Risk for Falls Nursing Diagnosis & Care Plan

According to the Centers for Disease Control and Prevention (CDC), there are approximately three million emergency department visits due to older adult falls annually. Of the three million hospital visits, over one million result in hospitalization. Additionally, falls are the most common cause of traumatic brain injuries. 

Even though most falls occur in the elderly population, understanding the risk for falls, nursing diagnosis, and how to properly develop a nursing care plan is essential for all nurses.

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Risk Factors for Falls

Risk factors for falls can be grouped into several categories, each influencing balance, mobility, or awareness in different ways.

Biological & Health-Related Factors

• Age-related changes – Reduced muscle strength, slower reflexes, and changes in vision or hearing.
• Chronic conditions – Stroke, Parkinson’s disease, arthritis, diabetes, cardiovascular disease.
• Cognitive impairment – Dementia, delirium, or other conditions that affect judgment and coordination.
• History of previous falls – Past falls significantly increase future fall risk.
• Sensory deficits – Poor vision, hearing loss, peripheral neuropathy.

Medication-Related Factors

• Polypharmacy – Taking multiple medications increases risk due to drug interactions.
• Specific high-risk drugs – Sedatives, sleeping pills, antidepressants, antipsychotics, antihypertensives, and certain pain medications.
• Side effects – Dizziness, drowsiness, low blood pressure, or impaired balance.

Environmental & Situational Factors

• Poor lighting – Inadequate illumination in hallways, bathrooms, or staircases.
• Tripping hazards – Loose rugs, clutter, electrical cords, uneven flooring.
• Unsafe footwear – High heels, slippers without grip, or worn-out soles.
• Lack of supportive equipment – Absence of handrails, grab bars, or walking aids.

Behavioral & Lifestyle Factors

• Risky movement patterns – Rushing, climbing on chairs, or bending awkwardly.
• Inactivity – Weak muscles and reduced balance from lack of exercise.
• Alcohol use – Impaired coordination and judgment.
• Improper use of assistive devices – Not using canes, walkers, or other supports correctly.

Acute & Temporary Factors

• Illness – Fever, infection, or dehydration causing weakness or confusion.
• Pain – Limiting mobility and altering gait.
• Sudden changes in health – New medications, recent surgery, or hospitalization.¹

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Scales Used to Assess Risk for Falls

1. Psychiatric Field
   1. Baptist Health High Risk Falls Assessment (BHHRFA)
   2. Wilson-Sims Fall Risk Assessment Tool (WSFRAT)
2. Pediatric Field
   1. 4-item Little Schmidy Pediatric Hospital Fall Risk Assessment Index
   2. Humpty Dumpty Fall Scale (HDS)
   3. Bayındır Hospital Risk Evaluation Scale for In-hospital Falls of Newborn Infants
3. Emergency Department
   1. KINDER 1 Fall Risk Assessment Tool
   2. Memorial Emergency Department (MED-FRAT)
4. Rehabilitation Field
   1. Casa Colina Fall Risk Assessment Scale (CCFRAS)
   2. Predict_FIRST
   3. Marianjoy Fall Risk Assessment Tool (MFRAT)
5. Home Care
   1. Simple clinical scale
   2. Home Falls and Accidents Screening Tool (HOME FAST)
6. Miscellaneous/No Specific Field
   1. Outdoor Falls Questionnaire
   2. Stroke Assessment of Fall Risk (SAFR)
   3. Questionnaire for Fall Risk Assessment in the Elderly²

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How to Develop a Risk for Falls Nursing Care Plan

When developing a risk for falls nursing care plan, the first step is determining a patient’s goals. Although you’ll generate parts of the nursing care plan on your own, the nursing diagnosis must be on the NANDA-I-approved nursing diagnosis list.

According to the North American Nursing Diagnosis Association (NANDA),  a nursing diagnosis is “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is rooted in Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis, you’ll set goals to resolve your patient’s problems through nursing interventions determined in the next step.

NANDA-I separates nursing diagnoses into four categories:

• Problem-focused: A diagnosis based on patient problems present during a nursing assessment.
• Risk: A diagnosis based on risk factors that requires intervention from a nurse or healthcare team before a real problem develops.
• Health promotion: A diagnosis that intends to improve the overall well-being of an individual, family, or community.
• Syndrome: Based on a cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions.

Determining the most important goals for the patient and the corresponding nursing diagnosis provides the basis to create a risk for falls care plan that can best support the patient while reaching those goals.

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Risk for Falls Nursing Care Plan Components

A nursing care plan has several key components, including: 

• Nursing Diagnosis
• Expected outcome
• Nursing interventions and rationales
• Evaluation

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections. Otherwise, it won’t make sense.

• Nursing diagnosis: A clinical judgment that helps nurses determine the plan of care for their patients
• Expected outcome: The measurable action for a patient to be achieved in a specific time frame. 
• Nursing interventions and rationales: Actions to be taken to achieve expected outcomes and reasoning behind them.
• Evaluation: Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

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Risk for Falls Nursing Care Plan Examples

All nursing diagnoses must be NANDA-I approved and have corresponding definitions to help guide nurses in writing a nursing care plan.

NANDA-I Definition of Risk for Falls: At risk for increased susceptibility to falling that may cause physical harm.³

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Other Nursing Care Plans

• Hypertension Nursing Care Plan
• Acute Pain Nursing Care Plan
• Infection Nursing Care Plan
• Constipation Nursing Care Plan
• Decreased Cardiac Output Nursing Care Plan
• COPD Nursing Care Plan
• Pneumonia Nursing Care Plan
• Diabetes Mellitus Nursing Care Plan
• Fluid Volume Deficit Nursing Care Plan
• Sepsis Nursing Care Plan
• Impaired Physical Mobility Nursing Care Plan
• Atrial Fibrillation (AFib) Nursing Care Plan
• Heart Failure Nursing Care Plan

References

^{1 “Risk Factors for Falls.” 2024. Government of Western Australia Department of Health. https://www.health.wa.gov.au/Articles/F_I/Falls-prevention-and-management-in-WA/Research-and-education-in-falls/Risk-factors-for-falls.}

^{2 Strini, Veronica, Roberta Schiavolin, Angela Prendin, and Richard Gray, ed. 2021. “Fall Risk Assessment Scales: A Systematic Literature Review.” National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC8608097/.}

^{3 Herdman, T. H., Shigemi Kamitsuru, and Camila Lopes, eds. 2024. NANDA-I International Nursing Diagnoses: Definitions & Classification, 2024-2026. 13th ed. N.p.: Thieme Medical Publishers.}

Nursing Care Plan