Risk for fall Nursing Care Plan

Potential Nursing Care Plan example from Nursing for Life Organization

1. Nursing Care Plan
"Risk for fall"
Patient
Problem
( Potential )
Nursing diagnosis \ Risk for fall related to (contributing factor according to the
patient’s condition)
Subjective
Data
 According to the nurse’s observation.
Objective
Data
 According to the patient description.
Objectives

 Patient will demonstrate selective prevention measures.
 Patient will relate the intent to use safety measures to prevent falls.
 Patient and caregiver will implement strategies to increase safety and
prevent falls in the home.
Nursing intervention

Assessment

 Assess for circumstances associated to increase the level of fall risk upon
admission, following any alteration in the patient’s physical condition or
cognitive status, whenever a fall happens, systematically during a hospital
stay, or at defined times in long-term care settings:
- Rationale: Using standard assessment tools, the level of risk and
subsequent fall precautions can be determined. These tools incorporate
the intrinsic and extrinsic factors.

 History of falls.
- Rationale: An individual is more likely to fall again if he or she has
sustained one or more falls in the past 6 months.

 Mental status changes.
- Rationale: Confusion and impaired judgment increase the patient’s
chance of falling.

 Age-related physical changes.
- Rationale: Older people with weak muscles are more likely to fall than are
those who maintain their muscle strength, as well as their flexibility and
endurance.
These changes include reduced visual function, impaired color perception,
change in center of gravity, unsteady gait, decreased muscle strength,

2. decreased endurance, altered depth perception, and delayed response
and reaction times.

 Sensory deficits.
- Rationale: Vision and hearing impairment limit the patient’s ability to
perceive hazards in the surroundings

 Balance and gait.
- Rationale: Older adults who have poor balance or difficulty walking are
more likely than others to fall are. These problems may be associated with
lack of exercise or to a neurological cause, arthritis, or other medical
conditions and their treatments.

 Use of mobility assistive devices.
- Rationale: Inappropriate use and maintenance of mobility aids such as
canes, walkers, and wheelchairs increase the patient’s risk for falls.

 Disease-related symptoms.
- Rationale: Increased incidence of falls has been demonstrated in people
with symptoms such as orthostatic hypotension, urinary incontinence,
reduced cerebral blood flow, edema, dizziness, weakness, fatigue, and
confusion.

 Medications.
- Rationale: Risk factors for falls also include the use of medications such as
antihypertensive agents, ACE-inhibitors, diuretics, tricyclic
antidepressants, alcohol use, antianxiety agents, opiates, and hypnotics or
tranquilizers. Drugs that affect BP and level of consciousness are
associated with the highest fall risk.

 Unsafe clothing.
- Rationale: Personal and situational factors such as poor-fitting shoes,
long robes, or long pants legs can limit a person’s ambulation and increase
fall risk.

 Assess the patient’s environment for factors known to increase fall risk
such as unfamiliar setting, inadequate lighting, wet surfaces, waxed floors,
clutter, and objects on the floor.
- Rationale: A fall is more likely to be experienced by an individual if the
surrounding is not familiar such as the placement of furniture and
equipment in a certain area.

3. Interventions

 For patients at risk for falls, provide signs or secure a wristband
identification to remind healthcare providers to implement fall precaution
behaviors.
- Rationale: Signs are vital for patients at risk for falls. Healthcare providers
need to acknowledge who has the condition for they are responsible for
implementing actions to promote patient safety and prevent falls.

 Transfer the patient to a room near the nurses’ station.
- Rationale: Nearby location provides more constant observation and quick
response to call needs.

 Move items used by the patient within easy reach, such as call light, urinal,
water, and telephone.
- Rationale: Items that are too far from the patient may cause hazard and
can contribute to falls.

 Respond to call light as soon as possible.
- Rationale: This is to prevent the patient from going out of bed without
any assistance.

 Use side rails on beds, as needed. For beds with split side rails, leave at
least one of the rails at the foot of the bed down.
- Rationale: According to research, a disoriented or confused patient is less
likely to fall when one of the four rails is left down.

 Avoid the use of restraints to reduce falls.
- Rationale: Studies demonstrate that regular use of restraints does not
reduce the incidence of falls.

 Guarantee appropriate room lighting, especially during the night.
- Rationale: Patients, especially older adults, has reduced visual capacity.
Lighting an unfamiliar environment helps increase visibility if the patient
must get up at night.

 Encourage the patient to don shoes or slippers with nonskid soles when
walking.
- Rationale: Nonskid footwear provides sure footing for the patient with
diminished foot and toe lift when walking.

 Familiarize the patient to the layout of the room. Limit rearranging the
furniture in the room.
- Rationale: The patient must get used to the layout of the room to avoid
tripping over furniture.

4.  Provide heavy furniture that will not tip over when used as support when
patient is ambulating. Make the primary path clear and as straight as
possible. Avoid clutter on the floor surface.
- Rationale: Patients having difficulty in balancing are not skilled at walking
around certain objects that obstruct a straight path.

 Bed and chair alarms must be secured when patient gets up without
support or assistance.
- Rationale: Audible alarms can remind the patient not to get up alone. The
use of alarms can be a substitute for physical restraints.

 Provide the patient with chair that has firm seat and arms on both sides.
Consider locked wheels as appropriate.
- Rationale: When patient experiences weakness and impaired balance,
this chair style will be useful and easier to get out of.


 Provide high-risk patients with a hip pad.
- Rationale: These pads when properly worn may reduce a hip fracture
when fall happens.

Health Teaching


 Teach client how to safely ambulate at home, including using safety
measures such as handrails in bathroom.
- Rationale: This will help relieve anxiety at home and eventually decreases
the risk of falls during ambulation.

Evaluation

Achieved ( ) Partially achieved ( ) Not achieved ( )

Evidence by:





Important Note
"We just recommend examples of nursing care plans. There are many references and
interventions may change according to patient condition. You should consider this, search,
and see more than one reference to reach the best quality for writing the care plan"