NANDA Risk for Falls Nursing Diagnosis

NANDA Definition: Increased susceptibility to falling that may cause physical harm

Related Factors: See Risk Factors

Risk Factors:

Adults

• History of falls; 
• wheelchair use; 
• (65 years of age; 
• female (if elderly); 
• lives alone; 
• lower limb prosthesis; 
• use of assistive devices (e.g., walker, cane)

Physiological

• Presence of acute illness; 
• postoperative conditions; 
• visual difficulties; 
• hearing difficulties; 
• arthritis; 
• orthostatic hypotension; 
• sleeplessness; 
• faintness when turning or extending neck; 
• anemias; 
• vascular disease; 
• neoplasms (i.e., fatigue/limited mobility, urgency and/or incontinence, diarrhea, decreased lower extremity strength, posprandial blood sugar changes, foot problems, impaired physical mobility, impaired balance, difficulty with gait, unilateral neglect, proprioceptive deficits, neuropathy)

Cognitive

• Diminished mental status (e.g., confusion, delerium, dementia, impaired reality testing)

Medication

• Antihypertensive agents; 
• ACE-inhibitors; 
• diuretics; 
• tricyclic antidepressants; 
• alcohol use; 
• antianxiety agents; 
• opiates; 
• hypnotics or tranquilizers

Environment

• Restraints; 
• weather conditions (e.g., wet floors/ice); 
• throw/scatter rugs; 
• cluttered environment; 
• unfamiliar, dimly lit room; 
• no antislip material in bath and/or shower

Children (<2 years of age)

• Male gender when <1 year of age; 
• lack of auto restraints; lack of gate on stairs; 
• lack of window guard; bed located near window; 
• unattended infant on bed/changing table/sofa; 
• lack of parental supervision

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Safety Behavior: Fall Prevention
• Knowledge: Child Safety

Client Outcomes

• Remains free of falls
• Changes environment to minimize the incidence of falls
• Explains methods to prevent injury

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Fall Prevention
• Dementia Management
• Safety

Read More : http://nanda-nic-noc.blogspot.com/2013/04/risk-for-falls-nursing-diagnosis.html

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