Nursing Care Plan: Fall and Fall Risk Prevention

Creating a Nursing Plan for Patients at Risk of Falls

Thank you for visiting our site.
This time, we will discuss nursing plans for individuals prone to falls and accidental slips.
To identify those at risk, the “Fall Risk Assessment Score” is a useful tool. It simplifies the process and ensures no one is overlooked, making it highly recommended.

 For those in a hurry, please jump from below.

• 2. Candidates for Fall Risk Management
• 3. Nursing Goals
• 4. Nursing Plan
  • 1) Observation Plan
  • 2) Action Plan
  • 3) Education Plan

1. Fall Risk Assessment Score

The Fall Risk Assessment Score categorizes patients into three risk levels (I to III) based on their scores. Patients with a risk level of II or higher are considered at high risk and should be included in the nursing plan.
Since patient conditions change over time, it is essential to perform regular evaluations starting at the time of admission.

Reference: Japanese Medical Association’s Fall Risk Prevention Manual
Link

https://www.med.or.jp/anzen/manual/pdf/score.pdf

• Score of 1 to 9 →→→ Risk Level I (Possibility of falls)
• Score of 10 to 19 →→ Risk Level II (Prone to falls)
• Score of 20 or higher →→ Risk Level III (Frequent falls)

2. Candidates for Fall Risk Management

Fall Risk Assessment Score: Level II or higher
Characteristics of at-risk individuals:

・Elderly patients (65 years or older)　
・Cognitive impairment
・HDS-R (Hasegawa Dementia Scale): ≤19 points (out of 30) suggests potential dementia
・MMSE (Mini-Mental State Examination): ≤21 points (out of 30) suggests potential dementia
　30–27: Normal
　26–22: Mild dementia suspicion
　≤21: Dementia suspicion (MMSE is the international standard)

・Health conditions influencing fall risk:
・Diseases or conditions causing walking instability:
　・Musculoskeletal disorders, arthritis, myositis, rheumatoid arthritis
　・Visual or hearing impairments, balance disorders, paralysis
　・Sarcopenia, frailty
　・Malnutrition (leads to frailty)
・Conditions causing dizziness or fainting:
　・Anemia, orthostatic hypotension, cardiovascular diseases, 　
　・cerebrovascular diseases, diabetic complications
　・Sarcopenia, frailty, decreased lower limb strength
・Urgent urination or abnormal urinary frequency:
　・Cystitis, bladder irritation, prostate enlargement, frequent urination
・Other factors affecting walking and safety:
　・Use of walking aids (canes, walkers, wheelchairs)
　・Prosthetics, improper footwear (e.g., slippers)
　・Therapeutic environment:

・Environmental changes (e.g., hospitalization)
　・Wet floors, bathrooms
　・Poor lighting, cluttered surroundings
　・Improper bed height, lack of bed rails
　・Difficulty rising from futons
　・Restraints (increased delirium risk)
・Other risk factors:
　・Impaired judgment: alcohol use, antipsychotics, sedatives
　・Presence of medical equipment: drains, IV lines, catheters
・Childcare environment: lack of stair or window guards, improper child seat installation

3. Nursing Goals

Nursing goals should be patient-centered.

Examples:

・Reduce the Fall Risk Assessment Score.
・Create a therapeutic environment where falls are prevented.

4. Nursing Plan

1) Observation Plan

• Age
• Cognitive impairment (Hasegawa score below 19, MMSE below 21)
• Visual impairment
• Hearing impairment
• Paralysis, numbness
• Limping gait
• Small-step or shuffling gait (e.g., Parkinson’s disease)
• Impaired sense of balance
• Muscle weakness
• Joint abnormalities
• Footwear (backless shoes, walking in socks, ill-fitting shoes)
• Walking condition (foot movement, stability, use of cane or walker)
• Assistive walking devices in use (cane, quad cane, walker)
• Prosthetic limb
• Consciousness disorders (postoperative delirium, fever, etc.)
• Delirium, agitation
• Medications: Sedatives, antipsychotics leading to confusion
• Medications: Laxatives causing urgency
• Medications: Diuretics causing urinary urgency
• Habit of nighttime urination
• Frequent urination
• Distance to the toilet
• Orthostatic hypotension
• Anemia
• Indwelling devices (drains, Ba catheters, etc.) that may cause tripping
• Postoperative ambulation stage
• Post-lower limb surgery (non-weight bearing, etc.)
• Impatient personality (does not use nurse call)
• Reserved personality (does not use nurse call)
• Rehabilitation progress
• Living environment (bed, futon on tatami)
• Measures against slippery areas (bathroom, dressing room, etc.)
• Region (snowy areas, icy roads, etc.)

2) Action Plan

• Environmental adjustments: Adjust bed height (lower or ultra-low for high fall risk patients).
• Environmental adjustments: Keep sheets and items organized to eliminate tripping hazards.
• Environmental adjustments: Use bed rails to prevent falls.
• Environmental adjustments: Use sensor mats to detect movements.
• Environmental adjustments: Organize indwelling devices (drains, IVs, balloon catheters) to prevent entanglement.
• Environmental adjustments: Place the nurse call within reach.
• Environmental adjustments: Provide a portable toilet or urinal to reduce urgency for patients with frequent urination or diarrhea.
• Environmental adjustments: If nighttime urination is frequent, consider using a portable toilet or urinal only at night.
• Environmental adjustments: Ensure bathroom and shower floors are dry.
• Clothing adjustments: Ensure pants are an appropriate length.
• Clothing adjustments: Encourage the patient or family to provide shoes with heels.
• Clothing adjustments: Encourage wearing anti-slip socks indoors instead of slippers.
• If walking is unstable, provide appropriate assistance such as supervision, escorting, or hand guidance.
• Improve nutritional status.
• Incorporate rehabilitation into daily life.
• Provide assistance according to rehabilitation progress.
• Share rehabilitation progress with physical and occupational therapists to ensure safe assistance.
• If sedatives significantly increase fall risk, consult with a physician.
• If delirium is likely (elderly, extensive or long surgeries, history of delirium), relocate the patient near the nurse station.
• If the risk of injury due to delirium is high, frequently check on the patient for safety.
• Ensure patients can walk safely while adhering to the treatment plan.

3) Education Plan

• Explain specific environmental adjustments to the patient and caregiver (organization, bed height, etc.).
• Explain dietary measures for maintaining muscle strength to the patient and caregiver.
• Explain the importance of rehabilitation in maintaining ADL to the patient and caregiver.
• Guide the patient in choosing appropriate footwear for walking.
• If using bed rails or sensor mats, explain and obtain consent from the family.
• Explain that bathrooms and dressing rooms are high-risk areas for falls and encourage caution.
• Advise patients experiencing pain to avoid overexertion.
• If assistance is needed for walking to the toilet, encourage the patient to use the nurse call without hesitation. (“If you fall and hit your head, it will be a bigger problem, so don’t hesitate.”)
• Explain the importance of using the nurse call.
• Propose a system to prevent unnecessary outings on snowy or icy days. (e.g., online grocery delivery, co-op services, video calls)

Thank you for reading until the end. If you have any questions, opinions, or comments, please leave them in the comment section below. Looking forward to working with you again.