Did you know that falls are one of the leading causes of injury in adults, especially those over 65? In fact, nearly one in four older adults will experience a fall each year. It’s a statistic that underscores why nursing care plans for fall risk are crucial.
Falls can happen in any setting, but with the right strategies, most of them are preventable. That’s where you come in as a nurse. Whether you’re in a hospital, nursing home, or at home, having a solid fall-prevention care plan can make all the difference in keeping patients safe.
In this article, you’ll find 10 nursing care plan risk for falls examples, complete with NANDA diagnoses, actionable interventions, and real-world rationales to guide your practice. Ready to learn how you can reduce fall risk for your patients? Let’s dive in!
In this article:
- Risk Factors for Falls
- How to Develop a Nursing Care Plan
- Expected Outcomes & Assessment
- Nursing Interventions and Rationales
- 10 Nursing Care Plan Examples
- Evaluation & References
Risk Factors for Falls
Risk factors for falls can be grouped into categories that affect balance, mobility, or awareness. Knowing what puts a patient at risk helps you plan the right interventions before an accident happens.
| Category | Risk Factors | Description / Examples |
| Biological & Health-Related | • Age-related changes• Chronic conditions• Cognitive impairment• History of previous falls• Sensory deficits | Muscle loss, slower reflexes, poor vision or hearing.Diseases like stroke, Parkinson’s, arthritis, or diabetes.Dementia, delirium, or confusion affecting judgment.Past falls predict future falls.Neuropathy or vision problems limit awareness. |
| Medication-Related | • Polypharmacy• High-risk drugs• Side effects | Taking several medications can cause drug interactions.Sedatives, antidepressants, antipsychotics, and blood pressure pills can cause dizziness or confusion.Common side effects include low blood pressure and unsteady gait. |
| Environmental & Situational | • Poor lighting• Tripping hazards• Unsafe footwear• Missing safety equipment | Dim rooms or stairs, clutter, loose rugs, or cords.Slippers without grip or worn-out soles.Lack of handrails or grab bars near bathrooms or beds. |
| Behavioral & Lifestyle | • Risky movements• Inactivity• Alcohol use• Improper use of aids | Rushing, reaching too far, or climbing furniture.Weak muscles from long inactivity.Alcohol affects balance and reaction time.Not using canes or walkers correctly. |
| Acute & Temporary | • Illness or dehydration• Post-surgery weakness• Pain or new medications | Fever, infection, or fatigue cause weakness.Anesthesia and post-operative recovery reduce coordination.New medications can alter balance and focus. |
How to Develop a Risk for Falls Nursing Care Plan
A nursing care plan is like a safety blueprint—it guides you step by step in preventing harm and supporting recovery. When it comes to fall prevention, your plan focuses on understanding why a patient is at risk and building strategies that keep them safe, confident, and mobile.
Understanding the Goal
The goal of a nursing care plan for risk for falls is simple: protect patients from injuries caused by falls while promoting independence whenever possible. Each plan should reflect your patient’s unique situation—no two cases are exactly the same.
According to NANDA-I (North American Nursing Diagnosis Association International), 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.”
The NANDA-I definition of Risk for Falls is:
“At risk for increased susceptibility to falling that may cause physical harm.”
This diagnosis aligns with Maslow’s Hierarchy of Needs, addressing safety and security before moving on to higher needs like belonging or self-fulfillment.
The Four NANDA Diagnosis Categories
| Category | Meaning |
| Problem-Focused | Diagnosis based on current, observable issues. |
| Risk | Identifies potential problems that could occur if preventive action isn’t taken. |
| Health Promotion | Focuses on improving overall well-being or function. |
| Syndrome | Combines related diagnoses that often appear together or respond to similar interventions. |
Steps to Create a Nursing Care Plan
Creating a strong plan involves both analysis and empathy. Follow these steps to build one that works in real clinical settings:
- Identify risk factors — Review the patient’s health history, environment, and medications.
- Choose the correct NANDA diagnosis — For falls, this is typically Risk for Falls.
- Set measurable outcomes — Define what “success” looks like (e.g., patient remains fall-free during hospitalization).
- Select interventions and rationales — Plan nursing actions supported by evidence or policy.
- Evaluate and revise — After implementing, check results and adjust the plan if needed.
Mini Example
Let’s put it together:
Patient: 72-year-old post-stroke client with left-side weakness and dizziness.
Diagnosis: Risk for Falls related to impaired mobility and altered balance.
Expected outcome: Patient will remain fall-free during hospital stay and demonstrate safe use of walker.
Expected Outcomes
Once you identify the nursing diagnosis, the next step is to set clear and measurable goals. These outcomes help you track progress and show whether your interventions are working.
A strong risk for falls nursing care plan includes outcomes that focus on safety, awareness, and mobility.
Examples of expected outcomes:
- Patient will remain free from falls during the hospital stay or care period.
- Patient will identify at least three personal fall risk factors and ways to reduce them.
- Patient will demonstrate safe ambulation with assistive devices before discharge.
- Patient’s environment will stay hazard-free, with proper lighting and clear walking paths.
- Caregivers will describe two or more safety strategies for preventing falls at home.
- Patient will report increased confidence when walking or transferring with assistance.
Nursing Assessment for Risk for Falls
Before you can prevent a fall, you need to understand what might cause it. Nursing assessment is the foundation of every fall prevention plan. It helps you spot risk factors early and choose the right interventions for each patient.
Key areas to assess:
- History of falls – Ask about previous incidents. One fall often predicts another.
- Mobility and gait – Watch how the patient walks or transfers from bed to chair. Look for unsteady steps or weak legs.
- Medications – Review prescriptions that may cause dizziness, low blood pressure, or drowsiness.
- Cognitive status – Assess for confusion, disorientation, or memory problems that affect safety.
- Vision and hearing – Check if the patient can see and hear well enough to move safely.
- Environment – Scan for clutter, cords, poor lighting, or slippery floors.
- Footwear and assistive devices – Ensure shoes have grip and canes or walkers are used correctly.
Nursing Interventions and Rationales
Once you’ve identified fall risks, it’s time to act. Nursing interventions should focus on preventing accidents, keeping the environment safe, and promoting patient independence.
Below are common, evidence-based actions with simple explanations of why they matter.
Fall Risk Interventions for Adults
- Create an individualized fall-prevention plan.
Each patient’s situation is different. Tailor the plan to age, mobility, medications, and cognitive status. - Use fall-risk identifiers.
Place wristbands or signs to alert staff that the patient needs extra precautions. - Keep patients close to the nurses’ station.
This allows faster response times and more frequent observation. - Ensure call lights and personal items are within reach.
When patients reach too far for things, they may lose balance or attempt to stand alone. - Respond promptly to call lights.
Quick responses reduce the chance that patients will try to get up unassisted. - Avoid physical restraints.
Restraints can cause more harm by increasing agitation and attempts to escape. Frequent observation is safer. - Provide proper footwear and assistive devices.
Encourage shoes with nonslip soles and teach patients how to use canes or walkers correctly. - Adjust the bed to its lowest position.
A low bed reduces the distance of a potential fall and makes transfers safer. - Use bed or chair alarms for high-risk patients.
Alarms alert nurses when a patient tries to stand alone, allowing timely help. - Maintain good lighting, especially at night.
A soft nightlight can prevent disorientation in unfamiliar rooms. - Encourage strength and balance exercises.
Physical therapy improves mobility and builds confidence during ambulation. - Collaborate with a pharmacist to review medications.
Adjusting or removing high-risk drugs can reduce dizziness and confusion. - Include the family in safety teaching.
Loved ones can help reinforce fall-prevention habits and provide supervision when needed.
Fall Risk Interventions for Children
- Make the environment child-safe.
Remove toys or clutter from walkways and secure rugs or cords. - Use safety equipment.
Install stair gates, window guards, and crib rails appropriate for the child’s age. - Educate parents or caregivers.
Teach them to use safety straps, lock wheels on strollers, and supervise children near heights. - Discourage the use of baby walkers.
Walkers are a major cause of injuries and can lead to falls down stairs. - Ensure floors and play areas are slip-resistant.
Mats, socks with grips, and closed shoes help prevent falls during play. - Monitor for fatigue or illness.
Tired or unwell children may lose balance more easily, increasing fall risk.
Nursing Care Plan: Risk for Falls Examples
Every fall prevention plan begins with identifying the cause of the risk — physical, environmental, or medication-related — and ends with a clear, measurable outcome.
Below are 10 sample nursing care plans for risk for falls, drawn from common clinical situations.
Care Plan #1 — Risk for Falls Related to Decreased Cognitive Status (Hospitalized Older Adult)
Diagnostic Statement:
Risk for falls related to confusion and impaired judgment.
Expected Outcomes:
- Patient will remain free from falls during hospitalization.
- Patient will call for assistance before getting out of bed.
- Patient will demonstrate improved orientation to the environment.
Assessment:
- Observe the patient’s level of alertness and orientation.
- Review history of dementia or delirium.
- Identify triggers that increase confusion (noise, fatigue, medication).
Interventions and Rationales:
- Place the patient near the nurses’ station — allows closer observation and quicker assistance.
- Use visual reminders (signs, colored wristbands) — alerts all staff to high fall risk.
- Keep environment familiar and uncluttered — reduces confusion and anxiety.
- Encourage family presence when possible — familiar voices help reduce agitation.
- Use bed and chair alarms — provide early warning when the patient tries to ambulate alone.
Care Plan #2 — Risk for Falls Related to Environmental Hazards (Home Setting)
Diagnostic Statement:
Risk for falls related to unsafe environment and cluttered living space.
Expected Outcomes:
- Home environment will be free of tripping hazards.
- Patient and family will demonstrate safety modifications within one week.
Assessment:
- Assess lighting, furniture placement, and floor surfaces.
- Observe for loose cords, rugs, or objects blocking pathways.
- Evaluate accessibility of frequently used items.
Interventions and Rationales:
- Remove clutter and rearrange furniture for clear pathways — prevents accidental tripping.
- Install grab bars and handrails — provides stable support during transfers.
- Ensure adequate lighting, especially in hallways and bathrooms — improves visibility at night.
- Educate family about regular safety checks — reinforces ongoing prevention habits.
- Encourage proper footwear — non-slip shoes reduce slips on smooth floors.
Care Plan #3 — Risk for Falls Related to Vertigo and Prolonged Bed Rest (Medical-Surgical Unit)
Diagnostic Statement:
Risk for falls related to dizziness and muscle weakness.
Expected Outcomes:
- Patient will report decreased dizziness during position changes.
- Patient will transfer safely with assistance.
Assessment:
- Assess for vertigo episodes and triggers.
- Evaluate muscle strength and coordination.
- Review medications for side effects like hypotension.
Interventions and Rationales:
- Assist patient when getting out of bed — reduces sudden orthostatic drops.
- Encourage slow position changes (sit–stand–walk) — prevents dizziness-related falls.
- Use non-slip socks or shoes — provides better traction.
- Keep bed in low position and wheels locked — minimizes injury if a fall occurs.
- Refer to physical therapy for mobility exercises — helps regain balance and strength.
Care Plan #4 — Risk for Falls Related to Polypharmacy (Rehabilitation Unit)
Diagnostic Statement:
Risk for falls related to side effects of multiple medications.
Expected Outcomes:
- Patient will not experience falls during stay.
- Medication side effects will be reviewed and managed appropriately.
Assessment:
- Review all prescribed and over-the-counter medications.
- Note drugs that cause sedation, dizziness, or confusion.
- Observe for orthostatic hypotension or fatigue.
Interventions and Rationales:
- Collaborate with pharmacist and physician — to adjust or discontinue high-risk drugs.
- Educate patient about medication timing and side effects — increases awareness.
- Monitor vital signs, especially postural BP — detects hypotension early.
- Encourage hydration — supports circulation and prevents dizziness.
- Plan rest periods after medication administration — reduces fatigue-related instability.
Care Plan #5 — Risk for Falls Related to Post-Surgical Weakness (Post-Op Recovery)
Diagnostic Statement:
Risk for falls related to temporary loss of strength and coordination.
Expected Outcomes:
- Patient will ambulate safely with supervision.
- Muscle strength and endurance will improve gradually.
Assessment:
- Assess motor strength and pain level before ambulation.
- Observe for balance issues during transfers.
- Evaluate incision pain or dizziness from anesthesia.
Interventions and Rationales:
- Encourage gradual activity increase — builds endurance safely.
- Provide mobility aids (walker, cane) — supports stable walking.
- Use gait belts during transfers — prevents accidental loss of balance.
- Ensure pain is well managed — reduces reluctance or sudden movements.
- Supervise first ambulation post-surgery — prevents injury during early recovery.
Evaluation
The final step in every nursing care plan is evaluation. This is where you check if your interventions worked and decide what to adjust.
For fall prevention, success is not only measured by the absence of a fall but also by how confident, safe, and independent your patient feels.
Key points to evaluate:
- Fall prevention success – The patient remained free of falls during the care period.
- Goal achievement – Expected outcomes were met (e.g., safe ambulation, improved balance).
- Patient understanding – The patient and family can explain fall risks and prevention strategies.
- Environmental changes – Hazards were identified and removed.
- Mobility and confidence – The patient moves more safely and with greater awareness.
If goals weren’t met, reassess the care plan. Look for new medications, illness, or environmental changes that might have increased fall risk. Nursing care plans are living documents — they evolve as your patient’s condition changes.
References and Sources
Recommended resources and references for this nursing care plan for Risk for Falls:
- Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Booth, C. E. (2004). Water exercise and its effect on balance and gait to reduce the risk of falling in older adults. Activities, Adaptation & Aging, 28(4), 45–57.
- Carpenito, L. J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Centers for Disease Control and Prevention. (2024). Important facts about falls. Retrieved from https://www.cdc.gov/falls/facts.html
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I international nursing diagnoses: Definitions and classification, 2024–2026. Thieme.
- Morris, R. (2017). Prevention of falls in hospital. Royal College of Physicians, 17(4), 360–362.
- Quigley, P. (2015). Tailoring falls-prevention interventions to each patient. The American Nurse Today, 10(11), 8–10.
- World Health Organization. (2021). Falls fact sheet. Retrieved from https://www.who.int/news-room/fact-sheets/detail/falls
