Assessment:

Objective Data:

1. Assess the patient’s mobility and balance through observation of gait, use of assistive devices, and overall coordination.
2. Evaluate the patient’s muscle strength and joint flexibility, particularly in lower extremities.
3. Identify any environmental factors that may contribute to falls, such as uneven flooring, poor lighting, or obstacles.

Subjective Data:

1. Interview the patient about their history of falls, including circumstances and frequency.
2. Inquire about the use of medications that may affect balance, including sedatives, antihypertensives, or psychotropic drugs.
3. Explore any sensory deficits, such as impaired vision or hearing, that may contribute to fall risk.

Diagnosis:

• Fall Risk related to impaired mobility, muscle weakness, environmental hazards, and medication effects.

Planning:

• The patient will maintain safety and minimize the risk of falls during their hospital stay, as evidenced by the absence of fall incidents within the next week.

Interventions:

1. Implement Bed Alarms:
   • Utilize bed alarms to alert healthcare providers if the patient attempts to leave the bed independently.
   • Ensure proper placement and functioning of bed alarms to enhance effectiveness.
2. Encourage Use of Assistive Devices:
   • Instruct and encourage the patient to use assistive devices such as canes, walkers, or handrails to support mobility.
   • Collaborate with physical therapy to assess and provide appropriate assistive devices.
3. Provide Adequate Lighting:
   • Ensure well-lit pathways, especially during nighttime hours, to enhance visibility and reduce the risk of tripping or stumbling.
   • Educate the patient on the importance of using bedside lighting during nighttime ambulation.
4. Medication Review and Adjustment:
   • Collaborate with the healthcare team to review and adjust medications that may contribute to dizziness or impaired balance.
   • Monitor for side effects of medications and communicate any changes to the healthcare provider.
5. Implement Fall Risk Education:
   • Educate the patient and family members about the identified risk factors and preventive measures.
   • Provide written materials or visual aids to reinforce fall prevention strategies.
6. Regular Monitoring and Assessment:
   • Conduct regular assessments of the patient’s mobility, gait, and overall fall risk.
   • Document any changes in the patient’s condition or environment that may impact fall risk.
7. Bedside Commode or Bathroom Assistance:
   • Provide a bedside commode or offer assistance with bathroom visits to prevent falls during toileting.
   • Ensure the call bell is within reach for the patient to request assistance when needed.
8. Collaborate with Physical Therapy:
   • Involve physical therapy in developing a personalized exercise plan to improve strength, balance, and coordination.
   • Schedule regular sessions to monitor progress and adjust the plan as needed.

Evaluation:

• Monitor and document the absence or occurrence of falls during the hospital stay.
• Assess the patient’s adherence to recommended fall prevention strategies.
• Evaluate the effectiveness of interventions in reducing fall risk and enhancing patient safety.
• Adjust the care plan based on ongoing assessments and any changes in the patient’s condition or environment.