Nursing Diagnosis: Risk for Falls Application of NANDA, NOC, NIC

Nursing Diagnosis: Risk for Falls
Betty J. Ackley and Teepa Snow

NANDA Definition: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

Nursing Interventions and Rationales

·         Determine risk of falling by using an evaluation tool such as the Fall Risk Assessment (Farmer, 2000), The Conley Scale (Conley, Schultz, Selvin, 1999), or the FRAINT Tool for fall risk assessment (Parker, 2000). Risk factors for falling include recent history of falls, confusion, depression, altered elimination patterns, cardiovascular/respiratory disease impairing perfusion or oxygenation, postural hypotension, dizziness or vertigo, primary cancer diagnosis, and altered mobility (Hendrich et al, 1995; Wilson, 1998; Farmer, 2000). Predictors of fall risk in the community included atrial fibrilation, neurological problems, living alone, and not adhering to a regular exercise program (Resnick, 1999).

·         Screen all clients for stability and mobility skills (supine to sit, sitting supported and unsupported, sit to stand, standing, walking and turning around, transferring, stooping to floor and recovering, and sitting down). Use tools such as the Balance Scale by Tinetti or the Get Up and Go Scale by Mathais. It is helpful to determine the client's functional abilities and then plan for ways to improve problem areas or determine methods to ensure safety (Lewis et al, 1994; Macknight, Rockwood, 1996).

·         Recognize that when people attend to another task while walking, such as carrying a cup of water, clothing, or supplies, they are more likely to fall. Those who slow down when given a carrying task are at a higher risk for subsequent falls (Lundin-Olsson, Nysberg, Gustafson, 1998).

·         Be careful when getting a mostly immobile client up. Be sure to lock the bed and wheelchair and have sufficient personnel to protect client from falls. The most important preventative measure to reduce the risk of injurious falls for nonambulatory residents involves increasing safety measures while transferring, including careful locking of equipment such as wheelchairs and beds before moves (Thapa et al, 1996). These immobile clients commonly sustain the most serious injuries when they fall.

·         Identify clients likely to fall by placing a "Fall Precautions" sign on the doorway and by keying the Kardex and chart. Use a "high-risk fall" arm band and room marker to alert staff for increased vigilance and mobility assistance. These steps alert the nursing staff of the increased risk of falls (Cohen, Guin, 1991).

·         If necesssary to place the client in a wrist or vest restraint, use increased vigilance and watch for falls. The risk of falling is highest soon after a client has been placed in a mechanical restraint (Arbesman, Wright, 1999).

·         Evaluate client's medications to determine whether medications increase the risk of falling; consult with physician regarding client's need for medication if appropriate. Polypharmacy, or taking more than four medications, has been associated with increased falls. Medications increasing the risk of falls include diuretics, hypnotics, sedatives, opiates, antidepressants, and psychotropic and antihypertension agents (Wilson, 1998). Medications such as benzodiazapines and antipsychotic and antidepressant medications given to promote sleep actually increase the rate of falls (Capezuti, 1999). Use of selective serotonin reuptake inhibitors and tricyclic antidepressants resulted in increased incidences of falls in a nursing home setting (Thapa et al, 1998; Liu et al, 1998).

·         Thoroughly orient client to environment. Place call light within reach and show how to call for assistance; answer call light promptly.

·         Use 1/4- to 1/2-length side rails only, and maintain bed in a low position. Ensure that wheels are locked on bed and commode. Keep dim light in room at night. Use of full side rails can result in the client climbing over the rails, leading with the head, and sustaining a head injury. Siderails with widely spaced vetical bars and siderails not situated flush with the mattress have been associated with asphxiation deaths because of rail and in-bed entrapment and should not be used (Todd, Ruhl, Gross, 1997; Capezuti, 1999).

·         Routinely assist client with toileting on his or her own schedule. Always take client to bathroom on awakening, before bedtime, and before administering sedatives (Wilson, 1998). Keep the path to the bathroom clear, label the bathroom, and leave the door open. The majority of falls are related to toileting. It is more acceptable to fall than to "wet yourself." Studies have indicated that falls are often linked to the need to eliminate in a hurry (Cohen, Guin, 1991; Wilson, 1998).

·         Avoid use of restraints; obtain a physician's order if restraints are necessary. Restrained elderly clients often experience an increased number of falls, possibly as a result of muscle deconditioning or loss of coordination (Tinetti, Liu, Ginter, 1992; Wilson, 1998). If elderly clients are restrained and fall, they can sustain severe injuries, including strangulation, asphyxiation, or head injury from leading with their heads to get out of the bed (DiMaio, Dana, Bix, 1986; Evans, Strumpf, 1990). Restraint-free extended care facilities were shown to have fewer residents with activities of daily living (ADLs) deficiencies and fewer residents with bowel or bladder incontinence than facilities that use restraints (Castle, Fogel, 1998). Restraint use can lead to depression, anger, infection, pressure ulcers, deconditioning, and sometimes death (Rogers, Bocchino, 1999). The risk of falling is highest soon after a client is placed in a mechanical restraint (Arbesman, Wright, 1999). No differences in nighttime fall rates was shown between a group that was restrained versus a similar group that was not restrained (Capezuti et al, 1999).

·         In place of restraints, use the following:

• Alarm systems with ankle, above the knee, or wrist sensors
• Bed or wheelchair alarms
• Increased observation of client
• Locked doors to unit
• Low or very low height beds
• Border-defining pillow/mattress to remind the client to stay in bed

·         If client is extremely agitated, consider using a special safety bed that surrounds client. If client has a traumatic brain injury, use the Emory cubicle bed. Special beds can be an effective alternative to restraints and can help keep the client safe during periods of agitation (Williams, Morton, Patrick, 1990).

·         If client has a new onset of confusion (delirium), provide reality orientation when interacting. Have family bring in familiar items, clocks, and watches from home to maintain orientation. Reality orientation can help prevent or decrease the confusion that increases risk of falling for clients with delirium. See interventions for Acute Confusion.

·         If client has chronic confusion with dementia, use validation therapy that reinforces feelings but does not confront reality. Validation therapy is for clients with dementia (Fine, Rouse-Bane, 1995). See Interventions for Chronic Confusion.

·         Ask family to stay with client to prevent client from accidentally falling or pulling out tubes.

·         If client is unsteady on feet, use a walking belt or two nursing staff members when ambulating the client. The client can walk independently with a walking belt, but the nurse can rapidly ensure safety if the knees buckle.

·         Place a fall-prone client in a room that is near the nurses' station. Such placement allows more frequent observation of the client.

·         Help clients sit in a stable chair with arm rests. Avoid use of wheelchairs and geri-chairs except for transportation as needed. Clients are likely to fall when left in a wheelchair or geri-chair because they may stand up without locking the wheels or removing the footrests. Wheelchairs do not increase mobility; people just sit in them the majority of the time (Lipson, Braun, 1993; Simmons et al, 1995).

·         Ensure that the chair or wheelchair fits the build, abilities, and needs of the client to ensure propulsion with legs or arms and ability to reach the floor, eliminating footrests and minimizing problems with shearing. The seating system should fit the needs of the client so that the client can move the wheels, stand up from the chair without falling, and not be harmed by the chair. Footrests can cause skin tears and bruising, as well as postural alignment and sitting posture problems (Lipson, Braun, 1993).

·         Avoid use of wheelchairs as much as possible because they can serve as a restraint device. Most people in wheelchairs do not move. Wheelchairs unfortunately serve as a restraint device. A study has shown that only 4% of residents in wheelchairs were observed to propel them independently and only 45% could propel them, even with cues and prompts. Another study showed that no residents could unlock wheelchairs without help, the wheelchairs were not fitted to residents, and residents were not trained in propulsion (Simmons et al, 1995).

·         Refer to physical therapy for strengthening exercises and gait training to increase mobility. Gait training in physical therapy has been shown to be effective for preventing falls (Galinda-Ciocon, Ciocon, Galinda, 1995; Wilson, 1998).

Geriatric

·         Encourage client to wear glasses and use walking aids when ambulating.

·         Help the client obtain and wear a specially designed hip protector when ambulating. Hip protectors are worn in a specially designed stretchy undergarment containing a pocket on each side for placement of the protector. The risk of a hip fracture in the elderly can be reduced by use of an anatomically designed external hip protector when ambulating (Kannus et al, 2000).

·         Consider use of a "Merri-walker" adult walker that surrounds body if client is mobile but unsafe because of wobbling.

·         If client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as rising slowly, remaining seated several minutes before standing, flexing feet upward several times while sitting, sitting down immediately if feeling dizzy, and trying to have someone present when standing. The elderly develop decreased baroreceptor sensitivity and decreased ability of compensatory mechanisms to maintain blood pressure when standing up, resulting in postural hypotension (Aaronson, Carlon-Wolfe, Schoener, 1991; Matteson, McConnell, Linton, 1997).

·         If client is experiencing syncope, determine symptoms that occur before syncope, and note medications that client is taking. Refer for medical care. The circumstances surrounding syncope often suggest the cause. Use of many medications, including diuretics, antihypertensives, digoxin, beta-blockers, and calcium channel blockers can cause syncope. Use of the tilt table can be diagnostic in incidences of syncope (Cox, 2000).

·         Refer to physical therapy for strength training, using free weights or machines. Strength improvement in response to resisted exercise is possible even in the very elderly, extremely sedentary client, with multiple chronic diseases and functional disabilities. Increased strength can help prevent falls (Connelly, 2000).

Home Care Interventions

·         If client was identified as a fall risk in the hospital, recognize that there is a high incidence of falls after discharge, and use all measures possible to reduce the incidence of falls. The rate of falls is substantially increased in the geriatric client who has been recently hospitalized, especially during the first month after discharge (Mahoney et al, 2000).

·         Assess home environment for threats to safety: clutter, slippery floors, scatter rugs, unsafe stairs and stairwells, blocked entries, dim lighting, extension cords (across pathway), high beds, pets, and pet excrement. Use antiskid acrylic floor wax, nonskid rugs, and skid-proof strips near the bed to prevent slippage. Clients suffering from impaired mobility, impaired visual acuity, and neurological dysfunction, including dementia and other cognitive functional deficits, are all at risk for injury from common hazards.

·         Instruct client and family or caregivers on how to correct identified hazards. Refer to occupational therapy services for assistance if needed. Notify landlord or code enforcement office of structural building hazards as necessary.

·         If client is at risk for falls, use gait belt and additional persons when ambulating. Gait belts decrease the risk of falls during ambulation.

·         Install motion sensitive lighting that turns on automatically when the client gets out of bed to go to the bathroom.

·         Have client wear supportive low heeled shoes with good traction when ambulating. Supportive shoes provide the client with better balance and protect the client from instability on uneven surfaces.

·         Refer to physical therapy services for client and family education of safe transfers and ambulation and for strengthening exercises (for client) for ambulation and transfers.

·         Provide a signaling device for clients who wander or are at risk for falls. If client lives alone, provide a Lifeline or similar call device. Orienting a vulnerable client to a safety net relieves anxiety of the client and caregiver and allows for rapid response to a crisis situation.

·         Provide medical identification bracelet for clients at risk for injury from dementia, seizures, or other medical disorders.

Client/Family Teaching

·         Teach client how to safely ambulate at home, including using safety measures such as hand rails in bathroom.

·         Teach client the importance of maintaining a regular exercise program such as walking. Lack of a consistent exercise program was one of the variables associated with a higher incidence of falls (Resnick, 1999).