Risk for Falls Nursing Diagnosis and Care Plans
Emergency departments deal with over 3 million fall injuries every year, and over 30% of those require hospitalization. Falls are the most common cause of hip fractures and traumatic brain injuries in older people. Moreover, fall-related deaths increased by 30% between 2007 and 2016, while the annual cost of addressing fall-related injuries exceeded $50 billion.
Since falls can dramatically reduce quality of life and lead to severe disabilities requiring additional medical and nursing care, the risk is a vital aspect of any care plan. In this post, we’ll review the key risk factors and evidence-based nursing interventions to reduce the risk of falls. But first, let’s ensure we’re on the same page regarding the purpose of a nursing diagnosis.
What Is a Risk for Falls Nursing Diagnosis?
The North American Nursing Diagnosis Association (NANDA) defines a nursing diagnosis as a “clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” The diagnosis helps determine and prioritize nursing interventions to achieve desired patient outcomes.
When it comes to the risk for falls, the goal is usually to ensure that the patient follows the safety precautions specified in the care plan to prevent fall-related injuries. Although any patient can benefit from fall prevention, it is vital for older patients, as well as those with cognitive impairments, post-surgery patients, and young children.
Risk Factors
Analyzing and assessing risk factors for falls is the first step to creating an effective care plan. Let’s go over the major risk categories to ensure you don’t miss anything.
Physiological Factors
A patient’s physical condition is one of the most important factors influencing the care plan:
- Age-related factors: elderly patients and children are at higher risk of falls.
- Chronic conditions: diabetes, arthritis, stroke, and other cardiovascular conditions may affect coordination and prompt falls.
- Cognitive impairment: delirium, dementia, and other mental health issues can result in falls.
- Sensory issues: hearing loss and deteriorating eyesight can affect coordination and balance.
Environmental Factors
Although nursing interventions usually focus on the patient’s well-being and behavior, environmental risk factors are equally dangerous. Here are some examples you should account for:
- Poor lighting, especially in staircases, bathrooms, and hallways;
- Tripping hazards, such as uneven flooring, rugs, cables, etc.;
- Unsafe footwear with slippery soles or poor grip;
- Lacking supportive equipment like walking aids, handrails, and grab bars, especially in combination with other environmental risk factors for falls.
Behavioral Factors
Your patients’ lifestyle choices and everyday behavior will also affect nursing interventions, especially when you consider:
- Substance use, including medications, recreational drugs, and alcohol;
- Unsafe movements that disrupt balance and create awkward, unstable poses;
- Low activity level, coupled with low muscle mass, also reduces balance.
Situational Factors
Temporary factors are often the hardest to address in a care plan, but you should always account for:
- Acute conditions like fever, hypertension, dehydration, etc.
- Pain, especially acute pain that affects mobility or alters gait.
Do not take this step lightly and try to account for as many potential risk factors as possible, since they’ll guide your next steps in creating an effective care plan.
Risk for Falls Nursing Assessment
Before you can formulate the risk for falls nursing diagnosis, you’ll need to assess the severity of risk factors. Depending on your field and specialty, you can use one (or more) of the standard scales, such as:
- Wilson-Sims Fall Risk Assessment (WSFRAT) in psychiatry
- Humpty Dumpty Fall Scale (HDS) in pediatrics
- Predict FIRST in rehabilitation
- Home Falls and Accidents Screening Tool (HOME FAST) for home care
- Stroke Assessment Fall Risk (SAFR) and others.
Most of these tools will walk you through the common risk factors we’ve covered above and help you hone your nursing diagnosis. From there, you can develop interventions and expected outcomes for the risk for falls care plan.
Risk for Falls Nursing Interventions
After you’ve established the fall risk nursing diagnosis and identified the major risk factors for falls for a patient, you can address them by planning relevant interventions. Here are a few examples:
- Environmental safety means minimizing clutter, especially tripping hazards, installing additional lighting, including night lights, and using non-slip footwear. For example, some hospitals provide fall-risk patients with brightly colored non-slip socks to help identify high fall risk.
- Mobility support nursing interventions include keeping canes, walkers, or wheelchairs within easy reach, as well as keeping hospital beds low with locked wheels and raised side rails.
- Supervision is also a vital part of a care plan. Nurses should check up on patients regularly, supervise their movement throughout the wards, and ensure alarm buttons are easy to reach. In some cases, you may need to resort to restraints or constant supervision for high-risk patients.
- Education for patients with a nursing diagnosis for falls and their families should include safety instructions, reminders to use glasses or hearing aids and reduce the risk of hypotension by dangling off the bed before getting up.
Although the basic care plan is standardized, you should always personalize it to address unique patient needs. This is particularly important for care plans for older patients with cognitive impairment and young children.
Risk for Falls Care Plan (Step-by-Step)
Now that we’ve covered every major aspect of the care plan, let’s put them together into a step-by-step algorithm you can follow:
- Formulate a nursing diagnosis. State the potential risk for falls and your rationale. It should focus on the most important fall risk for the patient. For example, “Risk for falls as evidenced by advanced age and associated slower reflexes, hearing and visual impairments.”
- Establish the care plan goals and desired outcomes. For instance, “Patient will not sustain falls” or “Patient will demonstrate fall prevention measures.” Ideally, your goal should be to prevent falls altogether while the patient is in your care, but it may not always be possible. In this case, the aim is to reduce the number of falls and their negative effect on the patient’s health.
- Run a fall risk assessment. Start by analyzing the patient’s medical and fall history. Pay special attention to their mental and physical changes, sensory deficits, mobility and balance issues, as well as their medications. Remember to include environmental factors in your risk for falls care plan.
- Use fall risk assessment tools. Choose one of the scales we’ve mentioned above that best suits your patient’s needs.
- Formulate nursing interventions and rationales. Develop an effective care plan to address every major risk factor you’ve identified. Personalize the risk for fall nursing care plan to address the patient’s unique needs and circumstances instead of relying on a standard approach.
After the patient’s discharge, remember to evaluate your nursing diagnosis risk for falls and the effectiveness of the interventions to improve future patient care.