NURSING DIAGNOSIS: Risk for trauma: falls

related to:
  1. weakness;
  2. dizziness and syncope associated with inadequate cerebral blood flow resulting from decreased cardiac output and the hypotensive effect of some medications (e.g. ACE inhibitors, diuretics);
  3. getting up without assistance as a result of restlessness, agitation, forgetfulness, and confusion (can result from cerebral hypoxia and fluid and electrolyte imbalances).
Desired Outcome
The client will not experience falls.
Nursing Actions and Selected Purposes/Rationales
  1. Implement measures to prevent falls:
    1. keep bed in low position with side rails up when client is in bed
    2. keep needed items within easy reach
    3. encourage client to request assistance whenever needed; have call signal within easy reach
    4. use lap belt when client is in chair if indicated
    5. instruct client to wear well-fitting slippers/shoes with nonslip soles and low heels when ambulating
    6. keep floor free of clutter and wipe up spills promptly
    7. accompany client during ambulation utilizing a transfer safety belt if he/she is weak or dizzy
    8. provide ambulatory aids (e.g. walker, cane) if client is weak or unsteady on feet
    9. instruct client to ambulate in well-lit areas and to utilize handrails if needed
    10. do not rush client; allow adequate time for ambulation to the bathroom and in hallway
    11. instruct and assist client to rise and change positions slowly in order to reduce dizziness associated with postural hypotension
    12. perform actions to improve cardiac output (see Diagnosis 1, action b) in order to improve cerebral blood flow and subsequently reduce dizziness, syncope, agitation, and confusion
    13. perform actions to restore fluid and electrolyte balance (see Diagnosis 3) in order to reduce the risk for changes in mental status that may result in the client getting up unassisted
    14. perform actions to increase strength and activity tolerance (see Diagnosis 6, action b)
    15. make sure that shower has a nonslip bottom surface and that shower chair, secure bath mat, call signal, grab bars, and adequate lighting are present
    16. administer central nervous system depressants judiciously
    17. if client is confused or irrational:
      1. reorient frequently to surroundings and necessity of adhering to safety precautions
      2. provide appropriate level of supervision
      3. consult physician about the temporary use of a bed alarm or jacket or wrist restraints if necessary
      4. administer prescribed antianxiety and antipsychotic medications if indicated.
  2. Include client and significant others in planning and implementing measures to prevent falls.
  3. If client falls, initiate first aid measures if appropriate and notify physician.