Risk for Falls

Increased susceptibility to falling that may cause physical harm

Related Factors: See Risk Factors

Risk Factors:

Adults
  • History of falls; 
  • wheelchair use; 
  • (65 years of age; 
  • female (if elderly); 
  • lives alone; 
  • lower limb prosthesis; 
  • use of assistive devices (e.g., walker, cane)
Physiological
  • Presence of acute illness; 
  • postoperative conditions; 
  • visual difficulties; 
  • hearing difficulties; 
  • arthritis; 
  • orthostatic hypotension; 
  • sleeplessness; 
  • faintness when turning or extending neck; 
  • anemias; 
  • vascular disease; 
  • neoplasms (i.e., fatigue/limited mobility, urgency and/or incontinence, diarrhea, decreased lower extremity strength, posprandial blood sugar changes, foot problems, impaired physical mobility, impaired balance, difficulty with gait, unilateral neglect, proprioceptive deficits, neuropathy)
Cognitive
  • Diminished mental status (e.g., confusion, delerium, dementia, impaired reality testing)
Medication
  • Antihypertensive agents; 
  • ACE-inhibitors; 
  • diuretics; 
  • tricyclic antidepressants; 
  • alcohol use; 
  • antianxiety agents; 
  • opiates; 
  • hypnotics or tranquilizers
Environment
  • Restraints; 
  • weather conditions (e.g., wet floors/ice); 
  • throw/scatter rugs; 
  • cluttered environment; 
  • unfamiliar, dimly lit room; 
  • no antislip material in bath and/or shower
Children (<2 years of age)
  • Male gender when <1 year of age; 
  • lack of auto restraints; lack of gate on stairs; 
  • lack of window guard; bed located near window; 
  • unattended infant on bed/changing table/sofa; 
  • lack of parental supervision


NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Safety Behavior: Fall Prevention
  • Knowledge: Child Safety
Client Outcomes
  • Remains free of falls
  • Changes environment to minimize the incidence of falls
  • Explains methods to prevent injury

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Fall Prevention
  • Dementia Management
  • Safety

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