CUES No subjective cues Objective cues; -physical mobility -decreased urine output NURSING DIAGNOSIS Risk for falls related to impaired physical mobility 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 injury is associated with prolonged hospitalizations for the adult. The quality of life for the adults is significantly changed following a fall-related GOALS/ OUTCOME CRITERIA After 8 hours of nursing intervention, no incidence of fall will occur, patients safety will be ensured. Spedifically the patient will: >Be free of injury >Modify environment as indicated to enhance safety >Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury NURSING RESPONSIBILI TIES INDEPENDENT Assess the person for factors known to increase fall risk such as history of falls, mentall status changes and sensory deficits Assess patient’s environment for factors known to increase fall risk such as unfamiliar setting and inadequate lighting Place items used by the patient within easy reach RATIONALE Evidence indicates that a person who has sustained one or more falls in the past year is more likely to fall again Patients who are not familiar with the placement of furniture and equipment in the room are more likely to experience a fall Stretching to get items from bedside tables that are out of reach can disrupt the patient’s balance and EVALUATION Goal met After 8 hours of rendering nursing interventions the patient will have no incidence of fall and safety is ensured

injury. The death ratetfrom fall-related injuries and their complications increases with the age of the patients. (Gulanick, 6th Edition, pg.59)

Use siderails on beds contribute to falls as needed. Patients who are disoriented or confused have been known to climb over siderails and fall Encourage the patient to participate in a program of regular exercise Evidence suggests that people who engage in regular exercise and activity will strengthen muscles Nonskid footwear provides sure footing for the patient with diminished foot and toe lift when walking The more familiar the patient is with the layout of the room, the less likely the patient

DEPENDENT Encourage the patient to wear shoes or slippers with nonskid soles when ambulating

Orient the patient to the layout of the room.

is to trip over furniture Provide the patient with a chair that has a firm seat and arms on both sides This chair style is easier to get out of,especially when the patient experiences weakness and impaired balance when transferring from bed to chair Incorrect use or improper maintenance of canes, walkers and wheelchairs can increase the risk for falls Physical therapy evaluation can identify problems with balance and gait that can increase a persons fall risk

Educate the patient and family caregivers about the correct use and maintenance of mobility assisted devices COLLABORATIVE Refer the person for diagnostic masculoskeletal evaluation

Collaborate with other health care team members to evaluate the patients medications that contribute to falling

A review of the patients medication by the prescribing health care provider and the pharmacist can identify side effects and drug interaction Many community service organizations provide financial assistance to help older alults make safety improvements

Refer the family to community resources for assistance in making home safety modifications

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