NURSING DIAGNOSIS: Risk for trauma: falls

related to:
  1. weakness, fatigue, and postural hypotension associated with the effects of major surgery and physiological changes that may have occurred if client is elderly;
  2. central nervous system depressant effect of some medications (e.g. narcotic [opioid] analgesics, centrally acting muscle relaxants, some antiemetics);
  3. weakness and pain in weight-bearing extremity associated with the initial injury and surgery on the hip;
  4. difficulty with transfer and ambulation techniques.
Desired Outcome
The client will not experience falls.
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 18, action a, for measures to prevent falls.
  2. Implement additional measures to reduce the risk for falls:
    1. perform actions to assist client to increase muscle strength:
      1. instruct and encourage client to perform isometric quadriceps- and gluteal-setting exercises
      2. encourage client to use the overhead trapeze to lift self (strengthens arm and shoulder muscles, which will facilitate use of ambulatory aids)
    2. reinforce physical therapist's instructions regarding correct transfer and ambulation techniques and proper use of ambulatory aids (e.g. walker)
    3. administer prescribed analgesics before exercise and ambulation sessions in order to reduce hip pain and subsequently maximize client's ability to utilize proper transfer and ambulation techniques.
  3. Include client and significant others in planning and implementing measures to prevent falls.
  4. If client falls, initiate first aid measures if appropriate and notify physician.