GERIATRIC SYNDROME:

FALL

NANDA:

RISK for INJURY

NIC RATIONALE NOC

 Thoroughly conform patient to 
surroundings. Put call light within reach
and teach how to call for assistance;
respond to call light immediately.
 Provide medical identification bracelet 
for patients at risk for injury from
dementia, seizures, or other medical
disorders.
The patient must get used to the layout of the  1809 Knowledge: Personal Safety Extent
environment to avoid accidents. Items that are of understanding conveyed about
too far from the patient may cause hazard. prevention of unintentional injuries
 3010 Client Satisfaction: Safety Extent of
positive perception of procedures,
Signs are vital for patients at risk for injury. information and nursing care to prevent
Healthcare providers need to acknowledge who harm or injury
has the condition for they are responsible for
implementing actions to promote patient safety.

 If patient has a new onset of confusion  Reality orientation can aid limit or decrease the
(delirium), render reality orientation confusion that increases risk of injury when the
when interacting with him or her. Have patient becomes agitated. Validation therapy is
family or significant other bring in more effective for patients with dementia
familiar objects, clocks, and watches
from home to maintain orientation. If
patient has chronic confusion with
dementia, use validation therapy that
reinforces feelings but does not
confront reality.