NANDA-NursingPlan Area 11 Safety/Defense

NANDA-nursing plan 00155  Risk for falls  (changed in 2021 version)

Area 11 Safety/defense Free from danger, bodily injury and immune system damage, protection from loss, guarantee of safety and security
Category 2 Bodily injury Bodily harm or injury

00155 Risk for falls


Nursing Diagnosis: 00155 Risk for falls
Definition: A condition in which tumbles or falls are likely and may result in physical harm or loss of health.

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Thank you for always watching (*゚▽゚*)
In NANDA-I 2021, “fall risk status” is divided into “adult fall risk status” and “pediatric fall risk status”. Here are the definitions for each.
Nursing diagnosis: 00303 Adult fall risk status
Definition: A condition in which an adult is likely to experience an accident inadvertently landing at a low height such as the ground or floor, which may impair their health.
Nursing diagnosis: 00306 Pediatric fall risk status
Definition: A condition in which a child is likely to experience an accident in which he or she inadvertently lands on the ground, floor, or other low height, potentially jeopardizing their health.
From the 2021 edition, it is divided into adults and children, making it more specific. Each of them is linked below, so please jump to it. Now let’s think about the fall risk.
Similar nursing diagnoses are Physical Injury Risk State (Injury Risk State) and Physical

1. Nursing diagnosis ” Risk for falls ” target


・ Fall assessment score risk level II or higher (See (✩ 1) for the fall assessment score)
・Elderly (over 65 years old)
・Decline in cognitive function
・ MMSE: Possibility of dementia at 21 points or less (30-27 normal, 26-22 suspected longitude dementia, 21 or less recognized
Suspected dementia) Full score of 30 points. MMSE is an international standard
・Use of walking aids (canes, walkers, wheelchairs), artificial legs, slippers (not sports shoes or rehabilitation shoes)
・Environment: Wet feet, bathroom, poor lighting makes it difficult to see feet, messy feet
・Use of restraints
・Things that impair judgment: alcohol, psychotropic drugs, sleeping pills
・Disease that causes lightheadedness or fainting: anemia, orthostatic hypotension, cardiovascular disease, cerebrovascular disease, diabetic complications
・Disease or condition that makes walking unstable: musculoskeletal disease, arthritis, myositis, rheumatoid arthritis, visual impairment, hearing impairment, balance disorder, paralysis, sarcopenia, weakness in lower extremity muscles
Urgent situation: incontinence, urinary urgency
・Many inserted conditions: drains, drips, indwelling bladder catheters
・Childcare environment: Lack of safety barriers on stairs and windows, inappropriate installation of child seats

✩ 1 Fall assessment score sheet

In Japan, there is a tool for predicting falls called the Fall Assessment Score Sheet.
Depending on where you live, there are various scales such as “Downton Fall Risk” and “Morse Fall Scale”, so please do your own research.
Introducing Japan’s “Tumble Fall Assessment Score Sheet”.
The risk is classified into I to III depending on the score. Level II or higher indicates a high fall risk.

Risk level I: 1 to 9 points (possibility of falling
Risk II: 10 to 19 points (easily to fall)
Risk III: Frequent falls
Because the patient’s condition changes, it is necessary to evaluate the patient periodically from the time of admission.

2. Goal setting by linkage


* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).


1) Linkage achievements

・Body balance (0202)
(Definition: being able to maintain the balance of the body)
· Coordinated movement: (0212)
(Definition: the ability to voluntarily move muscles together for a desired exercise)
· Fall prevention behavior (1909)
(Definition: behavior of the patient or caregiver to minimize risk factors for falls in the surrounding environment)
・Frequency of falls (1912)
(Definition: number of past falls)
・Knowledge/fall prevention behavior (1828)
(Definition: Degree of understanding shown about fall prevention)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

・To describe how to prevent falls.

・You can actually incorporate methods to prevent falls into your lifestyle.

3. nursing plan


1 >> Observation plan 《OP》


(1) Personal factors

・Age (older age, younger age): Insufficient awareness of danger
・Cognitive impairment (Hasegawa score of 20 or less, MMSE score of 21 or less)
・ADL
・MMT (Manual Muscle Test)
・Joint range of motion
・Frailty
・Sarcopenia
・Visual impairment
・Hearing impairment
・Motility disorders (paralysis, numbness, etc.)
・Sensory disturbance
・Lameness
・Short steps, shuffling (Parkinson’s disease, etc.)
・Balance disorder
・Muscle weakness
・Joint abnormalities
・Selection of footwear (shoes without heels, walking in socks, shoes that do not fit)
・Walking condition (walking, sense of stability, use of cane, walker, etc.)
・Walking aids used (canes, four-point canes, walkers)
・Prostheses
・Low motivation
・Disturbed consciousness (postoperative delirium, fever, somnolence, etc.)
Nocturnal delirium, restlessness
・Sleep disorder, reversal of day and night
・Activities during the day
・ Oral medications: Consciousness clouding due to sleep-inducing drugs and psychotropic drugs → Light-headedness
・ Oral medicine: Urgent urge to defecate due to laxatives
・ Oral medicine: Urgent urge to urinate due to diuretics
・Nocturnal urination habits
・ Frequent urination
・orthostatic hypotension
・Pathology/disease (anemia, hypoglycemia, obesity, prostatic hyperplasia)
・Indwelling objects (stumbling due to drains, Ba catheters, etc.)
・Stage of getting out of bed after surgery
・After surgery on the lower extremities (conditions that affect walking, such as casts and unloading)
・Impatient personality (does not press nurse call)
・Reluctant personality (does not press nurse call)
・Rehabilitation progress (Overconfidence in own walking ability → Trying to move forcibly thinking that it can be done)
・Anxiety (cannot move due to strong anxiety → reduced range of motion, decreased muscle strength)
(2) Environmental factors
·Environmental changes
・Distance to toilet
・Bedding (bed, tatami mat and futon), fence, bed height
・Cluttered bed area
・Floor steps
・Lighting (Is it bright enough to secure a field of view?)
・ Measures for slippery places (bathrooms, dressing rooms, etc.)
・Regions (areas with a lot of snow, areas with a lot of frozen road surfaces, etc.)・
・Long, long-term bed rest (opportunities for activities have decreased due to hospitalization or admission)

2 >> Action plan 《TP》

・Environmental improvement: bed height (low or ultra-low for people with a high risk of falling)
・Environmental maintenance: Tidy up sheets and other things to eliminate the cause of stumbling.
・Environmental maintenance: Make sure the room has enough illumination and secure a field of view.
・Environmental maintenance: Use fences to prevent falls.
・Environmental preparation: Use a sensor mat to catch the rising.
・Environmental maintenance: Organize in order not to get caught in indwelling objects (tubes such as drains, intravenous drips, balloon catheters, etc.).
・Environmental preparation: Place the nurse call system within reach.
・Environmental maintenance: In the case of frequent urination or diarrhea, use a portable toilet or a urinal to create an environment in which people do not panic.
・Environmental improvement: If the number of nighttime toilet visits is high, suggest using portable toilets and urinals only at night.
・Environmental maintenance: Make sure that the floor of the bathroom and shower room is not wet.
・Adjusting clothes: Adjusting the length of the pants.
• Clothing adjustments: Have the person or family member prepare to wear high-heeled shoes.
・Adjustment of clothes: Encourage them to wear non-slip socks instead of slippers even indoors.
・If the walking condition is unstable, provide assistance according to the condition, such as watching, accompanying, and guiding.
・Incorporate activities during the day to prevent day-night reversal.
• Manage the disease according to the treatment plan.
・Perform ROM training and gait training to maintain ADL and joint range of motion.
・Provide assistance according to the progress of rehabilitation.
・Share information on the progress of rehabilitation with physical and occupational therapists so that safe assistance can be provided.
・If you judge that the effect of sleeping pills is strong and the risk of falling is high, report it to your doctor.
・If delirium may occur after surgery (elderly, extensive surgery, long surgery, history of delirium, etc.), move the patient to a room close to the nurse station.
・If the risk of trauma such as delirium is high, visit the room frequently to confirm safety.
・Assist the patient to walk safely while adhering to the treatment plan.

3》Education Plan《EP》

・Concretely explain how to improve the environment for the person/caregiver. (organization, bed height, brightness, etc.)
・Teach students to choose appropriate footwear and clothing.
・When using a 4-point fence or sensor mat, a restraining consent form is required, so after obtaining permission from the attending physician, explain to the family and obtain consent.
・If you have symptoms such as nocturia or sleeplessness, tell them to consult.
・Introduce exercises that can be done in bed.
・Explain that falls are likely to occur in bathrooms and dressing rooms, and encourage caution.
・If you have symptoms such as pain, explain not to overdo it.
・Instruct the patient not to hesitate to press the nurse call button when walking assistance is required to go to the toilet, etc.
(If you fall and hit your head, it will be even more difficult, so it’s not the time to hold back.)
・Explain the need for a nurse call.
・Propose a system that does not force people to go outside when it snows or freezes.
(Using online supermarkets, co-op, video calls, etc.)

References

T. Heather Hardman, Shigemi Kamitsuru, Camila Takao Lopez. (July 1, 2021). NANDA-I Nursing Diagnosis – Definition and Classification 2021-2023 Original 12th Edition. Igaku Shoin Co., Ltd.
T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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