“Risk for Falls” is a common and important question regarding patient safety in healthcare. The answer is yes: “Risk for Falls” is a formally recognized diagnostic statement that guides professional nursing practice and care planning. Preventing falls is essential, as they are a leading cause of injury-related morbidity and mortality, particularly among older adults.
Understanding the Concept of a Nursing Diagnosis
A nursing diagnosis is a clinical judgment concerning an individual’s response to actual or potential health problems. This framework differs from a medical diagnosis, which focuses on identifying and treating a disease or pathological process, such as pneumonia. A medical diagnosis names the illness, while a nursing diagnosis describes the human experience and reaction to that illness or vulnerability.
For example, a patient with Parkinson’s disease may have corresponding nursing diagnoses like “Impaired Physical Mobility” or “Risk for Falls.” The nursing diagnosis directs the care provided by nurses, focusing on interventions within the scope of nursing practice, such as assessing mobility and modifying the environment. This patient-centered approach ensures care addresses functional limitations and safety concerns created by the underlying disease.
Risk for Falls as a Recognized Diagnostic Label
“Risk for Falls” is a standardized diagnostic label approved by NANDA International (NANDA-I), the leading authority for nursing terminology. NANDA-I defines this diagnosis as an “increased susceptibility to falling that may cause physical harm.” Since it is a “risk” diagnosis, the patient possesses vulnerability factors that make the event likely.
This diagnosis is focused on prevention, requiring the nurse to identify specific risk factors and implement measures to avoid the adverse outcome. The formal statement structure involves the diagnostic label followed by the specific risk factors identified during assessment. Using standardized terminology ensures clear communication among healthcare providers and supports evidence-based care planning.
Identifying Specific Contributing Factors
The diagnosis is established after a comprehensive assessment identifies specific contributing factors, categorized as intrinsic or extrinsic. Intrinsic factors originate within the patient’s body and physical condition, such as chronic diseases, medication effects, or age-related changes. Advanced age, specifically being 65 years or older, is a significant intrinsic factor due to associated declines in muscle strength, reflex speed, and vision.
Impaired mobility, including gait and balance problems, and muscle weakness are prevalent intrinsic risks. Cognitive impairments, such as dementia or delirium, affect judgment and awareness of hazards, further increasing the risk. Polypharmacy, which is the use of multiple medications, or the use of specific high-risk drugs like sedatives, contributes to dizziness and orthostatic hypotension.
Extrinsic factors involve environmental hazards and external circumstances that create unsafe conditions. These include physical elements in the patient’s surroundings, such as poor lighting, wet floors, and clutter, which create tripping hazards. Other extrinsic risks include the absence of supportive equipment, like handrails or grab bars, and the use of inappropriate footwear. In healthcare settings, extrinsic factors can also involve the incorrect use of assistive devices or improper placement of the call light.
Developing Targeted Safety Interventions
Once specific intrinsic and extrinsic risk factors are identified, the nurse develops and implements targeted safety interventions to mitigate the potential for a fall. Interventions focused on intrinsic factors include collaborating with a physical therapist to start a tailored exercise program to improve strength and balance. Medication management is another primary intervention, often involving a review of the patient’s drug regimen with a physician to adjust dosages or discontinue high-risk medications.
Interventions for extrinsic factors focus on environmental modification to eliminate hazards. This includes ensuring the patient’s bed is kept in the lowest position with the wheels locked and that the call button and personal items are always within easy reach. Providing non-skid footwear and ensuring adequate room lighting, especially at night, are effective measures. Patient and family education regarding identified risk factors and safe movement patterns empowers the individual to participate in fall prevention.