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 surgery on the knee;
  4. improper 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. reinforce preoperative instructions about and assist client with transfer and ambulation techniques, use of ambulatory aids, and exercises to improve muscle strength
    2. administer prescribed analgesics and/or apply ice packs to operative knee before exercise and ambulation sessions to reduce knee pain and subsequently maximize the client's ability to use proper transfer and ambulation techniques
    3. ensure that client has knee immobilizer on for ambulation sessions to provide additional support of operative leg.
  3. Include client and significant others in planning and implementing measures to prevent falls.
  4. If falls occur, initiate first aid measures if appropriate and notify physician.