From risk for trauma to unintentional injury risk: Fall – a concept analysis
Schoenfelder, Deborah Perry
TOPIC.Concept analysis of the nursing diagnosis risk for trauma.
PURPOSE. To examine the nursing diagnosis risk for trauma and to specify the risk factors for falling.
SOURCEs. Research and informational articles on falling, and NANDA Nursing Diagnoses: Definitions and Classification, 1999 – 2000. CONCLUSIONs. Replace the current nursing diagnosis risk for trauma with the more specific nursing diagnosis unintentional injury risk: falls. The other risks included in risk for trauma (e.g., burns) also will need to be developed.
Key words: Concept analysis, falls, nursing diagnosis, trauma
Falling is a problem, especially for the very young and for older adults (Losh, 1994; Runge, 1993). it is a concern not only for individuals but also for their families and communities. In a retrospective study of children ranging in age from birth to 14 years who sustained closed head injuries, falls were the cause in 22.5% of the cases (Henry, Hauber, & Rice, 1992). Another study examined home injuries to children (birth to 18 years) over a 1-year period and found that falls were the most frequent cause, with 35% of the injured sustaining head injuries and 17% being admitted to a hospital (Hu, Wesson, & Kenney, 1993). Falls accounted for an even larger proportion (almost one third) of all trauma admissions to a hospital in a large population-based study of subjects age 19 years and younger; one fourth of the injured sustained head injuries (Rivara, Alexander, Johnston, & Soderberg, 1993). hi addition to home injuries, injuries from falls at school are common (Di Scala, Gallagher, & Schneps, 1997). In an analysis of national mortality data, Rivara and Grossman (1996) reported that 264 children and adolescents died from falls in 1991, 40% of the deaths in children under 5 years of age.
For older adults, at least 30% to 40% of those living in the community fall in any given year, with about half falling more than once (Dayhoff, Baird, Bennett, & Backer, 1994; Edwards & Lee, 1998; Tinetti, Mendes de Leon, Doucette, & Baker, 1994). In a study of 115 apartment dwellers age 62 years and older (Walker & Howland, 1991), 53% of the respondents reported falling within recent years, and 29% reported a fall within the last year. Of those who had fallen within the past year, 69% were injured as a result of their last fall, 49% required medical attention, 36% required at least one day of limited activity, and 15% required hospitalization.
Falling is an especially serious problem for elderly nursing home residents, the mean incidence rate being 1.5 falls per bed per year (Rubenstein, Josephson, & Robbins, 1994). Falling multiple times also is problematic (Watson & Mayhew, 1994). In fact, repeated falling is a strong predictor for admission to a nursing facility (Tinetti & Williams, 1997). Gaebler (1993) found that hospitalized patients who were multiple fallers were 2.5 times more likely than a group of hospitalized single fallers to be transferred to a nursing home.
Given the incidence of falling and the potential for injury or death imposed by this serious health problem, naming risk for falling as a specific nursing diagnosis to replace the current North American Nursing Diagnosis Association (NANDA) diagnosis risk for trauma is imperative. Subsequently, the other risks included in the diagnosis risk for trauma (e.g., bums) also will need to be addressed and developed as distinct nursing diagnoses. The development of new nursing diagnoses and refinement of current nursing diagnoses to produce a comprehensive, standardized, and valid language is extremely important for the nursing profession, with much remaining to be done National Center for Nursin Research 1993).
The research for this ar@cle is part of a larger project conducted by The University of Iowa Nursing Diagnosis Extension and Classification (NDEC) research team. The team consists of a principal investigator and 2 co-principal investigators, approximately 25 investigators, 18 advisory board members, 6 consultants, and 3 research assistant. Clinicians, academics, and researchers representing all major clinical practice areas are included. The purpose of the NDEC research is to develop and validate a comprehensive taxonomy of nursing diagnoses, signs and symptoms, and related factors. Currently, the various diagnostic work groups (DWGs) are conducting concept analyses of the entire list of NANDA diagnoses. Concept analysis has been completed on 100 diagnoses, 96 of which have been forwarded to NANDA. The next steps will be expert validation and clinical validation of the refined nursing diagnoses, and concept analysis of the list of “candidate diagnoses” developed during work on the existing NANDA diagnoses (Craft-Rosenberg, 1999).
The conceptual analysis of the NANDA nursing diagnosis risk for trauma led to recommending a new diagnosis-unintentional injury risk: falls. An overview of the work of the NDEC research team to validate and extend the work of NANDA is presented, along with a description of the work of one of the DWGs. This group, the Community/Public Health DWB, analyzed the diagnosis risk for trauma, and is 1 of 10 DWGs within the large research team.
Definitions
The NDEC research team accepted the NANDA definition of a nursing diagnosis: “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes” (NANDA, 1999, p. 149). NDEC extended this definition by stating that nurses make diagnoses to reach desirable outcomes. The diagnosis label is a name describing the client state and represents a unique list of signs and symptoms. Each diagnosis must have at least one sign or symptom. Signs and symptoms are the indicators, cues, or observable, measurable, verifiable, and defining data for the diagnosis. Related factors are conditions/circumstances that contribute to the development or maintenance of a nursing diagnosis. A diagnosis should have a single or unique set of related factors that can be etiologies (causes), associated factors, or risk factors. In the case of the risk diagnosis unintentional injury risk. falls, there is a set of risk factors rather than related factors and signs and symptoms. Risk factors are associated with potential diagnoses, and treatment is aimed at reducing or eliminating risk factors that can be changed (Craft-Rosenberg, 1999).
Concept Analysis
Standardized languages (diagnoses, interventions, outcomes) are essential to identify and communicate what nurses do and to evaluate the effectiveness of nursing care. The work of NANDA for more than 20 years has been commendable, particularly because the efforts have been mostly voluntary and without funding. Limitations in this work have been acknowledged, however, especially regarding the lack of systematic diagnoses development. Refinement, expansion, and validation of the current list of nursing diagnoses in a systematic and scientific manner are essential so that nursing data can be included in computerized national and international healthcare databases.
The concept analysis methods used by NDEC team members are based on those proposed by Rodgers and Knafl (1993) and Waltz, Strickland, and Lenz (1991). There are four stages in this process: (1) identify literature related to the concept; (2) review each literature source for definitions, signs and symptoms, related factors and risk factors, linkages with nursing interventions and nursing outcomes, and patient population; (3) compare signs and symptoms and related factors and risk factors derived from the literature to signs and symptoms and related factors and risk factors from the NANDA taxonomy; and (4) generate or revise a diagnosis label, proposed definition for the diagnosis label, and a list of signs and symptoms and related factors or risk factors that reflect all dimensions of the diagnosis. This should include information from the literature review and signs and symptoms and related factors or risk factors from the NANDA taxonomy.
Diagnosis Group Work
The Community/Public Health DWG was composed of five members with clinical, academic, and research expertise in the areas of community/public health and nursing diagnoses. This DWG was given existing NANDA nursing diagnoses that were related to home care and self-care concepts, including the diagnosis risk for trauma. Each DWG member was assigned two to three diagnoses to analyze. For the diagnosis risk for trauma, as with all diagnoses, NANDA publications of existing diagnoses and literature from sources other than NANDA were reviewed. Articles or segments of books were reviewed that represented: (1) the nursing diagnosis being analyzed; (2) current information, preferably within the past 5 years; (3) research-based information when possible; (4) clients across the life span; and (4) as many settings as possible. Conceptual definitions, signs and symptoms, and related factors or risk factors were extracted from the sources and compared to the current NANDA diagnosis, in this case risk for trauma. Based on this review, the diagnosis label was revised to a more specific label, a definition for the new diagnosis label was proposed, and a list of risk factors that reflect the dimensions of the new diagnosis was generated.
Following initial conceptual analysis, the NDEC Rules Committee, consisting of the principal co-investigators and two team members, determines that the conventions for wording and format are followed consistently and the proposed diagnosis is understandable to those outside the DWG. Then the diagnoses are critiqued by the entire research team, again examining the diagnosis label, conceptual definition of the label, signs and symptoms, and related factors or risk factors. The research team also looks at the range, nature, and appropriateness of references used and suggests others as appropriate. Diagnoses are reviewed along each step of the way for content accuracy; consistency of terminology with other diagnosis labels, signs and symptoms, and related factors or risk factors; and overlap with other diagnosis labels, signs and symptoms, and related factors. Once consensus is reached, the research team forwards to NANDA nursing diagnoses that have completed this process. The proposed nursing diagnosis unintentional injury risk: falls has been sent to NANDA!s Diagnostic Review Group for consideration. Following this step, the refined diagnoses are placed in a database for clinical testing to provide further validation of the nursing diagnoses.
Definitions
The DWG decided to use “unintentional injury” as the first part of the diagnosis label to be congruent with current literature (National Safety Council, 1997). In addition, using the term “unintentional” distinguishes the diagnosis from others such as abuse or neglect, which are intentional in character. Defining a fall can be difficult but is nevertheless important to operationalize for research and clinical purposes. For this analysis, a fall was defined as an unexpected event in which a person finds himself/herself on the ground and the potential for injury exists (Tideiksaar, 1989).
Literature Review
Risk for trauma. The nursing diagnosis risk for trauma was developed in 1980 by NANDA and is defined as “accentuated risk of accidental tissue injury, e.g., wound, burn, fracture” (NANDA, 1999, p. 36). The list of risk factors specific to falling is extensive and is divided into intrinsic (individual) factors and extrinsic (environmental) factors. Examples of intrinsic factors are weakness, poor vision, reduced temperature and/or tactile sensation, and cognitive or emotional difficulties. Examples of extrinsic factors are unanchored rugs, entering unlighted rooms, unsafe window protection in homes with young children, bathing in very hot water, and exposure to dangerous machinery. The following is a review of the literature for falling.
Risk factors for falling. Intrinsic factors for children. Children are especially vulnerable to falling when 9 years old or younger (Hu et al., 1993). Boys 5 years of age or younger are more apt to fall and sustain injuries than girls of the same age (Crawley, 1996).
Intrinsic factors for adults. With adults, men tend to fall more often than women. In addition, general pathological conditions render adults more likely to fall, such as cardiac problems, diabetes mellitus (Malmivaara, Heliovaara, Knekt, Reunanen, & Aromaa, 1993), endoplasms, and anemias. The period following surgery also is a time of risk for falling (Plati, Lanara, & Mantas, 1992). These risk factors were relevant for older adults as well.
It is important to consider the role of medications in the occurrence of falls. Studies have found that taking medications such as hypnotics, tranquilizers, or antidepressants increases an adult’s chance of falling (Plati et al., 1992; Poster, Pelletier, & Kay, 1991). In addition, alcohol intake was found to be a significant fall risk factor for adults of all ages (Malmivaara et al., 1993).
Intrinsic factors for older adults. Intrinsic factors for older adults are numerous and include increasing age (Dunn, Rudberg, Furner, & Cassel, 1992; Kilpack, Boehm, Smith, & Mudge, 1991; Sattin et al., 1990); being fen-tale (Dunn et al.; Sattin et al.); being thin (body mass index [BMI]
Cardiovascular causes-vascular disease, hypertension, orthostatic hypotension, poor endurance, and symptoms when turning or extending the neck (Dunn et al., 1992)
Neurologic causes-vision and hearing deficits, and decreased mental status (Dunn et al., 1992; Edwards & Lee, 1998; Kilpack et al., 1991; Watson & Mayhew, 1994)
Musculoskeletal causes-arthritis, decreased lower extremity strength, poor back flexibility and mobility deficits (Dunn et al., 1992; Edwards & Lee, 1998; Kilpack et al., 1991; Watson & Mayhew, 1974)
– Urologic causes–noctur ia and involuntary elimination (Berryman, Gaskin, Jones, Tolley, & MacMullen, 1989)
Psychologic aspects-wandering behavior and depression (Tinetti, Williams, & Mayewski, 1986)
Other intrinsic risk factors for falling in older adults include the presence of acute illness, temperature elevation, sleeplessness, hospital admissions related to oncology or orthopedics, and preparation for radiology and/or the presence of diarrhea (Tinetti, Speechley, & Ginter, 1988; Tinetti et al., 1986).
Having difficulty with activities of daily living increases older adults’ chances of falling (Dunn et al., 1992). Further, balance and gait problems in elders are risk factors for falling in elders (Edwards & Lee, 1998). Tinetti and associates (1986) reported that balance and gait maneuvers were the factors that best identified recurrent fallers. from one-time fallers. More specifically, the items that best distinguished the two groups were difficulty with rising and sitting down, instability on first standing, staggering on turning, and short discontinuous steps. Whipple, Wolfson, and Amerman (1987) reported that fallers as a group had markedly weaker lower extremities than nonfallers in a nursing home sample. The ankle dorsiflexion power of fallers was the most compromised of motions tested, which could make older adults more prone to backward falls.
Tinetti and associates (1986) found that the addition to the subject’s regimen of any of several classes of drugs, including antidepressants, phenothiazines, or sleeping medications, increased the risk for falling. Watson and Mayhew (1994) reported that taking antihypertensive medications was a significant predictor of falls. In short, taking medications, especially cardiovascular and central nervous system effectors, needs to be considered as increasing older adults’ risk for falling.
Risk factors for falling. Extrinsic factors for children. Extrinsic factors include environmental hazards that increase the likelihood of a fall. Children are at risk for falling, especially at home, when safety precautions are not put in place. In particular, the lack of gates on stairs, no protection on sharp comers such as tables, no window guards on windows out of which a child can fall, and the lack of antislip material in baths and showers increases the chance that falls and injuries will occur in children (Wortel & de Geus, 1993). As might be expected, the lack of parental supervision was a risk factor for children falling (Hu et al., 1993). In addition to falling at home, falling at school also is a problem for children. A large study (Di Scala et al., 1997) examined injuries occurring at school to children in kindergarten through 12 grade. Most unintentional injuries (42.7%) were due to falls, either from falls on the same level or from playground equipment.
Extrinsic factors for adults. There was very little literature regarding extrinsic risk factors for falling in adults. One study did identify ramps, curbcuts, and doorways as frequent sites for tips and falls among adult wheelchair users (Kirby, Ackroyd-Stolarz, Brown, Kirkland, & MacLeod, 1994).
Extrinsic factors for older adults. In 1994, falls were the leading cause of death for adults ages 79 and older (National Safety Council, 1997). Research by Walker and Howland (1991) revealed that almost half the reported falls in older adults occurred at home. Environmental hazards also are present within nursing facilities. Watson and Mayhew (1994) and Gross, Shimamoto, Rose, and Frank (1994) reported the most frequent location of falls was the resident’s room at the nursing home. Most falls occurred during the day shift. Unfamiliar, dimly lit rooms; climbing over bed rails; and being confined to a d-tair were identified as risk factors for falling in hospitals as well as nursing facilities (Berryman et al., 1989). Thus, hazards are present in whatever environment older adults move about, whether at home or somewhere else, such as a long-term care setting.
In summary the literature identifies fall risk factors for children as mostly extrinsic, whereas the factors for adults and elders are both intrinsic and extrinsic. Regarding children, very young males are most vulnerable to falling, with environmental hazards and lack of adult supervision the most likely reasons. As individuals mature, the conditions that lead to falling become much more complex, such that multiple risk factors are involved. For example, as the chances increase that an adult will have surgery or take medications for various acute and chronic conditions, risk of falling also increases.
Based on this concept analysis, the authors recommend the nursing diagnosis unintentional injury risk. falls for clinical use as well as testing by expert and clinical validation. There is an extensive body of knowledge to support this diagnosis, which is further substantiated by research that identifies the risk factors, interventions, and outcomes. Therefore, unintentional injury risk: falls is recommended for staging at 2.3 (NANDA, 1999). The diagnosis, along with its definition, risk factors, and background readings are presented in Table 1.
Implications
Unintentional injury risk.- falls is useful in that it specifically targets the problem of falling and enables nurses to identify risk factors for individuals across the life span who are in various states of health or illness and are in any setting. When nurses have a client who has fallen either once or repeatedly, or who they believe may be at risk for falling, this diagnosis dearly will be appropriate.
Once the nursing diagnosis unintentional injury: falls is selected, the risk factor(s) can be linked with relevant nursing interventions to achieve the desired outcome of not falling in the first place or not having a repeat fall, therefore avoiding possible injury. Being at risk for falls or having fallen once or repeatedly is usually due to more than one factor. Correctly identifying those factors will facilitate accurate selection of outcomes and interventions to address the diagnosis. For example, the suggested Nursing Outcomes Classification (NOC) outcomes recommended for first consideration for the diagnosis risk for trauma are risk control and safety behavior: fall prevention (Johnson & Maas, 1997). And suggested Nursing Interventions Classification (NIC) interventions for risk for trauma that address falling include environmental management: safety, fall prevention, and surveillance: safety (McCloskey & Bulechek, 1996). These outcomes and interventions also are appropriate for the proposed diagnosis unintentional injury risk. falls. The outcome indicators and intervention activities focus on decreasing or controlling the specific risk factors identified for the individual who is vulnerable to falling.
Although older adults are the age group most at risk for falling, the diagnosis unintentional injury: falls reflects a concept analysis across the life span so that this diagnosis is applicable to all ages. It would, for instance, apply to a young adult who uses a wheelchair daily, may have experienced falls, and would benefit from nursing interventions to prevent falls. Also, the diagnosis and selected outcomes and interventions would be fitting for parents of a toddler identified as being at risk for falling.
Standardized assessment of risk factors is very important in considering whether elders can remain safely in their own homes. Nurses doing in-home assessments of this population will be able to help elders and their families decide the best options regarding avoiding falls. Such assessments not only point out risks for falling, but also allow for teaching prevention of falls, as the nurse uses an assessment form with identified demographic, physiological, cognitive, environmental, medications, and functional/situational risk factors.
By considering the elder’s risk for falling, a more appropriate recommendation can be made about independent living. Often, nurses from assisted living facilities, insurance companies, elder day care centers, or nursing homes are asked to assess the elder’s chances of falling and ability to independently complete activities of daily living. Nurses using assessment tools that include risk factors for falling would be able to make better recommendations for this population group.
Many American businesses are seeing more older adults continue in the workforce past the usual retirement age. Occupational health nurses are concerned about worker safety on the job; preventing injuries and injuries from falls is of prime importance. Workers at risk for falling can be identified with tools including the risk factors described in this paper, and programs implemented to prevent accidents and falls. Productivity is valued in industry and business. Decreasing sick days and lost time due to worker illness or injury is a top priority for occupational health nurses.
Nurses working with non-health-related personnel at fitness centers, shopping malls, senior centers, and civic centers or public buildings often will be asked for input about safety issues. Nurses using knowledge about risk factors for falls can help workers and planners design physical space that decreases risk of falling for the public using these facilities.
Prevention of falls is tied to teaching about risk factors. Nurses with this knowledge are in unique positions when assisting with classes for nursing assistants, orienting volunteers, addressing community groups, teaching parents of infants and young children, and engaging in their own professional practice-no matter what area of practice. By using these risk factors as described here to organize and enhance assessment, many will be spared the consequences of costly falls.
Conclusion
Falling is a serious problem that nurses can and should address. Consequences of falls are numerous and range from death to fractures and soft tissue inJury that may or may not require hospitalization to reported fear of falling again (National Safety Council, 1997; Sattin et al., 1990; USDHHS, 1991; Walker & Howland, 1991). The label unintentional injury risk. falls dearly states the problem and is recommended by the authors to replace the NANDA diagnosis risk for trauma. Once the risk factor(s) have been identified through careful assessment, appropriate nursing interventions can be selected and implemented to achieve desired outcomes.
Modification of nursing diagnoses such as risk for trauma must be research based and clinically validated. By doing this sort of refinement and extension, nursing will continue to move forward in standardized language development to reflect populations served and care received, so that the profession is visible and receives the credit due in this era of healthcare change.
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Deborah Perry Schoenfelder, PhD, RN, Carolyn M. Crowell, MN, RN, and The Nursing Diagnosis Extension and Classification Research Team*
Nursing Diagnosis Extension and Classification Research Team Principal Investigator: Martha Craft-Rosenberg, Phl), RN, FAAN Co-Principal Investigators: Connie Delaney, Phl), RN; Janice Denehy, Phl), RN
Investigators: Joanne Chapman, MA, RN; Judith Collins, MA, RN; Dame June Clark, PhD, RN; Mary Clarke, MA, RN; Carolyn Crowell, MN, RN; Mary Pat Donahue, PhD, RN, FAAN; Orpha Glick, PhD, RN; Cycl Graff, MS, RN; Jone Johnson, MSN, RN; Kathleen Hansen, PhD, RN; Leslie Marshall, PhD, RN; Meridean Maas, PhD, RN, FAAN; Sandra Powell, PhD, RN; Colleen Prophet, MS, RN; jean Reese, PhD, RN; Lavonne Ruther, MA, RN; Deborah Perry Schoenfelder, PhD, RN; Lu Sheehy, BSN
Research Assistants: Joseph Greiner, MA, RN; Sao Jirathummakoon, BSN; Jane Tang, BSN
Deborah Perry Schoenfelder, Phl), RN, is Clinical Assistant Professor, and Carolyn M. Crowell, MN, RN, is Assistant Professor, University of Iowa College of Nursing, Iowa City, IA.
Author contact: deborah-schoenfelder@uiowa.edu, with a copy to the Editor: JSimon6721@aol.com
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