A Nursing Care Plan for Fall Risk involves assessing a patient’s risk of falling, formulating a care plan, and creating a positive environment to prevent falls. It is important to assess the patient’s cognitive abilities, medications, physical environment, and other potential fall risk factors. This can help reduce falls while improving patient safety.
Assessing potential causes of falls includes reviewing the patient’s history and current medical status, including:
- Medications. Evaluate all medications the patient is currently taking and look for combinations or classes of drugs that have an increased side effect of falls.
- Physical environment. Assess the room, furniture, and other objects. Visual cues and warning signs should be placed around the room to help recall potential fall hazards.
- Cognitive abilities. Test the patient’s cognitive abilities with the Mini-Mental State Exam or similar tests.
- Musculoskeletal system. Evaluate joint mobility, strength, and flexibility. Identify any movement disorders or conditions that contribute to balance difficulty.
- Functional ability. Assess all activities of daily living and fine motor skills, such as writing and using small items.
- Nutritional status. Assess the patient’s diet and determine if the patient is getting the necessary nutrients and caloric intake needed to maintain a healthy body.
Currently, the most commonly used nursing diagnosis related to fall risk is:
- Imbalanced Nutrition: Less than Body Requirements. Nurses need to be aware of the nutritional status of patients and investigate the potential causes behind any nutritional deficiencies.
The expected therapeutically beneficial outcomes must be realistic, measurable and achievable in a given timeframe. Some of the common outcomes set for a nursing care plan for fall risk include:
- Increased knowledge. The patient will demonstrate an understanding of fall prevention strategies and an ability to identify fall risks and act accordingly.
- Improved balance. The patient will demonstrate an increase in strength and balance, enabling them to walk unassisted with fewer falls.
- Reduced mobility limitations. The patient will have increased range of motion, flexibility, and better muscle tone, allowing them to move from one position to another easily.
Interventions are based around the diagnosis, outcomes and individual needs. They include interventions to address environmental, educational and other contributing factors to fall risks. Examples include:
- Safety measures. Move furniture or remove clutter to create a safe environment. Visual cues should be updated and visible to alert patients about any potential dangerous situations.
- Monitoring. Monitor the patient closely at all times, especially during ambulation and transfers.
- Assistive devices. Provide the patient with assistive devices, such as a gait belt, cane or walker when needed.
- Education. Educate the patient and their family about the fall risks, safety precautions and how to use assistive devices appropriately.
- Activity programs. Recommends activity or exercise programs to improve strength, coordination, balance and gait.
Rationales are the reason or explanation used to justify the interventions. Rationales should be supported by theory and research. Rationales for the above interventions include:
- Safety measures. Properly positioning the furniture helps the patient feel more secure in the environment and reduces the risk of falls.
- Monitoring. Ensure the patient is safe during transfers and ambulations and that they do not over exert themselves.
- Assistive devices. Assistive devices improve balance and stability and help the patient better manage their mobility limitations.
- Education. By educating the patient and their family, they will be more aware of the fall risk factors and how to prevent falls.
- Activity programs. Exercise helps improve balance, coordination, strength, and gait, reducing the risk of falls.
Evaluation is an important part of the care plan. Evaluation measures should be established in order to ensure that the expected outcomes were met. Depending on the issue, some common evaluation methods include repeating cognitive assessments or monitoring balance over time.
Creating a Nursing Care Plan for Fall Risk allows nurses to assess a patient’s fall risk, develop interventions, and evaluate the effectiveness of their care. This information can then be used to adjust interventions and ultimately reduce the risks associated with falls in hospitals.
- What are the risk factors for falls?
Common risk factors for falls include age, medications, musculoskeletal system, unsteady gait, vision problems, poor balance, and functional limitations.
- How can nurses prevent falls?
Nurses can prevent falls by providing education to patients and their families, assessing environments, providing assistive devices, and monitoring patients closely at all times.
- What are some examples of interventions?
Examples of interventions include safety measures (i.e. moving furniture or removing clutter), monitoring, assistive devices, education, and activity programs.
- What is a rationale?
A rationale is the reason behind an intervention. It should be supported by research and theory.
- What is the most commonly used nursing diagnosis related to fall risk?
The most commonly used nursing diagnosis related to fall risk is Imbalanced Nutrition: Less than Body Requirements.