Nursing Care Plan: Risk for fall related to amputation, body weakness, and old age.

Scientific Basis:

Falls are a major safety risk for adults, especially older adults. Evidence indicates that about 30% to 40% of older adults experience at least one serious fall per year. The consequences of these falls for the older adult represent a major health concern. Injuries sustained as a result of a fall include soft tissue injury, fractures (hip, spine, and wrist), and traumatic brain injury. Fall-related injuries are associated with prolonged hospitalizations for older adult. The quality of life for older adults is significantly changes following a fall-related injury. Death rate from fall-related injuries and their complications increases with the age of the patient.

Prevention of falls is an important dimension of the nursing care of patients in hospitals and long-term care settings. Implementation of policies and procedures designed to prevent falls is an essential part of nursing care in any health care setting. Fall prevention strategies need to promote patient dignity and functional independence by significantly limiting the use of physical restraints to maintain safety. Nurses also have a major role in educating patients, families, and caregivers about prevention of falls in the home.

(Gulanick, 2007)

Intervention and Rationale

I: Assess the client for factors known to increase fall risk such as: History of falls.
R: Evidence indicates that a person who has sustained one or more falls in the past year is more likely to fall again.

I: Mental status changes.
R: Confusion and impaired judgment increase the person’s risk for falls.

I: Age-related physical changes.
R: Normal changes associated with aging increase the person’s risk for falling. These changes include decreased visual capacity, impaired color perception, change in center of gravity, decreased muscle strength, decreased endurance, altered depth perception, and delayed response and reaction times.

I: Sensory deficit.
R: Impaired vision and hearing limit the person’s ability recognize hazards in the environment.

I: Disease-related symptoms.
R: Increased incidence of falls has been demonstrated in persons with symptoms such as orthostatic hypotension, dizziness, weakness, fatigue, and confusion.

I: Unsafe clothing.
R: Poor-fitting shoes, long robes, or long pants legs can limit a person’s ambulation and increase fall risk.

I: Assess the client’s environment for factors known to increase fall risk such as unfamiliar setting, inadequate lighting, wet surfaces, waxed floors, clutter, and objects on floor.
R: Clients who are not familiar with the placement of furniture and equipment in their room are more likely to experience a fall. Anything that blocks or limits a clear, straight path for ambulation can contribute to a person’s fall risk.

I: Ensure appropriate room lighting, especially at night.
R: Older adults with reduced visual capacity will benefit from adequate lighting, especially in an unfamiliar environment. Using a night light helps increase visibility if the client must get up at night.

I: Encourage the client to wear shoes or slippers with nonskid soles when ambulating.
R: Nonskid footwear provides sure footing for the client with diminished foot and toe lift when walking.

I: Provide the client with a chair that has a firm seat and arms on both sides.
R: This chair style is easier to get out of, especially when the client experiences weakness and impaired balance when transferring from bed to chair.

I: Encourage the client to participate in a program of regular exercise.
R: Evidence suggested that people who engage in regular exercise and activity will strengthen muscles, improve balance, and increase bone density. Increased physical conditioning reduces the risk of falls and limits injury that is sustained when a fall occurs.

I: Educate the client and family members about risk factors for fall in the home. Adaptation to increase safety.
R: About 40% of older adults living in the community sustain at least one fall per year. Falls are the leading cause of accidental death in the home setting.

I: Place bright, nonskid strips on the edge of stair treads. May install handrails on both sides of stairs from top to bottom if necessary.
R: Older adults have problems differentiating shades of the sane color and have diminished depth perception. These physiological changes make it difficult to see the edge of a stair tread that is a uniform color.

I: Ensure all rugs are securely fastened to the floors or removed.
R: Loose throw rugs increase the risk of slipping and falling.

I: Rearrange furniture to have a clear pathway between rooms. Keep traffic patterns free of clutter and electrical cords.
R: People with diminished strength are less able to negotiate around obstacles on their paths.

I: Increase lighting at the top and bottom of stairs. Use nightlight in bathrooms, bedrooms, and hallways.
R: Older adults have poor vision at night and in dimly lit areas.

I: May refer the family to community resources for assistance in making home safety modifications.
R: Many community service organizations provide financial assistance to help older adults make safety improvements in their homes as necessary.

Gulanick, 2007; Doenges, et al, 2002; Kruse, et al. 2003

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