QLexNursing

History of falls

🟧A previous fall is one of the strongest predictors of future falls in older adults, according to the CDC and fall-risk guidelines.

🟧This client has already fallen down five steps before admission, indicating a pattern of instability or unsafe mobility.

🟧 A fall with possible head injury and momentary disorientation shows they are vulnerable to balance issues or neurological changes.

🟧Research consistently shows that older adults with a prior fall are twice as likely to fall again.

🟧Therefore, this information significantly elevates the client’s overall fall risk and must be highlighted.

Orthostatic hypotension

🟧The client’s blood pressure dropped from 130/90 (lying) to 98/60 (standing), confirming orthostatic hypotension.

🟧Orthostatic hypotension causes sudden dizziness, weakness, and syncope, all of which directly increase fall risk.

🟧 In older adults, the baroreceptors respond more slowly, meaning they are more susceptible to sudden drops in BP during position changes.

🟧This client already has a history of falls related to this condition, further compounding the danger.

🟧 This is a major red flag and must be highlighted as a fall-risk factor.

Uses a walker

🟧The need for an assistive device indicates impaired mobility, which already places a client in a higher fall-risk category.

🟧Clients who depend on walkers may experience balance instability when reaching, turning, or transferring.

🟧Incorrect use of devices or attempting to ambulate without assistance often leads to falls.

🟧This client was later found on the floor after trying to go to the bathroom alone, despite using such a device.

🟧Therefore, reliance on a walker is a strong contributor to fall risk and must be highlighted.

New glasses ordered but not yet received

🟧Vision changes are one of the most common contributors to falls in older adults.

🟧The client has not yet received prescribed glasses, meaning they are operating with suboptimal or incorrect vision.

🟧Poor vision impairs depth perception, hazard recognition, and balance.

🟧Older adults with impaired vision are at significantly higher risk for falls, especially in unfamiliar environments such as the hospital.

🟧This is a definitive fall risk factor and must be highlighted.

Standing BP: 98/60 mm Hg (Orthostatic finding)

🟧 This specific vital sign confirms a clinically significant drop in blood pressure, meeting diagnostic criteria for orthostatic hypotension.

🟧 The BP drop of more than 20 mm Hg systolic or 10 mm Hg diastolic from lying to standing increases the risk of fainting.

🟧 Falls often occur when clients rise quickly, especially when going to the bathroom—exactly what happened at 1400.

🟧 This BP reading correlates with the client’s earlier reported history of orthostatic hypotension.

🟧 Therefore, this vital sign is a key indicator and must be highlighted.

Items That Do NOT Increase Fall Risk

Exercises focusing on coordination three times per week

🟧Regular exercise improves balance, strength, and proprioception, all of which reduce fall risk.

🟧There is no evidence that these exercises are causing instability.

🟧Consistent physical activity is actually a protective factor in geriatric fall prevention programs.

🟧This information does not contribute to risk and should not be highlighted.

🟧Therefore, this is a positive health behavior, not a fall-risk factor.

Normal temperature, respiratory rate, and oxygen saturation

🟧These values (Temp 37°C, RR 20/min, O₂ 97%) indicate normal physiological stability.

🟧They do not contribute to dizziness, weakness, or impaired cognition.

🟧 Normal vitals do not increase likelihood of falling.

🟧The client’s fall risks are mainly mobility- and vision-related, not physiological instability.

🟧Therefore, these should not be highlighted.