A single fall can shatter more than just bones.
It can erode a client’s confidence, hinder their independence, and even alter the course of their lives. As a nursing student, you can help prevent falls by recognizing the signs and symptoms of at-risk clients.
That’s where the “risk for falls” nursing diagnosis comes in.
What is a ‘risk for falls’ nursing diagnosis?
Falls are the most common cause of injury among older adults, and unplanned falls can lead to serious injury or even death.
As a nurse, it’s important to recognize clients at high risk for falls and take appropriate steps to prevent them. A “risk for falls” nursing diagnosis is a clinical judgment indicating that a client has increased susceptibility to falling that can cause physical harm.
Common risk factors include:
- Age: Age-related changes in bone density, hearing, muscle strength, reaction time, and vision can increase fall risk.
- Cognitive function: The client’s mental status can influence their attention, decision-making abilities, judgment, and memory. This can affect their awareness of potential hazards and ability to respond appropriately.
- Environmental factors: The client’s surroundings can pose risks. For example, clutter, lack of handrails, loose rugs, poor lighting, slippery floors, and uneven surfaces can increase the risk of falling.
- Medications: Certain prescription or over-the-counter medications can cause side effects that impair the client’s coordination and stability.
- Medical conditions: Some conditions can affect the client’s cardiovascular, musculoskeletal, nervous, or sensory system. This can result in impaired perception, numbness, pain, or weakness.
- Mobility and gait: Foot problems, joint stiffness, muscle atrophy, or use of assistive devices can affect the client’s ability to move and walk independently.
How to assess a client’s risk for falls
Assessment is the first step to identify and prevent falls.
Here are some steps you can take to determine a client’s risk.
1. Conduct a comprehensive history.
Review their medical background, medications, past falls, and any complaints of dizziness or imbalance.
Conduct a physical exam to assess their:
- Balance and strength
- Gait and mobility
- Hearing
- Vision
Ask questions about the home environment and any activities that may impact their fall risk.
2. Use a fall-risk screening tool.
There are several screening tools you can use to determine the client’s likelihood of falling.
These tests include the:
- 30-second chair stand test
- 4-stage balance test
- Berg balance scale (BBS)
- Fall risk assessment tool (FRAT)
- Functional reach test
- Hendrich II fall risk model (HIIFRM)
- Morse fall scale (MFS)
- Timed up and go (TUG) test
- Tinetti performance-oriented mobility assessment (POMA)
3. Involve family or caregivers.
Involve the client’s family or caregivers to better assess and prevent falls.
They can help identify at-home risk factors, such as slippery floors or unsafe stairs. They can also help you understand behavioral or physical changes that can increase risk.
‘Risks for falls’ nursing diagnosis: Fall prevention tips
After identifying an at-risk client, you can implement nursing interventions to prevent falls and injuries.
Here are some best practices.
Educate clients and their families.
Explain the risk factors and consequences of falls, then share how to prevent them.
Provide written materials, videos, or other resources to help them understand and remember the information. Encourage them to share concerns and ask questions.
Implement fall prevention protocols.
Follow the established fall prevention protocols within your health care facility or organization.
Protocols may include using:
- Chair or bed alarms to alert staff when clients try to get up
- Color-coded wristbands or signs to identify high-risk clients
- Hourly rounding to check on clients regularly
Create a safe environment.
Ensure the client’s environment is safe and comfortable for them.
This may include:
- Installing handrails or grab bars in strategic places
- Keeping the floor clean and dry
- Lowering the bed height or raising the toilet seat
- Providing adequate lighting
- Removing clutter or obstacles
- Securing loose rugs or cords
Monitor and evaluate clients.
Monitor the client’s progress regularly and evaluate the effectiveness of interventions.