Nursing Care Plan (NCP) for Risk for Fall

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Outline

Pathophysiology

 

Risk of falling is due to a decreased physiologic reserve. There are multiple causes for people to be at risk that include intrinsic, extrinsic, and behavioral factors. 

 

Etiology

 

Intrinsic Factors: blood pressure, orthostatics, cognition, vision, spasticity, rigidity, strength, sensory deficit, cerebellar, Parkinsonism, musculoskeletal issues, antalgia 

Extrinsic Factors: include medications and the environment 

Behavioral Factors:  include risk-taking and gait aids

 

Desired Outcome

 

Patient will remain free from falls during hospital stay. Patient will verbalize strategies to prevent from harming self. Patient will demonstrate how to manipulate their environment to make it easier/safer to get around

 

Subjective Data

 

  • Weakness 
  • Dizziness

 

Objective Data

 

  • Hypotension 
  • Confusion 
  • Sensory deficit 
  • Unsteady gait

 

Nursing Intervention (ADPIE) Rationale
Apply risk for Fall Band (yellow band) this alerts staff this patient is at risk for fall 
Instruct patient to use the call light for assistance before getting up (may put up signs on walls/board as reminders for them) Patient safety is number one priority. Want to make sure they have assistance to do anything to avoid a fall 
Place patient close to nurses’ station  this provides increased observation and better ability for the nurse to respond quickly to the patient if needed 
Activate bed alarms/chair alarms- respond promptly when they go off  helps prevent a fall from happening 
Make sure bed is in the lowest position possible and a fall mat placed/non-skid socks on  some patients still may end up out of bed quicker then you can respond. These further measures may not prevent the fall, but reduce the risk of injury 

Non-skid socks-allow patient to not slip walking on the floor

Lock bed/chair wheels in place  furniture moving while patient is trying to sit down or sit up may cause them to lose balance and fall 
Place personal items within reach for the patient  trying to reach for items on the table or somewhere else in the room can cause a patient to lose balance and fall
PT/OT consults frequent exercises and gait training may help improve muscle strength and balance decreasing fall risk. Also, using canes, walkers, and wheelchairs may be necessary. 

Writing a Nursing Care Plan (NCP) for Risk for Fall

A Nursing Care Plan (NCP) for Risk for Fall starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.

References

https://my.clevelandclinic.org/health/articles/8977-reducing-your-risk-of-falls-in-the-hospitalhttps://www.mayoclinic.org/medical-professionals/physical-medicine-rehabilitation/news/evaluating-patients-for-fall-risk/mac-20436558

 

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Transcript

Hey everyone. Today, we’re going to be creating a nursing care plan for the risk for fall. So let’s get started. First, we’re going to go over the pathophysiology. So the risk of falling is due to a decreased physiologic reserve. There are multiple causes for people to be at risk that include intrinsic extrinsic and behavioral factors. Nursing considerations. You want to assess patient risk for fall, provide safety precautions, keep items within patients reach, and PT and OT consults. Desired outcome. The patient will remain free from falls during your hospital stay, the patient will verbalize strategies to prevent from harming self, and the patient will demonstrate how to manipulate their environment to make it easier and safer to get around. 

So we’re going to go ahead and get through our care plan. We’re going to talk about subjective data and some objective data. So what are we going to see with these patients? You’re going to notice they’re going to have some weakness and some possible dizziness. Some objective data can be hypotensive and confusion. Some others are a sensory deficit or an unsteady gait. 

So interventions. We want to apply a risk for fall band – those yellow risk for fall bands. You want to make sure that this alerts the staff that this patient’s at risk for fall. Another intervention. We want to instruct the patient to use the call light for assistance before getting up for anything. Patient safety is number one priority. We want to make sure that they have assistance to do anything and are able to avoid falling. Another intervention we want to do. We want to place the patient close to the nurses’ station. This provides increased observation and better ability for the nurse to respond quickly to the patient. If needed another mention, we want to make sure that we’re activating the bed alarms, chair alarms, and making sure the bed’s in the lowest position. Also, making sure we have fall mats on the floor and that a patient is wearing non-skid socks. Whenever alarms go off, we want to make sure we’re helping prevent a fall from happening. And we want to make sure that the patient is wearing those non-skid socks, which allows them to not slip when they’re walking. We want to make sure we’re locking the better chair wheels in place. Furniture moving while a patient’s trying to sit down or sit up may cause them to lose their balance and fall. So we want to make sure we’re avoiding that. So make sure we keep those locked. Another intervention we want to do. We want to make sure we’re placing personal items within reach for the patient. Trying to reach for items on the table or somewhere else in the room for a patient can cause them to lose their balance and fall. We want to make sure we try to avoid that from happening. And the last thing we want to think about are PT and OT consults.So frequent exercises and gate training may help improve muscle strength and balance for these patients. It’ll decrease their fall risk. Also, using things such as canes, walkers, and chairs may be necessary for these patients. 

Alright, we’re going to go over some key points. So the risk of falling is due to a decreased physiologic reserve. There are multiple causes for people to fall that include intrinsic extrinsic and behavioral factors. Some subjective and objective data. You may see that they have some weakness, dizziness, hypotension, confusion, sensory deficit, and unsteady gait. We want to make sure we have safety precautions. So risk for fall bands. Use of that call light. Place the patient near the nurses’ station so that you can see them more closely. Activate the bed alarm, the chair alarm, making sure you’re locking the wheels on the chairs and the bed. Placing that fall mat down and putting those non-skid socks on a patient. All are good safety measures to put in place. We want to make sure items are within reach and that you’re getting those OT and PT consults. And that is the end of that care plan for you. 

Awesome job. We’d love you guys. Go out. Be your best self today and as always happy nursing.

 

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