What is the Purpose of a Risk for Falls Nursing Diagnosis?
The formal identification of a patient's risk for falls is a cornerstone of patient safety. By using the standardized diagnosis from the North American Nursing Diagnosis Association (NANDA), nurses can systematically assess, document, and manage this critical patient concern. The primary purpose is to move beyond general precautions and develop an evidence-based, patient-centered care plan that addresses specific contributing factors. This proactive approach helps reduce the incidence of falls, minimize patient injury, and decrease associated healthcare costs.
Common Factors Assessed in a Risk for Falls Diagnosis
Identifying a patient's risk is a comprehensive process that considers a wide range of factors. These can be categorized as intrinsic, related to the individual's physical and mental state, and extrinsic, related to the patient's environment.
Intrinsic (Patient-Related) Risk Factors
- Age: Adults over 65 are at a significantly higher risk due to natural changes like reduced muscle strength, slower reflexes, and impaired vision.
- Medical Conditions: Chronic diseases such as arthritis, Parkinson's disease, and cardiovascular illnesses, or acute conditions like dehydration or infection, can cause weakness, dizziness, or impaired balance.
- Cognitive Impairment: Conditions like dementia, delirium, or confusion can affect a patient's judgment, coordination, and awareness of their surroundings.
- History of Previous Falls: A patient with a past fall is more than twice as likely to fall again, making it one of the strongest predictors.
- Medications: Certain medications, including sedatives, antidepressants, blood pressure drugs, and opioids, can cause side effects like dizziness, drowsiness, or orthostatic hypotension (a drop in blood pressure when standing).
- Impaired Mobility and Gait: Weakness in the lower limbs, a history of stroke, foot problems, or difficulty with walking or balancing all increase fall risk.
- Sensory Deficits: Poor vision, hearing loss, or peripheral neuropathy can hinder a person's ability to navigate safely.
Extrinsic (Environmental) Risk Factors
- Clutter: Objects, cords, or loose rugs in the patient's walking path pose tripping hazards.
- Poor Lighting: Inadequate or glaring light, especially in hallways or bathrooms, can obscure hazards and disorient patients.
- Unfamiliar Environment: Hospital rooms or new home settings can be confusing, particularly for those with cognitive deficits.
- Lack of Assistive Devices: An absence of handrails, grab bars, or properly fitted assistive devices like walkers or canes increases risk.
- Inappropriate Footwear: Slippers without proper grip, high heels, or shoes that are ill-fitting can contribute to imbalance and falls.
How Nurses Write a Risk for Falls Nursing Diagnosis
To create a formal diagnosis and care plan, nurses follow a systematic process. The diagnosis is typically written in a format that clearly states the problem and the contributing factors based on a thorough assessment.
Example: Risk for Falls related to unsteady gait, cognitive impairment, and side effects of medications
- Assessment: The nurse gathers both subjective and objective data. They ask the patient or family about their history of falls, dizziness, and mobility challenges (Subjective Data). They then conduct a physical assessment to observe gait, balance, and muscle strength, review the medication list, and use standardized tools like the Morse Fall Scale to quantify risk (Objective Data).
- Planning: The nurse sets expected outcomes for the patient, such as, "The patient will remain free from falls during their hospital stay," and "The patient will demonstrate safe use of assistive devices by discharge".
- Interventions: A set of specific, tailored interventions is developed to address the identified risk factors.
- Evaluation: The nurse continuously monitors the patient and evaluates the effectiveness of the interventions, making adjustments as needed.
Fall Risk Assessment Tools
Nurses use a variety of evidence-based tools to standardize fall risk assessment. These tools assign a score based on a patient's risk factors, which helps guide the level of precaution needed.
| Assessment Tool | Setting | Key Risk Factors Evaluated | Features |
|---|---|---|---|
| Morse Fall Scale (MFS) | Acute Care Hospitals | History of falls, secondary diagnosis, ambulatory aids, IV/heparin lock, gait, mental status | High score indicates higher risk; used for rapid assessment in hospital settings. |
| Hendrich II Fall Risk Model | Acute Care, Long-Term Care | Confusion, depression, dizziness/vertigo, male gender, medications (e.g., antiepileptics), history of falls | Higher scores indicate greater risk; focuses on specific patient characteristics. |
| Timed Up and Go (TUG) Test | All settings | Mobility, gait, and balance | Observes and times a patient as they rise from a chair, walk a short distance, and return. |
| CDC's STEADI Initiative | Outpatient, Community | Previous falls, mobility concerns, balance issues, and overall health | Comprehensive approach involving screening, assessment, and interventions, especially for older adults. |
Nursing Interventions for Preventing Falls
Interventions should be multifactorial and tailored to the individual patient's risk profile.
- Environmental Modifications: Ensure the patient's room is free of clutter, personal items are within easy reach, and the path to the bathroom is clear. Install proper lighting and grab bars.
- Personal Mobility Support: Provide appropriate, well-maintained assistive devices and ensure the patient is using them correctly. Offer non-skid footwear.
- Patient and Family Education: Teach patients about their specific risk factors and educate family on how to create a safer environment at home.
- Clinical Management: Review and adjust medications that increase fall risk, collaborate with physical therapy to improve strength and balance, and address any underlying medical conditions contributing to the risk.
- Enhanced Surveillance: For high-risk patients, implement additional supervision through increased rounding, placing the patient closer to the nursing station, or using bed/chair alarms.
Conclusion
A risk for falls nursing diagnosis is an essential clinical judgment for prioritizing patient safety. By conducting a thorough assessment of intrinsic and extrinsic factors, and utilizing standardized tools, nurses can accurately identify patients at risk and implement personalized interventions. This not only mitigates the likelihood of a patient falling but also protects them from potential serious injury, a crucial aspect of high-quality nursing care. Constant vigilance and interdisciplinary collaboration are vital for effectively managing fall risk and promoting a safer patient environment.
