00303 Risk Of Adult Falls

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00303
Nanda label: adult fall risk
Diagnostic focus: falls
approved 2020 • Evidence level 3.4

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « risk of adult falls ” is defined as: adult susceptibility to experience an event that is to end up lying on the ground or at another lower level by carelessness, than You can compromise health.

Risk factors

Physiological factors

  • Chronic musculoskeletal pain
  • Decrease in force in the lower extremities
  • Dehydration
  • Diarrhea
  • Dizziness when extending the neck
  • Dizziness when turning the neck
  • Hypoglycemia
  • deterioration of physical mobility
  • Postural balance deterioration
  • Incontinence
  • Obesity
  • Sleep alterations
  • Vitamin D

Psychoneurological factors

  • Confusional agitation
  • Anxiety
  • Cognitive dysfunction
  • Depressive symptoms
  • Fear of falls
  • Persistent wandering
  • Inappropriate use of substances

Non -modified environmental factors

  • Crowded environment
  • High bed surface
  • Exposure to insecure weather conditions
  • Inappropriate non -slip material in the bathroom
  • Inappropriate non -slip material in the soils
  • Inadequate lighting
  • Inappropriate toilet seat height
  • Lack of attention to pets
  • Lack of safety railings
  • Objects out of reach
  • Seats without arms
  • Backups without backup
  • Irregular soil
  • Unknown environment
  • Use of carpets

Other factors

  • Difficulty in carrying out daily life activities
  • Difficulty in carrying out the instrumental activities of daily life
  • Factors identified by a standardized and validated assessment scale
  • get up at night without help
  • Insufficient knowledge of modifiable factors
  • Inappropriate clothing for ambulation
  • Inappropriate footwear

Risk population

  • People at economic disadvantage
  • People> 60 years of age
  • People who experience prolonged hospitalization
  • People in geriatric residences
  • People in residences of palliative care
  • People in rehabilitation residences
  • People in the immediate postoperative period
  • People who live alone
  • People who receive home care
  • People with a history of falls
  • People with low educational level
  • People with fasteners

Associated problems

  • Anemia
  • Ambulation assistance devices
  • Depression
  • Endocrine system diseases
  • Prosthesis in lower extremities
  • Severe injury
  • Mental disorders
  • Musculoskeletic diseases
  • Neurocognitive disorder
  • Orthostatic hypotension
  • Pharmacological preparations
  • Sensitivity disorders
  • Vascular diseases

Suggestions of use

When specific risk factors are presented for falls, this diagnosis should be used instead of the most general risk of injury or risk of trauma. If there is an accident risk, in addition to falling, the most general diagnoses may be better.

Suggested alternative diagnostics

Other examples

  • The patient and family will be able to:
  • Provide a safe environment (for example, eliminate disorder and dry spilled liquids, place humps, use anti -muding bath rugs and grip bars)
  • Identify the risks that increase the tendency to falls
  • avoid the physical injuries caused by the falls

NIC Interventions

Note : The following interventions are related to the prevention of falls and aimed at specific risk factors. A detailed list exceeds the purpose of this manual, so that if a patient has risk factors not described here (for example, substance abuse, urinary incontinence), consult a medical-surgical text (or another) and the NIC manual.

  • Help in self -care: to help another person perform their daily activities
  • Intestinal incontinence care: Promotion of fecal continence and maintenance of the integrity of the perianal skin
  • Teaching: infant security: Security instruction during the first year of life
  • Teaching: Safety of the Small Child: Security Instruction during the second and third years of life
  • Cognitive stimulation: promotion of consciousness and understanding of the environment through the use of planned stimuli
  • Promotion of exercise: strength training: application of regular muscle training against resistance to maintain or increase muscle strength
  • Promotion of exercise: Stretching: application of muscular exercises of static stretching to produce relaxation, prepare the muscles of the joints for a more vigorous exercise, or increase or maintain body flexibility
  • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
  • Medication management: Facilitate the harmless and effective use of drugs with and without recipe
  • Peripheral sensation management: prevention or reduction of injuries or discomfort of patients with sensory alterations
  • Environment management: Security: Control and manipulation of the physical environment to favor security
  • Acute confusional state management: provision of a safe and therapeutic environment for the patient who experiences an acute confusion state
  • Improvement of bodily mechanisms: Application of the use of postures and movement in daily activities to prevent fatigue and musculoskeletic lesions or tensions
  • Precautions against seizures: prevention or reduction of injuries that a patient can suffer with a known convulsive disorder
  • Fall prevention: establishment of special precautions with the patient who is at risk of falling injuries
  • Exercise therapy: Muscle control: Use of activity or exercise protocols to improve or restore controlled body movement
  • Exercise therapy: Desembling: Promotion and Patient Help when walking, in order to maintain or restore the voluntary and autonomous functions of the organism during the treatment and recovery of the disease or injury
  • Exercise therapy: Balance: Apply specific activities, postures and movements to maintain, improve or restore balance
  • Exercise therapy: joint mobility: Apply active or liability body movement to maintain or restore the flexibility of joints
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and in order to make clinical decisions

Nursing Activities

Valuations

  • Identify factors that affect security needs, for example, changes in mental state, the degree of intoxication,
    151 fatigue, maturation age, medications and motor or sensory deficit (for example, in the march or balance)
  • Make an evaluation of the risk of falls to each patient who enters the institution
  • (NIC) Fall prevention:
    • Identify the characteristics of the environment that can increase the potential of falls (for example, slippery floors and stairs without railing)
    • Control the march, balance and fatigue level, with wandering

Patient and family education

  • (NIC) Fall prevention:
    • Teach the patient how to fall to reduce injuries to a minimum
    • Ask the patient to use their graduate glasses, as appropriate, when it is out of bed

Collaboration activities

  • (NIC) Fall prevention: collaborate with other members of the health team to reduce the side effects of medicines that contribute to falls (for example, orthostatic hypotension or unsafe march)
  • Channel to physiotherapy for training and exercises of locomotion, in order to improve mobility, balance and strength

Others

  • Reorient the patient to reality and the immediate environment, when required
  • Help the patient with wandering, as necessary; Use a transfer belt and receive the help of another person if the patient is unstable
  • If the patient is at risk of falls, place in a room near the Central de Nurses
  • Provide auxiliary devices for walking (for example, cane, walker)
  • Use an alarm to prevent the caregiver when the patient gets out of bed or room
  • If necessary, apply physical restrictions to limit the risk of falls
  • (NIC) Fall prevention:
    • Provide the dependent patient for a means to request help (for example, a bell or a call light) when the caregiver is absent
    • Put the articles available to the patient
  • Teach the patient to ask for help with the movement, according to proceed
  • Eliminate environment risks (for example, provide adequate lighting)
  • Do not make unnecessary changes in the physical environment (for example, furniture placement)
  • Ensure that the patient triggers adequate shoes (for example, of antiderrapant sole, with safe closures)

At home

  • Instruct the patient and family about techniques to prevent home injuries, and specify techniques
  • Provide educational materials related to strategies and measures to prevent falls
  • Provide information on the risks of the environment and its characteristics (stairs, windows, bars)
  • Teach family members the factors that contribute to falls and ways to reduce these risks
  • Channel to Physiotherapy to teach the family how to help with wandering and transportation safely
  • Evaluate the correct use of auxiliaries for wandering (for example, walker)

Babies and Children

  • Raise the railings when there is no one next to the bed
  • In the case of children with enough age to jump the railings, use a cradle with a higher network or lid
  • (NIC) Fall prevention:
    • Eliminate objects that could serve young children to climb high surfaces
    • Supervise continuously, or use devices to restrict the movement (as chairs for children with seat belt) by placing children on high surfaces (for example, high table and seat)

Older people

  • Evaluate the patient’s ability to walk safely, with or without auxiliary devices
  • Evaluate the vision and remind the patient to carry their glasses when I walk
  • Evaluate and treat urinary incontinence, which is associated with a greater incidence of falls
  • Recommend and help the patient obtain a call system for personal emergencies
  • Tai Chi classes can be beneficial for patients who can participate