Risk for adult falls

Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00303
Nanda label: Risk for adult falls
Diagnostic focus: Falls

Introduction to Nursing Diagnosis: Risk for Adult Falls

Explaining the risk of falls amongst adults, the nursing diagnosis ‘Risk for Adult Falls’ is a major concern that must be addressed among elderly patients. It is an important component of preventing falls and caring for elderly patients. Nurses must be able to recognize this diagnosis so they can provide proper interventions and treat each patient according to their individual needs.

NANDA Nursing Diagnosis Definition

The NANDA Nursing Diagnosis definition of ‘Risk for Adult Falls’ states that it is "a state in which an individual is at greater than normal risk for slipping or tripping, resulting in physical injury”. This definition places emphasis on the prevalence for adults to slip or trip, and the need for nurses to implement effective interventions to reduce this risk.

Risk Factors

There are a multitude of risk factors associated with falls amongst adults. These range from acute medical conditions related to vision, balance and strength, to hazardous environmental risks such as wet surfaces, poor lighting and slippery obstacles. Other factors include improper use of equipment, incorrect technique while transferring or ambulating, and the failure to use assistive devices or call bells when needed.

At-Risk Population

The population at most risk for adult falls are those individuals over 65, as well as those with chronic medical conditions. Cognitive impairments such as dementia or delirium, functional deficits caused by strokes, movement disorders and musculoskeletal problems are also major risks. Diabetes and neuropathy can cause a loss of sensation in the feet, thus making falls more likely. Other high-risk groups include patients who are malnourished and have a history of substance abuse.

Associated Conditions

Falls often have serious consequences because of associated conditions. These can include fractures, bruises, soft tissue injuries, head trauma and internal bleeding. Death can also occur in certain situations, especially among the elderly population due to pre existing medical conditions such as heart disease or stroke.

Suggestions of Use

It is essential that nurses take the necessary steps to detect and prevent patients from falling. This includes assessing each individual’s fall risk levels, screening them properly and ensuring they take the recommended safety measures while performing tasks. Furthermore, nurses must implement comprehensive interventions to reduce potential hazards and create a safe environment.

Suggested Alternative NANDA Nursing Diagnoses

In addition to the risk for adult falls, other NANDA Nursing Diagnoses to consider include:

• Powerlessness
• Ineffective Coping
• Self-care Deficit
• Risk for Injury
• Ineffective Therapeutic Regimen Management

Usage Tips

When assessing patients, nurses must gather detailed information about the patient’s medical past, recent health assessments and the patient’s home and living arrangements. This will help determine which strategies should be utilized, such as an interdisciplinary approach that involves pharmacists, physical and occupational therapists, as well as the family.

NOC Outcomes

The following Nurse Outcome Classification (NOC) Outcomes can serve as primary and secondary outcomes for nursing interventions:

• Fall Prevention: The ability to identify, evaluate and implement strategies to reduce and prevent falls.
• Mobility Level: The ability to independently move around using different forms of mobility.
• Performance: The ability to perform daily living activities with good safety and within acceptable time frames.
• Sensory Status: The ability to interpret and respond appropriately to sensory stimuli.
• Safety: The appropriate behaviors and actions taken to reduce the occurrence and severity of injury or harm.

Evaluation Objectives & Criteria

When evaluating and determining the effectiveness of interventions, the nurse must consider established criteria, such as frequency and duration of falls, number of injuries and fall-related costs, as well as gather feedback from the patient and his/her family.

NIC Interventions

The following Nursing Intervention Classification (NIC) interventions should be taken into consideration when developing a plan of care for reduced risks of falls:

• Fall Risk Monitoring: Frequently assess patients for fall risk and document findings with evidence-based interventions.
• Environment Management: Design physical environments to improve safety by reducing potential hazards and providing safety equipment, such as handrails, alarms and special footwear.
• Equipment and Assistive Technology: Provide patients with the necessary equipment and assistance to perform activities safely.
• Health Education: Educate the patient and family members on risk factors and safety tips.
• Assistive Mobility Training: Develop and teach breakthroughs adapted to the patients’ physical, cognitive and emotional abilities.

Nursing Activities

Nurses can play a major role in the prevention of falls amongst the adult population. They can focus on activities that promote patient safety by conducting fall risk assessments, monitoring vital signs, evaluating the patient’s physical and cognitive status, assisting with transfers and ambulation, further training and educating patients, families and caregivers on fall prevention, and implementing environmental and equipment adaptations.

Conclusion

Adult falls pose a serious threat to patient health and wellbeing, as well as to overall health care systems. Recognizing the seriousness of this risk is the first important step to reduce and prevent falls. Nurses must be able to effectively identify, assess and implement interventions to decrease this risk and ensure patient safety. Fast and correct intervention is crucial in the prevention of falls amongst adults.

5 FAQs

1. What is the Nursing Diagnosis “Risk for Adult Falls”?
   This diagnosis is a state in which an individual is at greater than normal risk for tripping or slipping, which usually results in physical injury.
2. Which population is at a greater risk for falls?
   Those individuals who are over the age of 65 and those with chronic medical conditions are often found to have an increased risk for falls.
3. What are the consequences of a fall?
   Common consequences of falls include fractures, bruises, soft tissue injuries, head trauma and internal bleeding. In some cases, death can occur as a result of a fall.
4. What strategies can nurses utilize to prevent falls?
   Nurses should assess each individual’s fall risk levels, screen them properly, and ensure they take the recommended safety measures while performing tasks. Additionally they must implement comprehensive interventions to reduce potential hazards and create a safe environment.
5. What interventions should be taken into consideration when developing a plan of care for reduced risks of falls?
   Frequently monitoring fall risk, designing physical environments to improve safety, providing necessary equipment, health education and assistive mobility training are all interventions that should be taken into consideration.

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