00155 Risk for falls

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00155 Risk for falls

Definition of the NANDA label

Increased susceptibility to falls that can cause physical harm.

Susceptible to increased susceptibility to falling, which may cause physical harm and compromise health.

Risk factors

In adults

• History of falls.
• Use of a wheelchair.
• Age equal to or greater than 65 years.
• Woman (if she is elderly).
• Living alone.
• Prosthesis in the lower extremities.
• Use of assistive devices (eg, walker, cane).

Physiological

• Acute illness.
• Postoperative states.
• Visual difficulties.
• Hearing difficulties.
• Arthritis.
• Orthostatic hypotension.
• Insomnia.
• Dizziness when turning or extending the neck.
• Anemia.
• Vascular disease.
• Neoplasms (ie, fatigue, limited mobility).
• Urgency or urinary incontinence.
• Diarrhea.
• Decreased strength in the lower extremities.
• Postprandial glucose changes.
• Foot problems.
• Degradation of physic movility.
• Altered balance.
• Difficulty in walking.
• Proprioceptive deficits (eg, one-sided inattention).
• Neuropathy.

Cognitive

• Altered mental status (eg, confusion, delirium, dementia, impaired perception of reality).

Medications

• Antihypertensive agents.
• Diuretics.
• Antidepressants.
• Alcohol consumption.
• Anxiolytics.
• Narcotics.
• Hypnotics or tranquilizers.

Environmental

• Fasteners.
• Weather conditions (eg wet streets, ice).
• Carpets.
• Messy environment.
• Unknown room, dimly lit.
• Lack of non-slip material in the bathtub or shower.

In children

• Age less than 2 years.
• Male sex when less than 1 year old.
• Lack of self-restraint.
• Absence of a guardrail on the stairs.
• Lack of window protection.
• Placing the bed near the window.
• Leave the child alone in bed, on the table to dress him, on the sofa.
• Lack of parental supervision.

Associated condition

• Acute illness
• Alteration in cognitive functioning
• Anemia
• Arthritis
• Condition affecting the foot
• Hearing impairment
• Impaired balance
• Impaired vision
• Lower limb prosthesis
• Neoplasm
• Neuropathy
• Orthostatic hypotension
• Pharmaceutical agent
• Postoperative recovery period
• Proprioceptive deficit
• Use of assistive device
• Vascular disease

NOC

• Fall prevention behavior.
• Balance.
• Level of mobility.
• Self-care: AVD.

NIC

• Environmental management: safety.
• Prevention of falls.
• Surveillance.
• Improved communication: hearing deficit.
• Improved communication: visual deficit.
• Medication management.
• Incident report.
• Promotion of family involvement.

This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless additional work is completed to bring it up to a level of evidence 2.1 or higher.

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