Assessment

  1. Assess the patient’s risk factors for falls, including history of falls, medication use, impaired mobility, vision or hearing deficits, and cognitive impairments.
  2. Assess the patient’s gait, balance, and ability to stand and sit.
  3. Assess the patient’s environment for hazards that could contribute to falls.

Nursing Diagnosis

  • Risk for falls related to impaired mobility, medication use, and environmental hazards as evidenced by history of falls and presence of risk factors

Planning

  1. The patient will remain free from falls during hospitalization
  2. The patient will receive education on fall prevention measures to reduce the risk of falls after discharge

Implementation

  1. Implement fall prevention measures, including bed rails, non-slip footwear, and assistive devices.
  2. Encourage the patient to use call bell when assistance is needed.
  3. Modify medication regimen to minimize fall risk.
  4. Collaborate with physical therapy to develop an exercise program to improve strength and balance.
  5. Educate the patient and family on fall prevention measures.
  6. Regularly assess the patient’s fall risk and modify interventions as needed.

Evaluation

  1. Assess the patient’s response to interventions and evaluate effectiveness of fall prevention measures.
  2. Continuously reassess and modify the plan of care as needed to prevent falls.
  3. Provide education on fall prevention measures to reduce the risk of falls after discharge.

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