Risk for Falls (Fall Risk & Prevention) Nursing Diagnosis & Care Plan

A fall on your unit is rarely just a fall. It is a hip fracture, a head bleed, a patient who never gets back to baseline, and a death investigation. Falls are the leading cause of injury death in adults 65 and older, and most hip fractures and most traumatic brain injuries in this group start with one. The work is preventable, and it is nursing work: screen every patient, read the intrinsic and extrinsic risk, and engineer the environment so that when a patient does go down, they have less distance and less to hit.

What is Risk for Falls?

A fall is an event in which a person comes to rest inadvertently on the ground, floor, or a lower level (WHO, 2021). Falls threaten both safety and independence. In 2024, 43,020 adults 65 and older died from preventable falls, and the fall death rate continues to climb. About one in four older adults falls each year, driving roughly 3 million emergency department visits and 1 million hospitalizations annually, with about $80 billion in health care spending for nonfatal falls. Worldwide, falls are the second leading cause of unintentional injury death.

Factors That Cause Falls

• Adults. Age 65 and older; lower-limb prosthesis; use of a walker, cane, or wheelchair; living alone.
• Children. Under 2 years; inadequate supervision of infants, toddlers, and preschoolers; missing window and height guards.
• Lifestyle. Unsafe worksites (buildings, bridges); insufficient fall-protection equipment.
• Physiological. Lower-body weakness; vision and hearing problems; foot conditions; balance difficulty; postoperative status; reliance on mobility aids.
• Emotional state. Stress and depression that reduce concentration.
• Environmental. Clutter, throw rugs, poor lighting, broken or uneven steps, unprotected water hazards.
• Cognitive. Impaired alertness, altered cognition, sleep loss, reduced consciousness, disorientation, confusion.
• Pharmaceutical. Polypharmacy; tranquilizers, narcotics, hypnotics, sedatives, antidepressants, and OTC drugs that affect balance and gait.

Nursing Diagnosis

Common diagnoses for the patient at fall risk:

• Risk for Falls as evidenced by advanced age (decreased muscle strength, slower reflexes, visual or hearing impairment)
• Risk for Falls as evidenced by medication side effects (sedatives, antihypertensives)
• Risk for Falls as evidenced by environmental hazards (poor lighting, cluttered walkways)
• Risk for Falls as evidenced by cognitive impairment (dementia, delirium)
• Risk for Falls as evidenced by neurological disorders (Parkinson's disease, stroke)
• Risk for Falls as evidenced by decreased sensory perception (neuropathy, vision loss)

Goals and Outcomes

• The patient does not sustain a fall.
• The patient states an intent to use fall-prevention safety measures.
• The patient demonstrates selected prevention measures.
• The patient and caregivers implement strategies to make the home safer.

Nursing Assessment

Falls have many causes, so assess the patient and the environment together. Any patient who screens high needs a fuller fall-risk assessment with a validated tool, and reassessment whenever health or circumstances change.

Conducting a Fall Risk Assessment

Assess fall risk on admission, after any change in physical or cognitive status, after every fall, on a set schedule during a hospital stay, and at defined intervals in long-term care. Weigh both intrinsic and extrinsic factors, and use a standard tool.

History of falls. One or more falls in the past 6 months sharply raises the odds of another. Older adults are especially prone to fall-related readmission.

Mental status. Confusion, disorientation, and impaired judgment leave a patient unsure of where they are or what to do, and prone to wandering into danger.

Age-related changes. Reduced visual function and color perception, a shifted center of gravity, unsteady gait, weaker muscles, less endurance, altered depth perception, and slower reaction times all raise risk. In age-related macular degeneration, worse vision tracks with more falls and injuries.

Sensory deficits. Vision and hearing loss limit the patient's ability to perceive hazards. Dim kitchens and cluttered entryways markedly raise risk.

Balance and gait. Poor balance or difficulty walking, whether from deconditioning, neurological disease, or arthritis, predicts falls. Patients with rheumatoid arthritis (swollen tender joints, fatigue, psychotropic use) are high risk.

Mobility aids. Wrong selection, poor fit, or poor maintenance of canes, walkers, and wheelchairs raises energy cost and instability and can increase fall risk. Frail older adults who need but do not use an aid fall more during ADLs.

Disease-related symptoms. Orthostatic hypotension, reduced cerebral blood flow, urinary urgency, edema, dizziness, weakness, fatigue, and confusion all raise risk. Stroke patients fall more often, lengthening stays and raising costs. In orthostatic hypotension, the blood pressure drop on standing brings lightheadedness that drops the patient.

Medications. Antihypertensives, ACE inhibitors, diuretics, tricyclic antidepressants, alcohol, antianxiety agents, opiates, and hypnotics or tranquilizers all raise risk. Drugs that affect blood pressure and level of consciousness carry the highest fall risk, and polypharmacy compounds it.

Unsafe clothing. Poorly fitting or overly tight clothing and shoes restrict movement and contribute to falls.

Environment. An unfamiliar layout, clutter, throw rugs, poor lighting, wet or slippery floors, broken or uneven steps, and floor obstacles all raise risk in the home, the workplace, and the community. Environmental hazards account for a larger share of falls in healthy older adults than in frail ones, who fall more from intrinsic causes.

Fall Risk Assessment Tools

Fall Risk Assessment Tool (FRAT). A 4-item screening tool for subacute and residential care, with three parts. Part 1, Fall Risk Status, covers recent falls, medications, and psychological and cognitive status. Part 2, Risk Factor Checklist, covers vision, mobility, transfers, behavior, ADLs, environment, nutrition, and continence. Part 3, Action Plan, applies clinical judgment to select individualized interventions.

Hendrich II Fall Risk Model (HIIFRM). Scores risk from sex, mental and emotional status, dizziness, and known fall-risk medication classes. A total of 5 or higher means high risk. A score of 4 or lower still carries some risk, so manage all risk factors as part of the care plan.

Pediatric patients. Assess sensory or motor deficits, recent illness, unsteady balance, running beyond ability, and inadequate supervision to guide interventions.

Nursing Interventions and Actions

Fall Prevention for Adults in Hospital or Long-Term Care

1. Build an individualized fall-prevention plan. Universal precautions set a safe baseline for everyone, but different patients need different measures, so do not rely on them alone.

2. Flag the patient. Use fall-risk signage and a secure wristband so every provider knows to apply precautions. Identify with two patient identifiers during all care.

3. Move the patient to a room near the nurses' station for closer observation and faster response.

4. Keep needed items within reach: call light, urinal, water, phone. Anything out of reach tempts the patient to overreach or get up.

5. Answer the call light fast. Quick response keeps the patient from getting up unassisted.

6. Avoid physical restraints. They do not reduce falls, and trunk restraints raise the risk of falls and fractures in patients with Alzheimer's or dementia.

7. Encourage eyeglasses and hearing aids, and regular vision and hearing checks. Sensory aids orient the patient to hazards.

8. Provide a hip pad for high-risk patients to cut hip-fracture risk in a fall.

9. Keep the bed at its lowest position, or place the sleeping surface near the floor when needed. Low beds do not prevent falls but shorten the distance, reducing trauma.

10. For tall patients, do not keep the bed low at all times. A tall, weak-legged patient can miss or fall onto a bed set too low.

11. Use bed and chair alarms for patients who get up unassisted. Alarms warn staff and prompt timely rescue, and can substitute for restraints, but they do not prevent the fall itself.

12. Raise side rails as needed. On split rails, leave at least one foot-of-bed rail down. A confused patient is less likely to fall when one of four rails is left down.

13. Place a nonskid floor mat at the bedside to cushion a fall.

14. Have the patient wear nonskid-soled shoes or slippers. Footwear affects balance through somatosensory feedback and shoe-floor friction; low heels and a large contact area help.

15. For shuffling gait or footdrop, avoid nonskid socks. These patients need shoes with little to no heel, thin slip-resistant soles, and ankle support.

16. Provide proper footwear. Nonskid socks can keep feet from sliding on standing, but use well-fitting shoes, not socks, for ambulation.

17. Improve home support. Community organizations can fund home-safety modifications for older adults.

18. Familiarize the patient with the room layout and discourage rearranging furniture, so they do not trip over moved objects.

19. Teach safe ambulation at home, including bathroom handrails. Raised toilet seats ease transfers.

20. Use heavy, stable furniture as support, keep the main path clear and straight, and remove floor clutter. Patients with poor balance cannot easily walk around obstacles.

21. Provide a chair with a firm seat and armrests on both sides, with locked wheels as appropriate. Firm armed chairs are easier to rise from.

22. Provide good room lighting, especially at night, so the patient can see if they must get up. Better home lighting lowers fall rates.

23. Provide assistive devices for transfer and ambulation. Gait belts promote safe transfers, and canes, walkers, and wheelchairs improve stability.

24. Refer to physical and occupational therapy for gait training. These therapies build exercise into daily routines, and group exercise lets older adults learn from peers.

25. Recognize that carrying objects while walking (a cup of water, clothing, supplies) raises fall risk. Have the patient keep hands free.

26. Limit wheelchair use, which can act as a restraint and reduce mobility.

27. For new-onset confusion (delirium), provide reality orientation and have family bring familiar items, clocks, and watches to maintain orientation.

28. Ask family to stay with the patient to prevent falls and tube dislodgement.

29. Consider sitters for patients who cannot follow directions, though the evidence that sitters reduce falls is weak, and video monitoring can reduce sitter use without raising fall risk.

30. Refer patients with musculoskeletal problems for evaluation. Osteoporosis raises injury risk, and musculoskeletal pain is a strong fall predictor in older women. Bone mineral density testing identifies fracture risk, and PT can find balance and gait deficits.

31. Collaborate with the team and pharmacist to review fall-contributing medications and check peak effects of drugs that alter consciousness. More medications mean more dizziness, orthostatic hypotension, drowsiness, and incontinence. Fall Risk-Increasing Drugs (FRIDs) include antihypertensives, antipsychotics, narcotics, sedatives, and anticholinergics, and long-term proton pump inhibitor use has been linked to higher fall risk.

32. Enroll the patient in regular exercise and gait training to strengthen muscle, improve balance, and increase bone density. Land and water programs both help, and water exercise benefits balance and gait in women 65 and older who cannot tolerate land-based work.

33. Encourage the Chair Rise (sit-to-stand) exercise to strengthen the thighs and buttocks and improve mobility. As the patient strengthens, work toward rising without using the hands.

34. Explain vitamin D supplementation. Vitamin D supports postural balance and gait, and at least 800 IU daily is a simple measure to fold into fall-prevention and postural-rehabilitation plans for older patients.

Fall Prevention for Children

1. Modify the surroundings. Keep toys and objects off the floor.

2. Improve window safety with window guards. Falls from windows and balconies cause severe injury and death.

3. Teach parents to use infant car seats, stair gates, life jackets, helmets, and sun protection to keep children safe.

4. Warn parents about high chairs and walkers. Always use safety straps and supervise. Walkers can send a child down a flight of stairs.

5. Train children to use stairs, porches, and decks. With supervision, have them hold the rail and take one step at a time.

6. Keep anticipating new hazards. Children remain prone to falls despite a modified home, so never leave them unattended and use every precaution.