This nursing care plan is for patients who are at risk for falls. According to Nanda the definition for falls is the state in which an individual has an increased susceptibility to falling. Many patient who falls suffer bodily injuries such as breaking a hip or internal brain swelling due to the impact of the fall. Nurses need to take many precautions in preventing falls in patient who are at risk for falling.

Every shift nurses assess patient fall risk. Patients who are at risk for falls include patients who have had a fall in the past 3 months, are taking medications that may increase falls such as Benzodiazepines or hypertension medication, or patients that have an unsteady gait. The most common tool used to assess a patient’s fall risk is the Morse Fall Risk Assessment. Below are the criteria for the tool:

Morse Fall Risk Assessment

•  History of falling within the last 3 months
  • 0  [] no
  • 25 [] yes
•  Gait characteristics/ abnormality

• 0  [] no normal/ bedrest/ wheel chair
• 10 [] yes weak
• 20 [] yes impaired

•  Mental status (patient’s own assessment of ability to walk)

• 0  [] oriented to own ability
• 15 [] overestimates/ forgets limit

• Secondary diagnosis (of any kind listed in medical chart)

• 0  [] no
• 15 [] yes

•  Ambulatory aid (used during gait)

• 0  [] no none/ bedrest/ nurse assistance/ wheel chair
• 15 [] yes crutches/ cane/ walker
• 20 [] yes furniture

•  Intravenous therapy/ saline lock

• 0  [] no
• 20 [] yes

• Scoring: 49 & below = low risk

Below is a nursing care plan with diagnosis and nursing interventions/goals for patients at risk for injury.

What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?

 

This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.

Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.

Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.

Nursing Care Plan for Risk for Fall

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.

Scenario

An 80 year old patient is admitted to your medical surgical floor with altered mental status. According to the patient’s family the patient had a fall last week and you find that the patient is unsteady on her feet. The patient scores 105 on the Morse Fall Tool. You are now working on the patient’s care plan and need a nursing diagnosis for risk for falls with nursing interventions and goals.

Nursing Diagnosis

Risk for falls related to altered mobility secondary to unsteady gait as evidence by patient unsteady on feet and Morse Fall Tool score of 105.

Subjective Data

According to the patient’s family the patient had a fall last week and you find that the patient is unsteady on her feet.

Objective Data

An 80 year old patient is admitted to your medical surgical floor with altered mental status.  The patient scores 105 on the Morse Fall Tool. You are now working on the patient’s care plan and need a nursing diagnosis for risk for falls with nursing interventions and goals.

Nursing Outcomes

-The patient will be free from any falls during her hospitalization.

Nursing Interventions

-The nurse will assess every shift the patient Morse Fall Score.

-The patient will wear a yellow fall risk bracelet and yellow non-skid socks so other nursing staff will know the patient is a fall risk.

-The nurse will keep the patient’s bed in the lowest position at all times.

-The nurse will use the bed and chair alarm as needed.

-The nurse will assess the patient need to use the bathroom every two hours.

-The nurse will move the patient close to the nurses station for closer observation.