Care Plan for Potential Falls

Category / Primary Body System

• Musculoskeletal System

Problem

• Patient is at risk for falls due to decreased muscle strength.

Goal

• Patient will not experience injury due to falls for 90 days.

Plan/Approach

1. Risk Assessment

   • Assess risk for falls on admission, quarterly, and as needed
   • Use a standardized fall risk assessment tool

2. Safety Measures

   • Ensure call light is within reach and check patient if unable to use call light
   • Monitor patient for toileting needs regularly to prevent rushing

3. Therapeutic Interventions

   • Conduct PT/OT evaluations and provide treatment as needed to improve muscle strength and mobility
   • Assist patient during mobility and transfer to ensure safety

4. Medication and Monitoring

   • Administer medications as ordered and monitor for side effects that may increase fall risk
   • Conduct labs as ordered to monitor health status

5. Psychological Support

   • Provide psychological consult as ordered to address any fear of falling or anxiety

Rationale

1. Risk Assessment

   • Regular assessment identifies patients at high risk for falls and allows for timely implementation of preventive measures.

2. Safety Measures

   • Keeping the call light within reach and monitoring toileting needs helps prevent situations where the patient might attempt to move without assistance, reducing fall risk.

3. Therapeutic Interventions

   • PT/OT can provide exercises and strategies to enhance muscle strength and balance, reducing fall risk.
   • Assisting with mobility and transfers ensures the patient moves safely, reducing the likelihood of falls.

4. Medication and Monitoring

   • Monitoring medication side effects and lab results ensures that any factors contributing to fall risk are promptly addressed.

5. Psychological Support

   • Psychological support helps address anxiety or fear of falling, which can impact mobility and willingness to move safely.

Actions

1. Risk Assessment

   • Perform a fall risk assessment using a standardized tool on admission, quarterly, and as needed.
   • Document and communicate the patient's fall risk status to all healthcare team members.

2. Safety Measures

   • Ensure the call light is always within the patient's reach and check regularly if the patient can’t use it.
   • Regularly check on the patient’s toileting needs and assist them to the bathroom to prevent hurried or unassisted movements.

3. Therapeutic Interventions

   • Schedule PT/OT evaluations and follow through with prescribed treatments to improve strength and balance.
   • Assist the patient during all mobility and transfer activities, ensuring they use assistive devices if prescribed.

4. Medication and Monitoring

   • Administer medications as ordered, watching for side effects that could increase fall risk, such as dizziness or hypotension.
   • Conduct and review lab tests as ordered, addressing any abnormalities that could affect fall risk.

5. Psychological Support

   • Arrange for psychological consults to address fears or anxiety related to falling.
   • Incorporate relaxation techniques or counseling as recommended by the psychologist.