NCP Risk for Falls
2
ASSESSMENT PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME S: O: >decreased strength in lower extremities >weak in appearance >absence of side rails >presence of scattered rugs Nursing Diagnosis: Risk for Falls r/t body weakness Scientific Explanation: Increased susceptibilit y to falling that may Within 2 to 3 hours of rendering proper nursing intervention , the patient will be free from fall. Identify factors that affect safety needs. Assess the patient ability to ambulate safely with or without assistive devices. Thoroughly orient the patient to environment. Assess vision and provide adequate lighting to clearly see the pathway. Ask the significant others to always stay with the client. Instruct the patient to call for assistance when moving. To know the intervention that will be established. It is helpful to determine the client’s functional abilities to plan for ways of improving the problem areas For the client to familiarize the surroundings. To provide well-lighted environment and avoid the occurrence of injury. To ensure clients safety. To prevent the patient from falling on bed. To reduce the risk of falling. For the clients support. After 2 to 3 hours of rendering proper nursing intervention, the patient will be free from fall as evidenced by ability to explain the safety precautions.
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Transcript of NCP Risk for Falls
ASSESSMENT PLANNING INTERVENTION RATIONALEEXPECTED OUTCOME
S:O:>decreased strength in lower extremities>weak in appearance>absence of side rails>presence of scattered rugs
Nursing Diagnosis:Risk for Falls r/t body weakness Scientific Explanation:Increased susceptibility to falling that may cause physical harm.
Within 2 to 3 hours of rendering proper nursing intervention, the patient will be free from fall.
Identify factors that affect safety needs.
Assess the patient ability to ambulate safely with or without assistive devices.
Thoroughly orient the patient to environment.
Assess vision and provide adequate lighting to clearly see the pathway.
Ask the significant others to always stay with the client.
Instruct the patient to call for assistance when moving.
Put side rails.
Provide assistive devices for walking such as cane, crutches and/o wheelchairs.
Ensure that the patient wears proper shoes
To know the intervention that will be established.
It is helpful to determine the client’s functional abilities to plan for ways of improving the problem areas
For the client to familiarize the surroundings.
To provide well-lighted environment and avoid the occurrence of injury.To ensure clients safety.
To prevent the patient from falling on bed.
To reduce the risk of falling.
For the clients support.
To prevent from slippering.
After 2 to 3 hours of rendering proper nursing intervention, the patient will be free from fall as evidenced by ability to explain the safety precautions.
