Risk for Falls: Nursing Care Plan and Diagnosis

About 1/4th of patients aged 65 and older report falling each year. Falls are the most reported safety event in the inpatient setting. Nursing Students Student Assist Care Plan

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Risk for Falls: Nursing Care Plan and Diagnosis

Table of Contents

Risk for Falls Overview

A fall is defined (1) as a patient coming to rest on the floor and can be described as an assisted or unassisted fall. An assisted fall is described as a patient being lowered to the ground by another person and is a controlled descent. An unassisted fall is a patient that falls without the assistance of someone else.

About 1/4th of patients (2) aged 65 and older report falling yearly. Falls are the most reported safety event in the inpatient setting (3). Recent studies show that 1/4th of falls that occur inpatient are injurious, costing more than $7,000 per injury (4). Patient safety is a priority in the hospital setting, but nurses must be able to identify which patient is at an increased risk and put it on the nursing care plan.

Risk Factors

Preventing falls is fundamental in reducing incidence of falls with injury. Many fall risk factors place a patient at a higher risk for falls. 

  • Age
    • Adults 65 years and older
  • Physiological
    • Impaired gait and mobility: paralysis, weakness, etc.
    • Sensory impairment
    • Use of assistive devices: cane, walker, wheelchairs, etc.
    • Neurological deficit: stroke (current or previous), dementia, brain tumors, delirium, confusion, etc.
    • Incontinence and urgency
    • History of falls (both at home and inpatient)
    • Vision and hearing impairment
    • Post-operative patients
  • Medications
    • Antihypertensives
    • Diuretics
    • Pain medications
    • Sedatives
  • Environmental
    • Wet floor
    • Clutter
    • Height of bed
    • Cords: IV pumps, sequential compression device
    • IVs
    • Inadequate footwear
  • Lifestyle
    • Work environment
    • Lack of fall prevention equipment: safety harness, etc
    • Alcohol and recreational drugs

Expected Outcomes

  • The patient will remain free from falls during their hospital stay.
  • The patient will demonstrate the use of call light.
  • The patient will demonstrate a clutter-free environment.
  • The patient will verbalize understanding of the risk for falls.

What Is the Nursing Assessment for Risk for Falls?

Before providing a nursing diagnosis, a nursing assessment for risk for falls must be completed. It is important that a thorough assessment is completed upon admission and anytime there is a patient condition change (post fall, each shift, environmental changes, etc.). An important note is that the care setting (progressive, acute care, etc.) can affect how much you can assess.

Physical Assessment:

Medical conditions and vitals can indicate that the patient is not at baseline. Example: A hypotensive patient is at an increased risk for a fall. Caregivers can provide information on the patient's baseline status at home to compare. 

Evaluation and Assessment of Primary Medical History:

Note the chronic conditions that the patient may have that impact their ability to walk, see, or hear. Other evaluations to consider during the medical history review are the patient's use of recreational drugs and alcohol.

Skin Assessment:

Ensure that the patient's skin is intact and that there are no wounds on the ankles, feet, or heels that could impact the patient's ability to ambulate.

Mobility Assessment:

How the patient moves to the bed, in the bed, and what kind of assistance the patient will need is important to be mindful of. There is a potential for loss of muscle strength and an impaired gait making it difficult for the patient to be independent in their activities of daily living. 

Neurological Assessment:

If the patient is hallucinating or confused, they are at an increased risk of overestimating their abilities and may be more impulsive in their actions.

Fall Assessment Tools:

The Morse Fall Scale is a fall risk assessment used to identify risk factors for falls in hospitalized patients (5). This fall scale considers the patient's history of falls, secondary diagnosis, ambulatory aid, IV therapy, gait, and mental status. A score is then provided, determining if the patient has a low, moderate, or high fall risk.

Review of Medications:

A thorough review of what medications the patient takes at home and what they receive in the hospital is important as many medications can cause changes in blood pressure resulting in hypotension (6) and lowered heart rate. Other medication side effects causing an increased risk for falls are dizziness, blurred vision, impaired cognition, and altered gait and balance. Collaborating with providers to reduce the medication the patient takes can be beneficial.

Assessment of Environment:

The environment should remain free of clutter, cords, and spills. Extra clutter and cords create trip hazards if the patient were to get up by themselves, putting them at an increased risk for falls.  

Interventions and Rationale

Nursing interventions and safety measures vary depending on the nursing assessment and the associated nursing diagnosis. Each intervention should be selected based on the patient's fall risk (low risk, moderate risk, or high risk) using the Morse Fall Scale. Once specific nursing interventions are selected, they should be placed on the nursing care plan.

Non-Skid Socks or Proper Footwear

Provides safe ambulation practices for the patient, ensuring there is little room for the patient to slip on the floor. 

Fall Risk Identification

Wristbands can remind patients to seek assistance when getting out of bed independently. Signs placed in the patient's room to remind patients to use the call light.

Provide a Safe Environment

A clean and clutter-free environment allows for safe ambulation if the patient gets up independently. 

Encourage the Use of Call Light

The use of a call light can be an important factor in reducing falls, as patients can ask for items to be moved closer or for assistance with mobilization. 

Personal Items and Possessions Within Reach

Having all items within reach of the patient can reduce the number of times the patient may attempt to get out of bed and ultimately reduce the risk of falling. 

Encourage Assistance When Ambulating and Toileting

Ensuring that patients are assisted can improve safety and the prevention of falls.

Call Light Responsiveness

Promptly answering the call light and assisting the patient will prevent the patient from getting out of bed unassisted.

Hourly Rounding

Patients have the opportunity to bring up things they need each hour and seek assistance with ambulation and toileting with a decreased need to use the call light. The nurse can ensure that each patient has everything they need. 

Bed Wheels Locked

Ensuring that the environment is ready for the patient and is safe is a top priority in preventing equipment from malfunctioning or moving when the patient is trying to sit in the bed. 

Orient the Patient to the Environment

Being in an unfamiliar environment places the patient at an increased risk for falls. When a patient has been shown where things are and how to use certain features (such as bed controls and TV controls), the patient is less likely to trip over something. 

Provide Assistive Devices

Patients that use assistive devices should have one within reach, allowing them to use it to ambulate when needed.

Physical and Occupational Therapy Plans

An evaluation and treatment plan is created for each individual to help them progress and strengthen, reducing the risk of falls with gait and assistive device training. Physical therapists can design an exercise program based on each patient's functional ability and mobility challenges (6).

Encourage Participation in Activities of Daily Living

Patients who actively participate in daily activities will improve their fine motor skills and allow them to do as much as possible without great assistance. 

Chair Alarm/Bed Alarm

Alarms can notify healthcare staff that a patient is up or attempting to get up.

Bed in Lowest Position

If a patient were to fall out of bed, they would be closer to the ground, reducing the risk of injury.

Original Allnurses Post

Quote

I'm having a problem with nursing diagnosis. I have to make a care plan for my patient. I chose risk for falls. However, I'm really having a hard time with the "related to" part of it. I followed Ackley's care plan constructor and came up with "Risk for falls related to history of falls." My professor handed back my care plan (after chewing me out) and said my "related to" wasn't NANDA. She said my related to MUST be a NANDA. I'm very confused ? I asked her for help, but she said I should have figured it out by now. [big sigh].

My patient is a 63 y/o male. He's diagnosed with osteomylitis, history of chronic paraplegia (he stated he does not have feeling from his knees to toes), acute renal failure, CHF.

I'm so confused. Any help would be very much appreciated! Thank you.

Think about what you could do to improve the physical mobility of the patient with osteomyelitis and how that intervention would improve their mobility. Range of motion exercises can improve the patient's range of motion, and by improving range of motion, it could improve their physical mobility. This will allow them to reach for things better if it's on a high shelf or items they drop on the floor.

Citations

  1. https://www.who.int/news-room/fact-sheets/detail/falls
  2. https://www.CDC.gov/falls/data/falls-by-state.html
  3. https://ojin.nursingworld.org/table-of-contents/volume-18-2013/number-2-may-2013/fall-program-measurement/
  4. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1368-8.
  5. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/
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Specializes in Behavioral Health.

hey snowkie, i know where you are right now. i am a third sememster nursing student and i remember those days.

first, always remember your nursing diagnosis has to be in a priority order. you know, airway first, breathing second , and circulation third. (abc)

also, i was taught that a risk for diagnosis cannot be a priority diagnosis. try another NANDA diagnosis that has to do with his airway, breathing, and circulation. let me know what you come up with.

the related to in your book are the reason why your patient has the problem. the as evidenced by is all your proof,like lab work, statements, and assessment data.

ie-ineffective airway clearance ( nursing diagnosis) related to (why) increased lung secretions, as evidenced by ( proof, this must be objective data) increased wbc( give levels ), coughing, and wheezing.

let me know if that helps. :yeah:you'll get there.

1 Votes

NANDA lists this nursing diagnosis: risk for injury/trauma

Risk factors may include:

Inability to recognize/identify danger in environment, impaired judgment

Disorientation, confusion, agitation, irritability, excitability

Weakness, muscular incoordination, balancing difficulties, disturbed perception (e.g., missing chairs, steps)

Seizure activity

"Possibly evidenced by" is not applicable here because the presence of signs and sx establises an actual diagnosis.

NOCs:

Safe home environment (recognize potential risks in the environment; identify and implement steps to correct/compensate for individual factors)

Client will be free of injury

From what I read of your post, I'd suggest risk for injury/trauma r/t balancing difficulties (if that's appropriate to what caused the falls)

1 Votes
Freedom42 said:
NANDA lists this nursing diagnosis: risk for injury/trauma

Risk factors may include:

Inability to recognize/identify danger in environment, impaired judgment

Disorientation, confusion, agitation, irritability, excitability

Weakness, muscular incoordination, balancing difficulties, disturbed perception (e.g., missing chairs, steps)

Seizure activity

Freedom, thank you!! May I ask where you got the "risk factors" for injury/trauma?? I have the Nursing Diagnosis Handbook by Ackley, but I couldn't not find that anywhere under Risk for injuries. Does the r/t have to be in nanda? How did you come up with or where did you get "Inability to recognize/identify danger in environment"? My patient has poor static sitting balance and I think risk for injury r/t balancing difficulties would be appropriate.

Is "Risk for injury r/t impaired physical mobility" a good nursing diagnosis? Or is "Risk for injury r/t balancing difficulties" more appropriate?

1 Votes
Specializes in med/surg, telemetry, IV therapy, mgmt.

About using "risk for" diagnoses. . .

  1. They do not have related factors. Instead they have risk factors. Risk factors are environmental [conditions] and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event (page 333, nanda-i nursing diagnoses: definitions & classification 2007-2008).
  2. You use a "risk for" diagnosis when you "think" a specific problem "might happen" to the patient
  3. Since these are potential, or anticipated, problems there are no defining characteristics (signs and symptoms) to use as evidence to support the diagnosis as there are with actual problems. So your nursing diagnostic statement has only two parts:
    • the nursing diagnosis label
    • the risk factor(s)
  4. You have to have a very clear and defined idea of the problem you are attempting to prevent, know it's signs and symptoms and preventative measures.
  5. Interventions for these nursing diagnoses are limited to:
    • Strategies to prevent the problem from happening in the first place
    • Monitoring for the specific signs and symptoms of this problem
    • reporting any symptoms that do occur to the doctor or other concerned professional
    • If symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis
  6. As a general rule, these types of nursing diagnoses do not have the same priority as actual nursing problems. Actual problems are usually attended to first.

I think that what your instructor meant by saying your related to must be a nanda and when you asked her for help she said you should have figured it out by now had to do with consulting the nanda taxonomy information. You will find this information directly below the title of the diagnosis in your Ackley nursing diagnosis book (see page 479 of the 7th edition for risk for falls and the risk factors, not related factors, are listed in great detail right below the definition of the diagnosis). In my nanda nursing diagnosis reference, the risk factors for the diagnosis of risk for falls is very clearly listed--and it's a whopping list. "history of falls" is not listed as a risk factor for this diagnosis. You can also view information for this diagnosis here: risk for falls. Risk for falls was split away from risk for injury because it was more specific in it's risk factors. If your patient has a history of falling, risk for falls would be the appropriate nursing diagnosis to use. It's definition, and you can also read this in your Ackley book, is increased susceptibility to falling that may cause physical harm.

1 Votes

Hi daytonite!

Thank you for your help. Now i understand the "risk for" part!! So, if i use any "risk for" diagnosis, there will be no related to, but "risk factors of". Is that correct?

For example, if i do plan to use the falls as a diagnosis, would this be correct: risk for falls with the risk factors of impaired physical mobility.

Please advise, thank you!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Yes.

Your diagnostic statement will still be Risk for Falls R/T impaired physical mobility. The "impaired physical mobility" part" is implied as being a risk factor because of the way the first part of the diagnostic statement is worded as "Risk for". Don't you have some better specific information about why the patient is falling all the time than "impaired physical mobility"? There is quite a long list of risk factors listed by NANDA. Doesn't your patient have at least one of them (i.e., difficulty with gait, foot problems, impaired balance, neuropathy)? There is also age over 65, use of assistive devices and diminished mental status which you can also add. You can list more than one risk factor. I suspect that the reason your instructor may not have liked "history of falls" was because of it's vagueness. I'm thinking that "impaired physical mobility" has that same vagueness (it also is another diagnosis--arguably, if the patient has impaired physical mobility, why not just use the diagnosis of Impaired Physical Mobility?)

1 Votes

Hi, Snowkei:

Thanks for your note. Half of my class, including me, uses Doenges, a remarkably non-user friendly text. I could not find falls in the index, only injury/trauma. The other half of our class uses Ackley, which I think is easier to use.

Good luck.

1 Votes

Hi daytonite! Thank you so much for your help!! I had to do 2 care plans (I made about 6 just so I can get a hang of it!) for the patient. I ended up not using "Risk for falls", instead I used "Impaired physical mobility r/t chronic paraplegia and decrease muscle strength." Since the patient could not move his lower extremities and has a pressure ulcer at his heel, I also came up with "Impaired skin integrity r/t physical immobility and pressure ulcer stage II as evidence by disruption of epidermal and dermal tissue."

Okay, I finally understand what you meant with the nursing diagnosis being vague. My mom kept stressing that I need to individualize each care plan and that helped. Even though I didn't use Risk for falls, I just wanted to make sure I was doing it right. I came up with, Risk for falls with the risk factors of decreased lower extremity strength, impaired balance and ineffective tissue perfusion.

I really hope these are good, I've been working on getting better with care plans. Thank you for your help daytonite! I very much appreciate it.

1 Votes
Specializes in med/surg, telemetry, IV therapy, mgmt.

You've got some problems with the construction of this diagnostic statement:

  • Impaired skin integrity r/t physical immobility and pressure ulcer stage ii as evidence by disruption of epidermal and dermal tissue.
    • "Disruption of epidermal and dermal tissue" is not a valid symptom. It is merely a restatement of the definition of this diagnosis, or problem
    • "Pressure ulcer stage ii" is not the underlying cause of the impaired skin integrity, but the result, or evidence, of it. Therefore, it is data and belongs following your "as evidenced by" statement.
    • The proper construction should be: impaired skin integrity r/t physical immobility as evidenced by stage ii pressure ulcer on the (location).
1 Votes

OH! I see what I did wrong. I described the pressure ulcer as the "as evidence by". The pressure ulcer IS the as evidence by. [sigh] I think I'm going to Barnes & Nobles to see if there are any other references that I can refer to. Thanks for your time Daytonite!

Impaired skin integrity r/t physical immobility as evidence by stage II pressure ulcer on the right heel.

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