NURSING DIAGNOSIS: Risk for trauma: falls

related to:
  1. weakness and fatigue;
  2. dizziness or syncope associated with postural hypotension resulting from peripheral pooling of blood and blood loss during surgery;
  3. central nervous system depressant effect of some medications (e.g. narcotic [opioid] analgesics, some antiemetics);
  4. presence of tubings or equipment.
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. instruct and assist client to rise and change positions slowly in order to reduce dizziness or syncope associated with postural hypotension
    8. carefully position tubings and equipment so that they will not interfere with ambulation
    9. provide ambulatory aids (e.g. walker, cane) if client is weak or unsteady on feet
    10. accompany client during ambulation and use a transfer safety belt if he/she is weak or dizzy
    11. instruct client to ambulate in well-lit areas and to utilize handrails if needed
    12. do not rush client; allow adequate time for ambulation to the bathroom and in hallway
    13. make sure that shower area has a nonslip bottom surface and that shower chair, secure bath mat, call signal, grab bars, and adequate lighting are present
    14. perform actions to increase strength and improve activity tolerance (see Diagnosis 11, action b).
  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.