LESSON 5

 Risk for Falls - are a common problem in geriatric care, and they can have serious consequences, including injury, decreased mobility, and decreased quality of life. In this article, we will explore the risk for falls in geriatric care, the key components of an effective assessment, and evidence-based interventions for preventing falls in older adults.

Nursing Diagnosis

     ● Risk for Falls

Risk Factors                                                                                                                       Common risk factors for the nursing diagnosis risk for falls:

●     Age (especially ≥ 65 years)

●     Impaired physical mobility

●     Loss of muscle strength

●     Altered sensory perception

●     Presence of illness (Alzheimer’s disease, dementia, osteoporosis)

●     Urinary incontinence

●     Use of medications

●     Disorientation

●     Dizziness

●     Lack of knowledge of environmental hazards secondary to confusion

● Improper use of aids (e.g., canes, walkers, wheelchairs, crutches

Defining Characteristics

●  Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes 

Expected outcomes or patient goals for risk for falls nursing diagnosis:

●     The patient will be free from falls.

●     The patient and caregiver will implement measures to increase safety and prevent falls in the home.

Nursing Assessment and Rationales

Risk for falls assessment is important in geriatric care because it helps healthcare providers identify older adults who are at risk for falls and implement interventions to reduce the risk. By conducting an effective risk for falls assessment, healthcare providers can prevent falls, which can improve patient outcomes and prevent injury.

1. Identify factors that increase the level of fall risk
These factors will help in determining interventions necessary for the patient. Risk factors include age, presence of an illness, sensory and motor deficits, medication use, and inappropriate use of mobility aids.

2. Assess the patient’s environment for factors associated with an increased risk for falls.
A patient who is not familiar with the placement of furniture in an area or who has inadequate lighting in the house increases the risk for falls.

Nursing Interventions and Rationales

Once a risk for falls assessment has been conducted, healthcare providers can implement evidence-based interventions to prevent falls in geriatric care. The following are some common interventions for preventing falls in older adults:

1. Secure a wristband identification to warn healthcare providers to implement fall precautions on the patient.
Healthcare providers need to recognize patients at high risk for falls to implement measures to promote patient safety and prevent falls.

2. Place assistive devices and commonly used items within reach.
Provides easy access to assistive devices and personal care items. Items such as call bells, telephones, and water should be kept close to avoid frequent reaching

3. Review hospital protocols regarding transferring a patient.
Hospital facilities should have clear policies and procedures during transfers that will ensure the patient’s safety.

4. Keep the patient’s bed in the lowest position at all times.
Keeping the bed closer to the floor prevents injury and the risk of falls.

5. Answer the call light as soon as possible.
This is to prevent an unstable patient from ambulating without any assistance.

6. Use side rails on the bed as needed
Raising the side rails reduces the risk of patients falling out of bed during transport.

7. Advise the patient to wear shoes or slippers with non-slip soles when walking.
Wearing non-slip footwear help prevents slips and falls.

8. Orient the patient to the surroundings. Avoid rearranging the furniture in the room.
The patient should be familiarized with the bed, location of the bathroom, furniture, and other environmental hazards that can cause older patients to trip or fall.

9. Ensure the patient’s room is well-lit. Consider the use of a bedside lamp that is turned on at night.
Providing lighting in key places can reduce fall risk and avoid obstacles during mobility.

10. Encourage the family and other significant others to stay with the patient at all times.
Prevents the patient from accidentally falling or pulling out tubes.

11. Ensure the patient’s eyesight is regularly checked and explain the importance of wearing eyeglasses if needed. Make sure glasses and hearing aids are always worn.
Hazard can be lessened if the patient utilizes appropriate aids to improve visual and auditory orientation to the environment. Visually impaired patients are at high risk for falls.

12. Instruct the patient how to ambulate at home, including using safety measures such as handrails in the bathroom.
Help relieve anxiety at home and eventually decreases the risk of falls during ambulation.

13. Encourage the patient to engage in a program of regular exercise and gait training.
Exercise can improve muscle strength, balance, coordination, and reaction time. Physical conditioning reduces the incidence of falls and avoids injury that is sustained when a fall happens.

14. Collaborate with other healthcare teams to assess and review patient’s medications that can contribute to the risk for falls. Identify the peak effects of the medications that can alter the consciousness of the patient.
A review of the patient’s prescribed medications will recognize side effects and drug interactions that may enhance fall injury risk. The more medications a patient takes, the greater the risk for side effects and interactions such as orthostatic hypotension, dizziness, confusion, urinary incontinence, and altered gait and balance. Polypharmacy in older adults is a significant risk factor for falls

15. Evaluate the need for physical and occupational therapy to assist the patient with gait techniques and provide the patient with assistive devices for transfer and ambulation. Initiate a home safety evaluation as needed. The use of gait belts provides a more secure means to safely assist patients when transferring from bed to chair. Assistive aids such as wheelchairs, canes, and walkers allow the patient to have stability and balance during ambulation. High toilet seats can facilitate safe transfer on and off the toilet.