Nursing Care Plan for Risk for Falls

Deanna Gray-Micelli, PhD, GNP-BC, FAANP, Patricia A. Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.

Goals

A. Prevent falls and serious injury outcomes in hospitalized older adults. B. Recognize multifactorial risks and causes of falls in older adults. C. Institute recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care.

Overview

Falls among older adults are not a normal consequence of aging; rather, they are considered a geriatric syndrome most often due to discrete multifactorial and interacting, predisposing (intrinsic and extrinsic risks), and precipitating (dizziness, syncope) causes.,
Fall epidemiology varies according to clinical setting. In acute care, fall incidence ranges from 2.3 to 7 falls per 1, 000 patient days depending on the unit. Nearly one-third of older adults living in the community fall each year in their home. The highest fall incidence occurs in the institutional long-term-care setting (i.e., nursing home), where 50% to 75% of the 1.63 million nursing-home residents experience a fall yearly. Falls rank as the eighth leading cause of unintentional injury for older Americans and were responsible for more than 16, 000 deaths in 2006. (Ref 3)

Background and Statement of the Problem

A. Definition

1. Fall: A fall is an unexpected event in which the participant comes to rest on the ground, floor, or lower level. (Ref 4)

B. Fall Etiology

1. Fall risk factors include intrinsic risks of cognitive, vision, gait or balance impairment, high-risk/contraindicated medications, and/or the extrinsic risks of assistive devices, inappropriate footwear, restraint, use of nonsturdy furniture or equipment, poor lighting, uneven or slippery surfaces. (Ref 5)

2. Fall causes include, among others, orthostatic hypotension, arrhythmia, infection, generalized or focal muscular weakness, syncope, seizure, hypoglycemia, neuropathy, and medication.

Parameters of Assessment

A. Assess and document all older adult patients for intrinsic risk factors to fall:

1. Advancing age, especially if older than 75

2. History of a recent fall

3. Specific co-morbidities: dementia, hip fracture, Type II diabetes, Parkinson's disease, arthritis, and depression

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