Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00306
Nanda label: Risk for child falls
Diagnostic focus: Falls
Nursing Diagnosis Risk for Child Falls
Introduction
Falls are a major cause of injury in children, leading to significant morbidity, disability, and mortality. A nursing diagnosis of Risk for child Falls is used to determine the likelihood of a child falling and the potential harm or injury that could result. This nursing diagnosis is based on the recognition of risk factors, at-risk populations, and associated conditions. With careful assessment, early identification of risk for a fall can be made and preventive interventions implemented.
NANDA Nursing Diagnosis Definition
Risk for Injury related to falling as evidenced by (Specify)
Risk Factors
There are numerous risk factors that may increase an individual’s risk of falling. These include physical, environmental, and psychological factors. Physical risks may include age (infants and toddlers are particularly vulnerable), poor balance and coordination, cognitive delay, poor vision, limited mobility, age-inappropriate furniture, or hurried and distracted behavior. Environmental factors such as unsafe sleeping equipment or toys can cause falls, as well as hazardous materials in the environment. Psychological risk factors may manifest as fear and anxiety or lack of understanding of safety.
At Risk Population
Infants, children, and adolescents are all at risk for falls and related injuries. In fact, falls are the leading cause of injury in this age group. Young children have less developed coordination and balance, and may not understand the potential for danger. Older children who are actively engaged in sports or activities may be prone to more risky behaviors and aggressive physical movements.
Associated Conditions
Injuries from falls can range from mild bruising and scrapes to broken bones and traumatic brain injuries. Other associated conditions may include ecchymosis (bruises) or contusions, abrasions, ligament strains, sprains, fractures, or head injuries. Depending on the severity of the fall, minor to major health concerns can occur.
Suggestions for Use
To determine a nursing diagnosis of Risk for child Falls, a thorough assessment of the child, the family, and the environment must be conducted. During this assessment, any potential fall risks should be identified and addressed. The nurse should also review developmental stages, prior falls, and any activities that would place the child at increased risk.
Alternative NANDA Nursing Diagnosis
Some alternative nursing diagnoses to consider in relation to Risk for child Falls may include:
- Ineffective Protection related to environmental hazards
- Altered Mobility related to decreased circulation
- Knowledge Deficit related to safety precautions
- Pain related to injury from fall
- Impaired Physical Mobility related to specific muscle weakness
Usage Tips
When assessing for Risk for child Falls, the nurse should observe the child as they move through their environment. While this will provide valuable information regarding coordination and balance, it can also identify any related risks or protective factors. The nurse should also stay alert for any changes in behavior that may lead to the child assuming a greater risk of falling.
NOC Outcomes
The NOC Outcomes listed in relation to Risk for child Falls include:
- Safe Home Environment: ability to identify and eliminate environmental hazards that may contribute to an accident or injury
- Injury Prevention: ability to prevent accidental injury
- Safety Status: awareness of potential hazards and ability to respond appropriately
- Pain Level: intolerance to pain and limitation in functioning due to pain
- Mobility Level: ability to assume and maintain physical positions for safe movement
Evaluation Objectives and Criteria
When evaluating the patient, the nurse should assess the individual’s ability to recognize potential danger and take appropriate action, as well as their physical abilities and any contributing factors that may affect their safety. Evaluation objectives and criteria should also focus on identifying any slip or trip hazards in the home and providing the child with the knowledge and tools needed to keep themselves safe. The goals of the evaluation should be to reduce the risk of injury, encourage the use of protective devices, and improve outcomes.
NIC Interventions
NIC Interventions recommended in relation to Risk for child Falls include:
- Safety Education: teaching the child safe practices to prevent falls
- Risk Reduction: identifying and correcting environmental hazards and potential impediments to mobility
- Home Modifications: making changes to the home to reduce risks, such as installing foam corner protectors and guardrails on stairs
- Equipment Selection: selecting appropriate items to aid in the safe movement of the child and reduce risks of falls
- Supervision: providing supervision to minimize risks while allowing freedom of movement
Nursing Activities
Nursing activities that should be implemented in order to reduce the risk of falls and related injuries in children include:
- Provide education to the family and caregivers regarding fall prevention strategies
- Design and implement fall prevention programs in the home
- Select appropriate equipment for mobility and transfer activities
- Monitor the child’s movement in the environment and intervene as necessary to decrease risk
- Advocate for use of safety devices and protective gear
Conclusion
Risk for child Falls is a serious nursing diagnosis that requires a thorough assessment of the child and their environment. Early recognition and intervention are essential to reducing the risk of falls. Through careful teaching and education, the nurse can help families and caregivers reduce their child’s risk of falling and suffering an injury.
5 FAQs
Q1: What is the risk for child falls?
A1: Risk for child falls is the likelihood that a child may fall and potentially suffer an injury. This is a serious nursing diagnosis that requires a thorough assessment to identify and address any risk factors that may be present.
Q2: What are some of the risk factors for child falls?
A2: Risk factors for child falls include age, physical capabilities, environmental hazards, and psychological factors. Examples include low muscle tone, impaired vision, unsafe sleeping equipment, hazardous materials in the environment, fear and anxiety, and lack of understanding about safety.
Q3: What kind of interventions can the nurse perform to reduce the risk of falls?
A3: Nurses can reduce the risk of falls by providing safety education, risk reduction strategies, home modifications, equipment selection, and supervision. Teaching the child and their caregivers how to control the physical environment can help lower the risk of falls.
Q4: What kinds of injuries can result from a fall?
A4: Injuries resulting from falls can range from minor bruising and scrapes to broken bones, head injuries, and other major health concerns.
Q5: How is the safety status evaluated when assessing risk for child falls?
A5: The safety status is evaluated by assessing the individual’s ability to recognize potential danger and take appropriate action. The nurse should also observe the child in their environment and look for any changes in behavior that may lead to a greater risk of falling.