Falls are the most frequently reported safety incident among hospitalized patients, with 30-50% of falls resulting in injury of varying severity. Not all falls are preventable, though safety measures should always be implemented to reduce the risk. Falls can be reduced by 20-30% when risk factors are identified and matched with appropriate interventions.
Nurses who are diligent about assessing risk factors, incorporating fall prevention measures, and verbalizing to patients the rationales behind the falls precautions, will have the best outcomes for their patients.
In this article:
- Risk Factors (Related to)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Risk Factors (Related to)
The following are common risk factors for falls:
Adults
- History of falls
- Assistive device use
- Age 65 or over
- Lower limb prosthesis
Physiological
- Low visual acuity
- Hearing-impaired
- Orthostatic hypotension
- Incontinence
- Impaired mobility and strength
- Poor balance
- Confusion
- Delirium
Medications
- Antihypertensive medications
- Sedatives
- Narcotics
- Alcohol use
Environmental
- Restraints
- Cluttered environments
- Inadequate footwear
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for risk for falls:
- 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
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to risk for falls.
1. Assess the patient’s general health status.
Take note of conditions, both acute and chronic, that may affect safety. For example, use of hearing aids or glasses, polypharmacy, or confusion.
2. Assess muscle strength, coordination, and use of devices.
Decreased strength, recent surgery, and physical injuries can alter coordination, gait, and balance.
3. Use the Morse Fall Scale.
The Morse Fall Scale is used to identify risk factors for potential falls in hospitalized patients. It offers a rapid assessment of the likelihood that a patient will experience a fall. A score of “0” indicates no risk for falls, and a score of more than 45 indicates a high risk for falls, with a low to moderate risk in between.
4. Evaluate mental status.
A patient who is confused, sedated, or hallucinating may overestimate their physical abilities or may forget their physical limitations.
5. 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 use them properly.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a risk for falls.
1. Incorporate appropriate safety measures.
There is a range of fall prevention interventions and the nurse should pick interventions appropriate to the patient’s condition and risk level. 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. However restraints should only be used as a last resort.
2. 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 at high risk for falls.
3. 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.
4. Keep the patient’s room free of clutter.
Remove excess furniture and keep cords and IV lines off the floor to prevent falling.
5. 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.
6. 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.
7. Keep the bed in the lowest position.
Except when the nurse is at the bedside performing a task that requires raising the bed, the bed should always stay in the lowest position to prevent injuries from falling out of bed.
8. 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 and the safety measures in place will increase adherence to interventions.
9. Coordinate with physiotherapy and occupational therapy.
Therapy services should be utilized to assist the patient in increasing their strength and balance and instructing on the proper use of new equipment such as crutches.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for risk for falls.
Care Plan #1
Diagnostic statement:
Risk for falls as evidenced by improper use of walker and orthostatic hypotension.
Expected outcomes:
- Patient will be free of injury.
- Patient will demonstrate the proper use of a walker.
Assessment:
1. Evaluate how the patient uses the walker.
Identifying the exact errors in using the assistive device would help the nurse develop a suitable health teaching plan and focus on the needed skills.
2. Review the current medication regimen.
It is important for the nurse to note the number and class of current medications as this may trace the cause of the patient’s orthostatic hypotension.
3. Obtain complete medical history.
Some diseases and conditions (e.g., stroke, brain injury, musculoskeletal disorders) may predispose the patient to fall incidents.
Interventions:
1. Assist the patient with the proper use or maintenance of assistive devices.
Some patients take time to adjust to using assistive devices in their daily activities. Note that incorrect use or maintenance of mobility devices increases the risk of falls and injury. The device should be appropriately fit for the patient.
2. Assist the patient in engaging in exercise routines.
If appropriate, the nurse can collaborate with the patient to set exercise goals. Engaging in exercise may improve gait, balance, and ankle strength.
3. Provide proper room lighting, especially at night.
Adequate lighting will reduce environmental hazards and the chances of falls for people with difficulty ambulating and reduced visual capacity.
4. Provide an ID wristband indicating the patient is at risk for falls.
An ID would notify the other team or hospital staff members that the patient is at increased risk for falls and that fall precautions must always be instituted.
5. Collaborate with a physical therapist.
The physical therapist is trained to recommend exercises that improve the patient’s balance, strength, or mobility. The patient may need to improve or relearn ambulation. The physiotherapist can also help to identify and obtain appropriate assistive devices for mobility, environmental safety, or home modification.
Care Plan #2
Diagnostic statement:
Risk for falls as evidenced by vertigo and prolonged bed rest.
Expected outcomes:
- Patient will remain free of falls.
- Patient will not exhibit dizziness, visual disturbances, and orthostatic hypotension.
Assessment:
1. Assess for muscle strength.
Prolonged bed rest diminishes muscle strength, which causes reduced physical mobility.
2. Obtain a history of vertigo.
Vertigo is a sensation that the environment is spinning. The patient may describe dizziness and unsteadiness, sometimes accompanied by visual disturbances.
3. Assess the environment for hazards such as clutter, slippery floors, and scattered rugs.
Removing environmental hazards decreases the chances of falls. Any object that may restrict a patient’s path is an environmental hazard that increases fall risk.
Interventions:
1. Address environmental risk factors.
Place the bed in the lowest possible position, use a raised edge mattress, pad the floor at the side of the bed, or place the mattress on the floor as appropriate. Use half-side rails instead of full-side rails or upright poles to assist individuals in getting out of bed. Patients may have decreased muscle strength after prolonged bed rest. The lowest possible bed position, pad floors, and raised edge mattresses help reduce the risk of injury when the patient attempts to stand up from bed.
2. Assist the patient in getting up from bed.
Prolonged bed rest leads to several complications, such as a decrease or loss of muscle strength, muscle contractures, decreased cardiac reserve, and reduced endurance. The patient may need assistance to transfer out of bed.
3. Instruct the patient to change position slowly, dangle the legs, and stand beside the bed before walking.
This strategy helps to prevent orthostatic hypotension.
4. Administer medications as indicated.
Patients with vertigo may be prescribed antihistamines, benzodiazepines, or antiemetics to manage vestibular symptoms.
5. Refer to physical therapy or other programs for exercise programs that target strength, balance, flexibility, or endurance.
Programs with at least two of these components have been shown to decrease the rate of falling and the number of people falling.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Dittmer, D. K., & Teasell, R. (1993). Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Canadian family physician Medecin de famille canadien, 39, 1428–1437.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- 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/
- 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
- Stanton, M.& Freeman, A.M. (2023). Vertigo. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482356/
