A “Risk of falls” in nursing diagnosis refers to the clinical assessment of the patient who has a high risk of falls. This means that the patient has the likelihood of falling which can cause severe injury. Identifying the risk of fall diagnosis is important to prevent serious injuries, especially in people of age. In this blog, we will discuss in detail the factors, prevention strategies, and regular assessment of the risk of falls.
Risk for falls Nursing diagnosis
The Risk of fall nursing diagnosis helps the nurses identify vulnerable patients and guide intervention to minimize this risk. Now let us discuss the internal and external factors that can result in a risk of falls.
Instinctive Factors
- Age-related factors such as impaired vision or muscle weakness.
- Chronic conditions such as Parkinson’s disease, arthritis, etc.
- Some medications such as sedatives.
- Cognitive impairments such as dementia.
- A drop in blood pressure when standing is known as postural hypotension.
- Mobility and balance impairments such as foot problems.
Extrinsic factors
- Environmental hazards such as wet floors clutter or poor lightning.
- Improper footwear such as heels or slippery shoes.
- Lack of assistive devices that help you walk with support such as a cane.
Signs and symptoms to assess the Risk of Falls
The signs and symptoms to look for to assess the risk of falls are the following:
- History of previous falls
- Difficulty in walking
- Dizziness while standing
- Difficulty in daily life activities such as bathing, dressing, and more.
“Risk for falls” Nursing diagnosis: Nursing assessment
- Physical assessment: Conduct a physical exam to assess the patient’s muscle strength, neurological status, and range of motion (ROM). Physical assessment is very crucial because it is one of the major reasons for falls.
- Environmental assessment: Many falls occur due to unsafe environmental settings. It is important to evaluate the patient’s living environment or hospital settings that might result in the patient’s risk of falls. You can look for the following.
- Room layout
- Lightning
- Assistive devices
- flooring
- Medications review: Certain medications can also result in dizziness or confusion which increases the risk of falls. These medications include sedatives, tranquilizers, pain medications, taking multiple medications at one time, etc. All these factors can result in a high risk of patient falls.
- Cognitive and Sensory Assessment: Cognitive and sensory assessment helps the nurses to evaluate patient alertness, awareness of the surroundings, and sensory impairments.
- Use fall risk screening tools: fall risk screening tools are also one of the crucial parts of nursing assessments of patients who might have a high risk of falling. These fall risk screening tools are used to reduce the likelihood of falls and ensure patients’ safety to avoid any major injuries. Some fall risk screening tools are as follows:
- Morse fall scale (MFS)
- Timed Up and Go (TUG) Test
- Berg Balance Scale (BBS)
- Fall Risk Assessment Tool (FRAT)
- The Hendrich II Fall Risk Model
- The St. Thomas Risk Assessment Tool (STRATIFY)
“Risks for falls” Nursing diagnosis: Fall prevention Tips
- After identifying the patients at risk of falls, nurses should consider the following fall prevention tips to ensure reduced patient falls and injuries.
- Educate patients and their family members about fall prevention strategies such as using assistive devices, using non-slip footwear, etc.
- Make sure that the surroundings or environment of the patient are free from any kind of tripping hazards. The patients should be provided with proper lighting so they can see clearly and have handrails that they can use to walk without tripping.
- Review and adjust medications that may cause dizziness or confusion and can result in a risk of falls.
- Recommend physical therapy and exercises to improve the patient’s strength and mobility.
- Use assistive devices such as walkers, canes, etc.
- Always provide supervision.
Goals and outcomes of risk of fall prevention tips
- Increase patient and family awareness.
- Improve balance and mobility.
- Prevent falls and injuries.
What is NANDA-International (NANDA-I) for falls?
According to the NANDA-I statement “at risk for increased susceptibility to falling that may cause physical harm.”
What are the 5 P’s of fall prevention?
The 5 P’s of fall prevention are used to make patients safe from falls they are Pain, Potty, Periphery, Position, and Pump.
Conclusion
Identifying and assessing the risk of falls in nursing diagnosis is very important to reduce falls and prevent serious injuries. This factor is more common with patients of age who have weak muscles, hearing and vision impairments, and mobility issues. However, adults and children can also be at high Risk of fall due to many factors such as poor lighting, uneven floors, slippery shoes, wet floors, etc. Regular monitoring, proper education, and making the environment safe for the patients are very important for the nurses to make sure that there is reduced risk of falls.
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