Need help for risk for falls careplan

AliNajaCat · Nov 5, 2016

I need an at risk nursing diagnosis for one of my patients I had in the hospital in medicine. Pt had als still had complete mobility but was unable to swallow (had peg) or talk anymore.
I think risk for falls is the best at risk diagnosis for this project I am doing as she has a history of falls, and looking at all of my data from clinical (which j realize I am giving g you the super short version of) it is evident this is the most concerning g at risk diagnosis.
I usually do well with nursing diagnosis however this one I am struggling...
This pt is primarily at risk for falls because she moves quickly and impulsively and doesn't ring the call bell for help and she really should be.
The problem is we use the carpenito textbook for nursing diagnosis and none of the related to factors fit for the client, especially there is nothing g related to falls and impulsive movements, if someone could please help me out with this one it would be greatly appreciated
Thanks!

You're beginning to head in the right direction,but you're not beingw ell-served by your textbook.

First, kudos for recognizing that you need to have defining characteristics (or, in the case of a risky situation, risk factors) to make a nursing diagnosis. If you can't identify approved ones, you can't make that diagnosis (you don't pick one, you make one, as one of my mentors always used to say). You have identified factors in your patient's condition by assessing her.

You are also working from an old book, since the definitive nursing diagnosis resource is the NANDA-I 2015-2017. It's updated q2yrs, so if your textbook was printed in 2012, it's about 6 years out of date (since it takes about 2 years to produce a text book-- I know, I've done it).

The current NANDA-I (Amazon, 2day delivery) edition says

Nsg Dx, Risk for Falls

Definition: Vulnerable to increased susceptibility to falling, which may cause physical harm and compromise health.

Risk factors:

Adults (I won't give you the ones for children, but there is a different list for them): Age >/= 65 yrs, history of falls, living alone, lower limb prosthesis, use of assistive device (e.g., cane, walker, wheelchair)

Cognitive: Alteration in cognitive functioning

Environment: cluttered, exposure to unsafe weather-related conditions (wet floors, ice), insufficient lighting, insufficient anti-slip material in bathroom, unfamiliar setting, use of restraints, use of throw rugs

Pharmaceutical agents: alcohol consumption, pharmaceutical agent

Physiological: Acute illness, alteration in blood glucose level, anemia, arthritis, conditions affecting the foot, decrease in lower extremity strength, diarrhea, difficulty c gait, faintness when extending or turning neck, hearing impairment, impaired balance, impaired mobility, incontinence, neoplasm, neuropathy, orthostatic hypotension, postop recovery period, proprioceptive deficit, sleeplessness, urinary urgency, vascular disease, visual impairment.

Whew.

Now your way is clear-- you have assessed at least one risk factor from this list (and I am sure you can list quite a few for your lady c ALS-- a few I assumed, but you are the one making the assessment). You have therefore appropriately made the diagnosis of risk for falls. The impulsivity may be related to an alteration in cognition-- lack of safety awareness is evidence of cognitive deficit in itself-- or she may have urinary urge incontinence she's not telling you about, and/or other factors.

Knowing that should give you a way to think about several things nursing can do to decrease her risk of falls. What do you think?