Falls Risk Nursing Care Plan Example

Patient falls are one of the most common adverse events in hospitals and long-term care facilities, with significant consequences including fractures, head injuries, increased length of stay, and in some cases, death. Fall prevention is a core nursing responsibility and a national patient safety goal. This care plan example demonstrates a comprehensive approach to falls risk using NANDA-I diagnoses, NIC interventions, and NOC outcomes for a hospitalized patient at high risk for falls.

Condition Overview

Falls in the healthcare setting are defined as an unplanned descent to the floor or other lower surface, with or without injury. The Joint Commission identifies fall prevention as a National Patient Safety Goal, and CMS classifies preventable falls with injury as a "never event" that is not separately reimbursed. Approximately 700,000-1,000,000 patients fall in hospitals each year in the United States, with 30-35% resulting in injury and 1-2% resulting in fractures.

Fall risk is multifactorial, involving intrinsic factors (age-related changes, gait and balance disorders, cognitive impairment, visual deficits, orthostatic hypotension, polypharmacy, urinary urgency/incontinence, history of prior falls, lower extremity weakness) and extrinsic factors (unfamiliar environment, wet floors, inadequate lighting, improper footwear, clutter, IV lines and tubing, bed height). Effective fall prevention requires systematic risk assessment using validated tools (Morse Fall Scale, Hendrich II), implementation of evidence-based interventions, and continuous reassessment as the patient's condition changes.

Typical Patient Presentation

Patients at high risk for falls may present in many ways. Common profiles include elderly patients admitted for any reason who have baseline gait instability and polypharmacy, post-operative patients (especially orthopedic and cardiac surgery) with pain, sedation, and altered mobility, neurological patients with weakness or altered coordination (stroke, Parkinson's, multiple sclerosis), patients receiving new medications that affect balance or consciousness (opioids, benzodiazepines, antihypertensives, diuretics), and patients with cognitive impairment (delirium, dementia) who may not recognize their limitations or remember to call for assistance.

Assessment tools quantify risk. The Morse Fall Scale evaluates history of falling, secondary diagnoses, ambulatory aids, IV therapy, gait characteristics, and mental status. A score of 45 or above is considered high risk. The Hendrich II Fall Risk Model evaluates confusion/disorientation, depression, altered elimination, dizziness/vertigo, gender, antiepileptic use, benzodiazepine use, and the Get Up and Go test.

Sample Assessment Scenario

NANDA-I Nursing Diagnoses

1. Risk for Falls (00155)

Definition: Susceptibility to increased risk of falling, which may cause physical harm and compromise health.

Risk factors:Age over 65, history of falls (2 in 3 months, one with fracture), Parkinson's disease with gait impairment (festinating gait, decreased balance), orthostatic hypotension (24 mmHg systolic drop on standing), nocturia (3-4 times nightly), cognitive impairment (oriented x2, does not call for assistance), polypharmacy with fall-risk medications (opioid, alpha-blocker, antihypertensive, trazodone), unfamiliar environment, osteoporosis (increased fracture risk with falls), Morse Fall Scale 75.

2. Impaired Physical Mobility (00085)

Definition: Limitation in independent, purposeful physical movement.

Related factors:Neuromuscular impairment (Parkinson's disease — rigidity, bradykinesia, postural instability), deconditioning from hospitalization and acute illness, no assistive device available in hospital.

Evidence: Shuffling, festinating gait, forward-flexed posture, decreased arm swing, impaired balance, requires assistive device (walker) for safe ambulation.

3. Risk for Injury (00035)

Definition:Susceptibility to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources.

Risk factors: High fall risk combined with osteoporosis (T-score -3.1), increasing fracture risk from any fall. History of wrist fracture from prior fall. Anticoagulant-like effects are not present in this case, but the combination of fall risk and bone fragility places this patient at very high risk for injurious falls.

4. Disturbed Sleep Pattern (00198)

Definition: Time-limited interruptions of sleep amount and quality due to external factors.

Related factors: Nocturia (3-4 episodes nightly from BPH), unfamiliar environment, illness-related sleep disruption.

Evidence: Reports waking 3-4 times per night to urinate, trazodone prescribed for insomnia (contributes to sedation and fall risk), nighttime is the highest-risk period for falls in hospitalized patients.

NIC Interventions

For Risk for Falls

• Fall Prevention (6490):Implement high-risk fall prevention bundle: yellow non-skid socks, yellow fall-risk wristband, falling star sign on door, bed alarm activated at all times, call bell within reach and demonstrate use each shift. Keep bed in lowest position with brakes locked. Ensure the room is free of clutter and cords. Adequate lighting — nightlight on at all times. Provide a bedside commode to reduce the distance and risk of nighttime ambulation to the bathroom. Implement purposeful hourly rounding with the 4 P's (pain, position, potty, possessions). Anticipate toileting needs — offer toileting assistance every 2 hours during the day and before sleep. Consider 1:1 sitter or video monitoring if patient continues to get up unassisted despite interventions. Post fall prevention plan in the room and communicate to all team members during handoff.
• Medication Management (2380):Review medication list with the pharmacist and provider for fall-risk medications. Discuss with the provider: timing of trazodone (sedation risk), opioid necessity (can non-opioid alternatives manage pain?), tamsulosin timing (contributes to orthostatic hypotension), amlodipine dose (BP 128/72 lying, dropping to 104/62 standing). Measure orthostatic vital signs every shift and after medication changes. Administer Parkinson's medications on time — even small delays in carbidopa/levodopa can significantly worsen mobility and increase fall risk. This is a time-critical medication.

For Impaired Physical Mobility

• Exercise Therapy: Balance (0222): Consult physical therapy for fall risk assessment and individualized exercise program. Obtain a walker from the PT department for use during hospitalization (patient uses one at home). Supervise all ambulation — instruct patient not to walk alone. Teach the patient to rise slowly from sitting to standing (count to 10 while sitting on the edge of the bed before standing) to mitigate orthostatic hypotension. Encourage seated exercises (ankle pumps, knee extensions, arm exercises) when in bed or chair. Stand-pivot transfers with assistance.
• Exercise Therapy: Ambulation (0221):Ambulate with walker and nursing/PT assistance at least 3 times daily. Use a gait belt for all ambulation. Monitor for freezing episodes (common in Parkinson's — teach cueing strategies: visual targets on the floor, rhythmic counting, rocking weight side to side before stepping). Document ambulation distance, steadiness, and vital sign response.

For Risk for Injury

• Environmental Management: Safety (6486):Ensure non-skid floor surfaces. Remove all unnecessary equipment and furniture from the walking path between the bed and the bathroom. Secure IV tubing and oxygen tubing to prevent tripping. Place frequently needed items (phone, glasses, water, urinal) on the patient's dominant side within arm's reach. Ensure the call bell is always clipped to the bed linen within reach. Verify bed rails are in the half-up position (full side rails are considered a restraint in many facilities and can actually increase fall height if climbed over). If the patient falls: assess for injury before moving, check neurological status, obtain appropriate imaging, complete incident report, and reassess fall prevention plan.
• Hip Pad Application: Consider hip protector undergarments for a patient with osteoporosis and high fall risk. While evidence is mixed for hospital settings, hip protectors may reduce hip fracture risk during falls when worn consistently. Discuss with patient and family.

For Disturbed Sleep Pattern

• Sleep Enhancement (1850): Implement a nighttime toileting schedule (proactive toileting before bedtime and during routine nighttime rounding to reduce unprompted nighttime ambulation). Keep the bedside commode within reach and well-lit at night. Minimize nighttime disruptions (cluster care, reduce monitor alarms where safe). Discuss trazodone necessity with the provider — if possible, use non-pharmacological sleep aids (warm milk, reduced stimulation, consistent bedtime routine). If trazodone continues, educate the patient to remain seated on the bed edge for 1 minute after waking before standing.

NOC Outcomes

Fall Prevention Behavior (1909)

• Target: No falls during hospitalization
• Indicator: Patient uses call bell before attempting to get out of bed (at least 75% of the time)
• Indicator: Patient uses walker for all ambulation within 24 hours of PT provision
• Indicator: Patient verbalizes understanding of fall risk factors

Mobility (0208)

• Target: Patient ambulates with walker and supervision safely by discharge
• Indicator: Gait steadiness maintained or improved during hospitalization
• Indicator: Patient demonstrates safe transfer technique (bed to chair and back)
• Indicator: Orthostatic symptoms managed with positional strategies

Physical Injury Severity (1913)

• Target: No fall-related injuries during hospitalization
• Indicator: Skin integrity maintained
• Indicator: No fractures, head injuries, or soft tissue injuries from falls

Sleep (0004)

• Target: Nighttime awakenings reduced from 3-4 to 1-2 with proactive toileting
• Indicator: Patient reports improved sleep quality
• Indicator: All nighttime toileting episodes are assisted (no unattended ambulation)

Discharge Planning Considerations

Discharge planning for a high fall-risk patient requires a comprehensive home safety assessment. Key considerations: Is the walker in good condition? Are there throw rugs, loose cords, or uneven surfaces in the home? Is bathroom accessibility adequate (grab bars, non-skid mats, raised toilet seat)? Is lighting sufficient, especially in hallways and the bathroom? Can the patient navigate stairs safely, and if not, is the living arrangement adaptable? Refer to outpatient PT for ongoing balance and strength training (Parkinson's-specific programs like LSVT BIG if available). Review all medications with the primary care provider and neurologist for fall risk reduction. Ensure the patient has a follow-up appointment with the neurologist for Parkinson's medication optimization. Discuss a medical alert device for the patient who lives alone or is home alone for extended periods. Refer to occupational therapy for home safety evaluation and adaptive equipment recommendations.

Building Your Own Falls Risk Care Plan

Fall risk profiles vary dramatically — an elderly patient with Parkinson's disease has different risk factors and interventions than a post-operative patient on opioids or a patient with acute delirium. The key is systematic assessment using a validated tool, identification of modifiable risk factors, and implementation of a bundled prevention approach tailored to the individual.

CarePlanHQ generates individualized falls risk nursing care plans from your patient assessment. Enter the Morse Fall Scale score, mobility status, medications, cognitive function, and environmental factors to receive a complete NANDA-I care plan with targeted interventions, measurable outcomes, and a downloadable PDF.