Nursing Care Plan (NCP) for Risk for Fall

Lesson Objective

What is Risk for Fall?

 

It’s when someone has a higher chance of accidentally falling. Just like someone might slip on a wet floor, some people, especially older adults or those with certain health issues, are more likely to fall because of things like weak muscles, balance problems, or even medications that make them dizzy or sleepy.

 

Why It’s Important:

 

Falls can cause serious injuries like broken bones or head injuries, so it’s really important to prevent them, especially in hospitals or nursing homes.

 

Factors That Increase Fall Risk:

 

• Being older, having trouble walking or balancing.
• Certain illnesses or medications.
• Hazards like slippery floors or poor lighting.

 

Upon completion of this care plan, nursing students will be able to:

• Identify risk factors contributing to falls in diverse patient populations, considering age-related, environmental, and medical factors.
• Conduct a comprehensive fall risk assessment, incorporating standardized tools and subjective data to determine the level of risk.
• Develop individualized nursing interventions to minimize fall risk, addressing specific patient needs and risk factors.
• Collaborate with the interdisciplinary healthcare team to implement a multifaceted approach to fall prevention, involving patient education, environmental modifications, and therapeutic interventions.
• Evaluate the effectiveness of fall prevention strategies through ongoing assessment, data collection, and adjustment of interventions based on patient responses.
• Engage in effective communication with patients and their families, fostering shared decision-making and promoting a culture of safety.
• Promote a patient-centered approach by incorporating patient preferences and values into the development and implementation of fall prevention strategies.

Pathophysiology

 

• Impaired Mobility and Balance:
  • Muscle Weakness: Weakened muscles, especially in the lower extremities, can compromise balance and stability.
  • Joint Stiffness: Conditions affecting joint flexibility can impact the ability to maintain balance.
• Cognitive Impairment:
  • Neurological Conditions: Disorders affecting cognition, such as dementia or delirium, can lead to confusion and reduced awareness of surroundings.
  • Medication Side Effects: Certain medications may contribute to dizziness or cognitive impairment, increasing the risk of falls.
• Sensory Deficits:
  • Visual Impairment: Poor eyesight or visual disturbances can impede the ability to detect obstacles or hazards.
  • Hearing Loss: Impaired hearing may lead to difficulties in responding to auditory cues, contributing to falls.
• Orthostatic Hypotension:
  • Blood Pressure Regulation: Dysregulation of blood pressure upon standing can cause dizziness or fainting.
  • Dehydration: Inadequate fluid intake can contribute to orthostatic hypotension.
• Medication-Related Factors:
  • Polypharmacy: Taking multiple medications may increase the risk of side effects or drug interactions that affect balance and coordination.
  • Sedatives and Hypnotics: Medications with sedative effects can contribute to drowsiness and unsteadiness.
• Chronic Conditions:
  • Neurological Disorders: Conditions like Parkinson’s disease or multiple sclerosis can impact coordination and balance.
  • Cardiovascular Diseases: Conditions such as heart failure may limit physical exertion and contribute to deconditioning.

 

Etiology

 

• Intrinsic Factors:
  • Advanced Age: The risk of falls generally increases with age due to factors such as decreased muscle strength, joint flexibility, and balance.
  • Medical Conditions: Chronic illnesses, neurological disorders (e.g., Parkinson’s disease), and cardiovascular diseases can impact mobility and contribute to falls.
  • Cognitive Impairment: Conditions like dementia or delirium can lead to confusion and an increased risk of falls.
  • Visual Impairment: Poor eyesight or conditions affecting depth perception can contribute to misjudging distances and obstacles.
  • Orthostatic Hypotension: A drop in blood pressure upon standing can result in dizziness or fainting, increasing the risk of falls.
  • Foot Problems: Painful foot conditions, deformities, or inappropriate footwear can affect gait and stability.
• Medication-Related Factors:
  • Polypharmacy: Taking multiple medications, especially those with side effects affecting balance or cognition, increases the risk of falls.
  • Sedatives and Hypnotics: Medications with sedative effects can cause drowsiness and impair coordination.
• History of Falls:
  • Previous Falls: Individuals who have fallen in the past are at an increased risk of experiencing subsequent falls.
  • Fear of Falling: Fear of falling can lead to a reduction in physical activity, contributing to muscle weakness and further increasing the risk of falls.
• Functional Impairments:
  • Impaired Mobility: Difficulties in walking, transferring, or performing activities of daily living contribute to an increased risk of falls.
  • Muscle Weakness: Weak muscles, particularly in the lower extremities, compromise balance and stability.
• Extrinsic Factors:
  • Environmental Hazards: Clutter, inadequate lighting, uneven flooring, and poorly maintained walkways pose external risks for falls.
  • Inappropriate Footwear: Wearing shoes with inadequate support or high heels increases the risk of tripping.
  • Assistive Devices: Improper use or lack of assistive devices, like canes or walkers, can contribute to falls.

 

Desired Outcome

 

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

 

• Prevention of Falls:
  • Short-Term Goal: Minimize the occurrence of falls during the hospital stay.
  • Interventions: Implement safety measures, such as bed alarms, to alert staff, and use mobility aids appropriately. Monitor the patient’s movements closely.

 

Subjective Data

 

• Weakness 
• Dizziness

 

Objective Data

 

• Hypotension 
• Confusion 
• Sensory deficit 
• Unsteady gait
• Unsafe environment
• Increased fall risk score

Nursing Assessment for Fall Risk

 

• History Taking:
  • Obtain a comprehensive health history, including any previous falls, the circumstances surrounding falls, and the presence of any contributing factors.
  • Inquire about the patient’s medical conditions, medications, and recent changes in health status.
• Medication Review:
  • Conduct a thorough review of the patient’s current medications, including prescription and over-the-counter drugs.
  • Identify medications that may contribute to dizziness, sedation, or orthostatic hypotension.
• Functional Assessment:
  • Assess the patient’s functional status, including their ability to perform activities of daily living (ADLs) and mobility.
  • Observe the patient’s gait, balance, and coordination during transfers and ambulation.
• Cognitive Assessment:
  • Evaluate cognitive function using a standardized tool, such as the Mini-Mental State Examination (MMSE) or the Confusion Assessment Method (CAM), to identify any cognitive impairment.
  • Monitor for signs of delirium or confusion.
• Visual and Auditory Assessment:
  • Assess visual acuity and field of vision. Address any visual impairments or conditions that may affect depth perception.
  • Evaluate auditory function and address any hearing deficits that may impact the patient’s ability to respond to environmental cues.
• Fall Risk Assessment Tools:
  • Utilize validated fall risk assessment tools, such as the Morse Fall Scale or Hendrich II Fall Risk Model, to quantify the level of risk.
  • Incorporate the patient’s risk factors into the assessment.
• Patient and Family Education:
  • Educate the patient and family about fall risk factors, emphasizing the importance of communication and collaboration in fall prevention.
  • Provide guidance on the use of assistive devices and the implementation of safety measures.
• Psychosocial Assessment:
  • Assess the patient’s psychosocial well-being and mental health status.
  • Explore any psychosocial factors, such as depression or anxiety, that may contribute to fall risk.

Nursing Intervention

 

Nursing Intervention (ADPIE)	Rationale
Apply risk for Fall Band (yellow band)	this alerts staff that this patient is at risk for a 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 the 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 a 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 than 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 the 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.

 

Evaluation of Fall Risk Care Plan

 

• Reduction in Fall Incidents:
  • Expected Outcome: A decrease in the number of falls during the patient’s hospital stay.
  • Evaluation Criteria: Compare the number of falls before and after implementing the fall prevention interventions. Monitor incident reports and document any changes.
• Optimized Medication Management:
  • Expected Outcome: Adjustment of medication regimens to minimize side effects contributing to fall risk.
  • Evaluation Criteria: Review medication changes and monitor for any adverse effects related to adjustments. Collaborate with healthcare providers for ongoing medication management.
• Enhanced Environmental Safety:
  • Expected Outcome: Implementation of environmental modifications to enhance safety.
  • Evaluation Criteria: Inspect the patient’s environment for changes and modifications. Ensure the removal of hazards and assess the patient’s and family’s adherence to safety recommendations.
• Use of Assistive Devices:
  • Expected Outcome: Appropriate and consistent use of assistive devices.
  • Evaluation Criteria: Observe the patient using assistive devices during mobility. Provide reinforcement and education if necessary. Document any issues or concerns raised by the patient.
• Orthostatic Vital Signs Stability:
  • Expected Outcome: Stable orthostatic vital signs with minimal changes upon standing.
  • Evaluation Criteria: Measure orthostatic vital signs regularly and compare to baseline assessments. Adjust interventions if there are persistent issues related to orthostatic changes.

 

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