Which of the following is a major risk factor for FALLS in older adults that nurses should assess?

FALLS are the leading cause of injury death and one of the most common causes of injury in adults aged 65 and older. FALL RISK ASSESSMENT is a key PN nursing responsibility.

Major fall risk factors: (1) POLYPHARMACY — taking multiple medications increases interaction risks; medications contributing to falls include antihypertensives (orthostatic hypotension), diuretics (frequent urination, dizziness), sedatives/hypnotics (benzodiazepines, sleep aids), opioids, antidepressants, antipsychotics, anticonvulsants, and alcohol; (2) HISTORY OF PREVIOUS FALLS — strongest single predictor; (3) GAIT AND BALANCE PROBLEMS — shuffling gait, Parkinson's disease, stroke deficits; (4) MUSCLE WEAKNESS — sarcopenia; (5) IMPAIRED VISION — cataracts, macular degeneration, glaucoma; (6) ENVIRONMENTAL HAZARDS — poor lighting, loose rugs, no grab bars, clutter, slippery surfaces; (7) ORTHOSTATIC HYPOTENSION — check by measuring BP lying, sitting, standing (significant if drops ≥20 mmHg systolic or ≥10 mmHg diastolic); (8) COGNITIVE IMPAIRMENT — dementia increases fall risk; (9) URINARY URGENCY — rushing to bathroom; (10) FOOT PROBLEMS — neuropathy, poor footwear.

Standardized tools: Morse Fall Scale, Hendrich II — used in hospitals and care settings.

Nursing interventions: bed in lowest position, call light within reach, non-skid footwear, frequent toileting rounds, adequate lighting, remove environmental hazards, ensure assistive devices are available, medication review, post fall precaution signs, family education.