The variables the nurse will use to evaluate the client for fall risk are:
- Fall history
- Medical diagnosis
- Use of assistive devices
- Mental status
A history of previous falls is a significant predictor of future falls. If a client has fallen before, they are more likely to fall again, making this an essential variable in fall risk assessment.
Certain medical conditions, such as Parkinson's disease, stroke, or arthritis, can increase the risk of falls. Evaluating the client's medical diagnosis helps identify those at higher risk.
The use of assistive devices like canes, walkers, or wheelchairs can indicate mobility issues, which may increase fall risk. Assessing whether a client uses these devices is crucial in determining their fall risk.
Cognitive impairments, such as dementia or delirium, can affect a person's ability to recognize and avoid hazards, increasing the risk of falls. Evaluating mental status is an important part of the assessment.
This status is related to end-of-life care preferences and does not directly impact fall risk. Therefore, it is not typically used in fall risk screening.