Introduction to NANDA Nursing Diagnosis: Risk of Adult Falls
Falls are a leading cause of injury and death in adults, particularly those over the age of 65. Fall-related injuries cost tens of billions of dollars per year throughout the world. Fortunately, nurses can utilize NANDA nursing diagnosis to better assess and prevent risk of adult falls.
NANDA Nursing Diagnosis Definition
The medical definition for the NANDA nursing diagnosis “Risk of Adult Falls” is:
‘At risk for falls due to physical, cognitive and psychosocial factors’
- Feeling unsteady on their feet or legs
- Fear of falling
- Loss of balance
- Staggered gait
- Tripping over obstacles
When assessing the risk of adult falls, nurses must take into account contributing related factors such as:
- Weakness or fatigue
- Impaired muscle coordination
- Decreased mobility
- Dizziness or vertigo
- Impaired vision
- Impaired mental processes or cognition
- Side effects from medications
- Alcohol or drug use
Adults most at risk for falls are those aging with particular physical conditions, such as:
- Joint pain
- Parkinson’s Disease
- Low vision
- Previous fall history
- Recurring dizziness or vertigo
Falls in adults can lead to a variety of associated problems, such as:
- Loss of independence
- Head injury
- Fractured bones
- Cuts or bruises
- Psychological issues
Suggestions for Use
In order to use the NANDA nursing diagnosis “Risk of Adult Falls”, nurses should conduct assessments for:
- Current balance
- Height and weight
- Medication side effects
- Cognitive abilities
- Pain levels
- Overall safety environment
- Patient knowledge of how to reduce the fall risk
Suggests Alternative NANDA Diagnoses
Alternative NANDA diagnoses may be appropriate depending on patient assessment and situation. These include:
- Ineffective coping
- Risk for injury
- Chronic confusion
- Imbalanced Nutrition – Less Than Body Requirements
- Impaired Mobility
When using the NANDA nursing diagnosis “Risk of Adult Falls”, it is important to remember:
- Healthcare providers must assess the patient’s individual risk factors for falls
- Nurses should assess the home environment for any hazards
- Assess if the patient has the knowledge to reduce their risk for falls
- Encourage the patient to be active
- Provide the family with fall prevention resources and recommendations
NOC (Nursing Outcomes Classification) results that may be expected after implementation of an appropriate plan of care include:
- Mobility Level: The patient is able to move and maintain balance without assistance.
- Balance: Patient is able to ambulate independently without risk of falling.
- Self-Care: The patient is able to identify potential risks and develop strategies to prevent falls.
- Safety Awareness: Patient is able to maintain knowledge of home environment, with necessary adaptations, to promote safety and reduce risk of falls.
NIC (Nursing Interventions Classification) interventions that are most likely to produce positive patient outcomes when enacted include:
- Fall Prevention: Provide interventions to minimize the risk of falls based on the patient’s evaluated risk.
- Home Assessment: Inspect the home environment to identify any hazards that potentially contribute to falls.
- Safety Education: Educate patient and family regarding appropriate precautions to reduce the risk of falls.
- Balance Training: Train patient in ambulation and body mechanics to reduce risk of falls.
Conclusion and FAQ
Utilizing the NANDA nursing diagnosis “Risk of Adult Falls” allows nurses to better assess and prevent the risk of falls in adults. Taking into consideration contribution factors, risk population, associated problems, usage tips, alternative diagnosis, NOC (Nursing Outcomes Classification) and NIC (Nursing Interventions Classification) can help provide the most effective assessment and care for at-risk individuals.
Commonly asked questions about the NANDA nursing diagnosis “Risk of Adult Falls”:
- What are the most common falls risk factors?
- What does the NANDA nursing diagnosis “Risk of Adult Falls” mean?
- What are some general fall prevention techniques?
- Who is most at risk for falling?
- What are some of the associated complications of falls in adults?