Nursing Diagnosis Analysis Goal & Objectives Intervention Rationale Evaluation

Risk for Falls as A risk factor is Objective a. Independent After 8 hours of

evidenced by something that Within 8 hours of nursing Observe individual’s Noting multiple nursing
increases a person’s intervention, the client general health status factors that might affect intervention, the
risk or susceptibility will be free from risk of safety, such as chronic or client has no
for falling.The falls. debilitating conditions, incidence of fall
complex nature of the use of multiple and no injury
deficits related to fall   medications, recent during the shift.
risk requires close trauma (especially a fall
case management and within the past year), [/] MET
coordination of prolonged
services (Moyer, bedrest/immobility, or a
2012) Multiple factors sedentary lifestyle.
play a role in falls and Evaluate client’s
related injuries, general and hip Altering coordination,
however poor balance muscle strength, gait, and balance.
is the cause of the postural stability, gait
majority of falls in and standing balance,
older adults. and gross and fine
Human balance motor coordination.
depends on the Review history of past
interaction of our or current physical
senses of sight, touch, injuries (e.g.,
etc. and our ability to musculoskeletal
control the movement injuries; orthopedic
of our bodies. These surgery)
abilities decline
significantly as we Assess mood, coping Individual’s temperament,
age, which can lead to abilities, and typical behavior,
falls, even when there personality styles. stressors, and
are no identifiable level of self-esteem can
neurological or affect attitude toward
musculoskeletal safety issues,
problems. resulting in carelessness
or increased risk taking
Falls and balance. without
(2017, July 26). consideration of
Retrieved April 05, consequences.
2021, from
https://www.neura.ed Ascertain May reveal lack of
u.au/health/falls- client’s/SO’s level of understanding,
balance/ knowledge about and insufficient resources, or
attendance to safety simple disregard for
ATrain education. needs. personal
(n.d.). Retrieved April safety (e.g., “I can’t watch
05, 2021, from him every minute,” “We
https://www.atrainceu can’t
.com/content/4-risk- hire a home assistant,”
factors- “It’s not manly...” etc.)
falls#:~:text=The
%20risk%20of Signs are vital for patients
%20falling For patients at risk for at risk for falls.
%20increases,functio falls, provide signs or Healthcare providers need
nal%20dependency secure a wristband to acknowledge who has
%2C%20and%20drug identification to the condition for they are
%20use. remind healthcare responsible for
providers to implementing actions to
implement fall promote patient safety
precaution behaviors. and prevent falls.

To manage conditions
that could contribute to
Recommend or falling and to promote
implement needed safe environment for
interventions such as: individual and
others

Keeping the beds closer to

the floor reduces the risk
Place bed in lowest of falls and serious injury.
possible position, use In some healthcare
a raised-edge mattress, settings, placing the
pad floor at side of mattress on the floor
bed, or place mattress significantly reduces fall
on floor as appropriate risk.

To assist individual in
Use half side rail arising from bed
instead of full side
rails or upright pole
This is to prevent the
Respond to call light patient from going out of
as soon as possible. bed without any
assistance.

Ask family to stay This is to prevent the

with the patient. patient from accidentally
falling or pulling out
tubes.
Review medication
regimen and how it Use of certain
affects client. Instruct medications (e.g.,
in monitoring of narcotics/opiates,
effects and side psychotropics,
effects. antihypertensives,
diuretics) can contribute
to weakness, confusion,
and balance and gait
disturbances
Review medications
with client and To determine if changes
primary care provider (e.g., different medication
or dosage) could reduce
client’s
Collaborative fall risk
Refer to rehabilitation
team, physical or To improve client’s
occupational therapist, balance, strength,
as appropriate or mobility; to improve or
relearn ambulation; and to
identify and obtain
appropriate assistive
devices for mobility,
environmental safety, or
home modification.
Refer to other
resources as indicated Client/caregivers may
need financial assistance,
home modifications,
referrals for counseling,
home care, sources for
safety equipment, or
placement in extended-
care facility
Doenges, M. E.,
Moorhouse, M. F., Doenges, M. E.,
 & Murr, A. C. Moorhouse, M. F., &
(2019). Nursing Care Murr, A. C. (2019).
Plans Guidelines for Nursing Care Plans
Individualizing Client Guidelines for
Care Across the Life Individualizing Client
Span (13th ed.). Care Across the Life Span
Philadelphia: F.A. (13th ed.). Philadelphia:
Davis. F.A. Davis.