be due to a decline in their physical, sensory, and cognitive ability i.e. mental status. Aside from old age, children are also known to be at a higher risk of sustaining falls and fall-related injuries. This is caused by their evolving developmental stages, their innate curiosity to explore things, and their general behavior as children.
  • 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:
    • 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

Risk for Falls Nursing Diagnosis

Risk For Falls Nursing Care Plan 1

Osteoporosis

Nursing Diagnosis: Risk for falls related to major bone loss secondary to osteoporosis

Desired Outcome: The patient will understand the importance of using assistive devices and extra measures for preventing falls.

Nursing Interventions For Fall RiskRationales
Complete a fall risk assessment. *Factors contributing to falls risk.
*Functional ability.
*Use of mobility devices
The use of a standard tool will help identify the status of the patient’s risk for falling and will help determine the factors contributing to the high risk for falls.
Assess for fractures.Osteoporosis leads to a loss in bone mass which predisposes patients to fractures.
Provide identification to alert everyone of the high risk for fall.This will help healthcare staff, families and friends acknowledge the need for caution when dealing with the patient.
Put the bed at the lowest level.Low set beds reduce the possibility of falls and serious injuries related to falls.
Explain the bed settings to the patient including how bed remote controls works.Allowing patients to set their own bed minimizes the risk of them jumping off the bed while it is at a higher position.
Place items within the patient’s reach.Items far away from the patient’s reach may contribute to falls and fall-related injuries.
Evaluate patient’s understanding of the use of mobility assistive devices such as zimmer frame and crutches.Improper use of mobility devices may cause more harm than good.
Assess the proper size and height of the mobility device to the patient’s physique.Using the wrong size on mobility devices does not give full mobility support to patients and may even cause further problems such as falls and fall-related injuries.
Assess the need for pain medications.Osteoporosis patients that had recent fracture/s may experience pain; and pain leads to unstable gait and mobility.
Referral to physiotherapy and occupational therapy.Patients with osteoporosis may need therapies to help them regain independence and lower their risk of falling.

Risk For Falls Nursing Care Plan 2

Parkinson’s Disease (PD)

Falls Nursing Diagnosis: Risk of falls related to cognitive impairment secondary to the disease process of Parkinson’s Disease

Desired Outcome: The patient will maintain the ability to perform activities of daily living without having a fall.

Nursing Interventions For Fall RiskRationale
Complete fall risk assessment.Creating an accurate status of the patient’s fall risk will help determine the needed interventions to help prevent falls from happening
Assess cognitive ability.PD can affect the neurocognitive status of the patient. This assessment of their cognitive ability will help identify the gaps and lapses in memory and judgment which will lead the care plan and identify care needs.
Assess the patient’s environment.Trip hazards can increase the risk of the patient falling. Also, making the environment familiar will improve navigation for the patient
Assess ability to complete activities of daily living and assist as needed.PD can also affect the patient’s ability to perform simple tasks. Identifying the lapses in personal care will help identify the patient’s changing care needs.
Ensure the availability of mobility assistive devices.Mobility aids should be kept within the patient’s reach to avoid accidental falls.
Ensure the safety of the patient’s environment through the following:
*Declutter the space.
*Avoid wet floors.
*Provide adequate lighting.
*Provide proper shoes/slippers.
*Bed at the lowest level.
*Valuables should be within reach
The safety of the environment plays a vital role in providing safety and avoiding trips and falls.
Provide an adequate time when completing a task.PD greatly affects the person’s movement. Tasks may take longer to perform.
Ensure regular intake of Parkinson’s medications.The regular intake of medications for PD improves the patient’s gait and muscle coordination which lessens the risk of the patient from falling.
Refer to physiotherapy and occupational therapy.PT and OT are helpful in promoting patient’s mobility and independence.

Risk For Falls Nursing Care Plan 3

Orthostatic Hypotension

Nursing Diagnosis: Risk for falls related to previous fainting secondary to orthostatic hypotension

Desired Outcome: Patient will maintain safety by having no falls and fall-related injuries.

Nursing Interventions For Fall RiskRationales
Obtain baseline vital signs and monitor for signs of dizziness.Baseline data provides for comparison for future measurements. It will also give information of the normal statistics on the patient when at rest.
Ensure the safety of the environment through the following:
*The patient’s bed should be at the lowest possible level.
*Provide adequate lighting.
*The patient’s valuables should be within reach.
*Provide call bell and teach the patient how to use it.
*Show the patient how to use the bed controls  
A safe environment will minimize possible injuries in case a fall happens. Also, putting patient’s valuables within reach will minimize the need for the patient to walk around and stand up which may trigger an attack.
Promote proper hydration.Hypovolemia can lower blood pressure even more increasing risk for falls.
Assist the patient with mobility aids when going around the room or when using the toilet.The presence of a second person will provide the opportunity for a quicker response when help is needed in case fainting occurs.
Provide an adequate time when taking showers or using the toilet.The patient will need to take time when changing position.
Ensure the availability of a call bell when in the toilet.Fainting can occur anywhere. Having a call light in place will improve the patient’s confidence to carry out activities as usual.
Monitor vital signs regularly including lying and standing blood pressure.Regular monitoring of blood pressure will help map out the progress of the patient’s condition.

Risk For Falls Nursing Care Plan 4

Glaucoma

Nursing Diagnosis: Risk for Fall related to loss of vision and/or reduced visual acuity secondary to glaucoma

Desired Outcome: 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 Interventions For Fall RiskRationale
Assess the patient’s degree of visual impairment.To establish a baseline of visual acuity and gain useful information before modifying the patient’s environment.  
Place the bed in the lowest position. Place the call bell within reach (if admitted) and keep the visual aids and patient’s phone and other devices within reach.To prevent patient fall.
Promote adequate lighting in the patient’s room.To promote appropriate safety measures and support to the patient in doing ADLs optimally.
Ensure that the floor is free of objects that can cause the patient to slip or fall.To promote safety measures and support to the patient in doing ADLs optimally.
Advise the patient to wear sunglasses especially when going outdoors.To reduce glare and help protect the eyes.

Risk For Falls Nursing Care Plan 5

Epilepsy

Nursing Diagnosis: Risk for Fall related to loss of sensory coordination and muscular control

Desired Outcome: The patient will be able to prevent fall by means of maintaining his/her treatment regimen in order to control or eliminate seizure activity.

Nursing Interventions For Fall RiskRationale
Explore the usual seizure pattern of the patient and enable to patient and caregiver to identify the warning signs of an impending seizure.To empower the patient and his/her caregiver to recognize a seizure activity, and help protect the patient from any serious injury or trauma. To reduce the feeling of helplessness on both the patient and the caregiver.  
Create a seizure chart, a falls risk assessment, and a bed rails assessment.To effectively assess and monitor the patient’s seizure activity and falls risk, as well as the need to use bed rails.
Place the bed in the lowest position. Put pads on the bed rails and the floor.To prevent or minimize injury in a patient during a seizure.
Advise the caregiver to stay with the patient during and after the seizure.To promote safety measures and support to the patient. To ensure that the patient is safe if the seizure recurs.
Administer anti-epileptic drugs as prescribed.To prevent the occurrence of seizures and treat epilepsy.
During seizure, turn the patient’s head to the side, and suction the airway if needed. Do not leave the patient. Ask for another member of staff for help as needed.To maintain a patent airway and to promote patient’s safety during seizure.      

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.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

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.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any 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.

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Anna C. RN, BSN, PHN

Anna C. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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