NURSING DIAGNOSIS: Risk for trauma: falls
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);
getting up without assistance as a result of restlessness, agitation, forgetfulness, and confusion (can result from cerebral hypoxia and fluid and electrolyte imbalances).
The client will not experience falls.
Nursing Actions and
to prevent falls:
keep bed in low position with side rails up when client is in bed
keep needed items within easy reach
encourage client to request assistance whenever needed; have call signal within easy reach
use lap belt when client is in chair if indicated
instruct client to wear well-fitting slippers/shoes with nonslip soles and low heels when ambulating
keep floor free of clutter and wipe up spills promptly
accompany client during ambulation utilizing a transfer safety belt if he/she is weak or dizzy
provide ambulatory aids (e.g. walker, cane) if client is weak or unsteady on feet
instruct client to ambulate in well-lit areas and to utilize handrails if needed
do not rush client; allow adequate time for ambulation to the bathroom and in hallway
instruct and assist client to rise and change positions slowly
in order to reduce dizziness associated with postural hypotension
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
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
perform actions to increase strength and activity tolerance (see Diagnosis 6, action b)
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
administer central nervous system depressants judiciously
if client is confused or irrational:
reorient frequently to surroundings and necessity of adhering to safety precautions
provide appropriate level of supervision
consult physician about the temporary use of a bed alarm or jacket or wrist restraints if necessary
administer prescribed antianxiety and antipsychotic medications if indicated.
Include client and significant others in planning and implementing measures to prevent falls.
If client falls, initiate first aid measures if appropriate and notify physician.