NURSING DIAGNOSIS: Risk for trauma: falls
weakness and fatigue;
dizziness or syncope associated with postural hypotension resulting from peripheral pooling of blood and blood loss during surgery;
central nervous system depressant effect of some medications (e.g. narcotic [opioid] analgesics, some antiemetics);
presence of tubings or equipment.
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
instruct and assist client to rise and change positions slowly
in order to reduce dizziness or syncope associated with postural hypotension
carefully position tubings and equipment so that they will not interfere with ambulation
provide ambulatory aids (e.g. walker, cane) if client is weak or unsteady on feet
accompany client during ambulation and use a transfer safety belt if he/she is weak or dizzy
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
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
perform actions to increase strength and improve activity tolerance (see Diagnosis 11, action b).
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.