Risk for Falls Nursing Diagnosis & Care Plan

Falls are the most frequently reported safety incident among hospitalized patients, with 30-50% of falls resulting in injury. Not all falls are preventable, though safety measures should always be implemented to reduce the risk. In fact, falls can be reduced by 20-30% when risk factors are identified and matched with appropriate interventions. 

Nurses who are diligent about assessing for risk factors, incorporating fall prevention measures, and verbalizing to patients the rationales behind precautions that may seem excessive, will have the best outcomes for their patients.

Risk Factors (Related to) 

Adults:

  • History of falls 
  • Assistive device use
  • Age 65 or over 
  • Lower limb prosthesis 

Physiological:

  • Low visual acuity
  • Hearing-impaired 
  • Orthostatic hypotension 
  • Incontinence 
  • Impaired strength and mobility 
  • Poor balance
  • Confusion 
  • Delirium 

Medications:

  • Antihypertensive medications
  • Sedatives 
  • Narcotics 
  • Alcohol use 

Environmental:

  • Restraints 
  • Cluttered environments 
  • Inadequate footwear 

*A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions are aimed at prevention. 

Expected Outcomes:

  • Patient will remain free of falls 
  • Patient will demonstrate a safe environment free from potential hazards 
  • Patient will verbalize understanding of risk factors for falls

Nursing Assessment for Risk for Falls

Assessment Rationale 
Assess the patient’s general health status  Take note of conditions, acute and chronic, that may affect safety. For example, use of hearing aids or glasses, polypharmacy, or confusion. 
Assess muscle strength, coordination, and use of devices Decreased strength, recent surgery, and physical injuries can alter coordination, gait, and balance. 
Use the Morse Fall Scale The Morse Fall Scale is used to identify risk factors for potential falls in hospitalized patients. It measures: History of Falling Secondary diagnosis (or more) Ambulatory aids IV therapy Gait Mental status A score of “0” is no risk for falls, and >45 is a high risk with a low to moderate risk in between. 
Evaluate mental status A patient who is confused, sedated, or hallucinating may overestimate their physical abilities. 
Evaluate the use of assistive devices Ensure the patient has necessary devices such as a walker or bedside commode and that they understand how to properly use them. 

Nursing Interventions for Risk for Falls

Incorporate appropriate safety measures An alert and oriented young adult may only require the support of a walker, while an elderly confused patient may need a bed alarm. Severely confused patients who cannot follow directions may require restraints or 1:1 supervision to keep them safe. 
Provide footwear and encourage use All hospitalized patients should be encouraged to wear non-slip footwear. Hospitals often have color-coded socks with yellow socks signifying patients who are a high risk for falls. 
Use fall risk identification Fall alert identifiers such as patient wristbands, chart stickers, and wall signs alert all staff members of the high risk for falls when assisting the patient. 
Keep the patient’s room free of clutter Remove excess furniture and keep cords and IV lines off the floor to prevent falling. 
Keep the call button and personal items within reach Before exiting the room, always ensure the patient has their call button and personal items such as water within reach. This prevents the risk of reaching or attempting to get out of bed alone and potentially falling. 
Encourage assistance when getting out of bed Encourage the patient to use their call button and request assistance when going to the bathroom or getting out of bed to promote safety. 
Keep the bed in the lowest position  Except when the nurse is at the bedside performing a task that requires raising the bed, it should always stay in the lowest position to prevent falling out of bed. 
Educate the patient on their fall risk factors  Having an open and direct conversation with the patient about the individual risk factors that increase their risk for falls as well as the safety measures in place will increase adherence to interventions. 
Coordinate with PT/OT Therapy services should be utilized to assist the patient in increasing their strength and balance as well as instructing on the proper use of new equipment such as crutches. 

References:

  1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company. 
  1. Preventing Falls in Hospitals. (2013, January). Agency for Healthcare Research and Quality. Retrieved October 13th, 2021, from https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html 
  1. Morris, R. (2017). Prevention of falls in hospital. Royal College of Physicians, 17(4), 360-362. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297656/ 
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Maegan Wagner, BSN, RN, CCM

Maegan has over 10 years of healthcare experience. Her nursing career has led her through many different specialties, but her passion lies in educating through writing for other healthcare professionals and the general public.