Risk for fall nursing diagnosis with rationale
3
Priority # Nursing Process: Plan of Care for your Patient DATA NURSING DIAGNOSIS GOAL & OBJECTIVES NURSING INTERVENTIONS RATIONALES EVALUATION Subject ive Data : Pt stated “I feel dizzine ss all the time” Objecti ve Data : 72 year- old, white female patient , Larynge al cancer, Dizzine ss, weaknes s Risk for fall R/t age, dizziness and weakness secondary to chemother apy and radiology . Patient will remain free of falls during shift 1. Screen pt for balance and mobility skills 2. Use a “high-risk fall” armband/bracel et and fall risk room sign to alert staff for increased vigilance and mobility assistance 3. Place items used by the patient within easy reach It is helpful to determine the client’s functional abilities and then plan for ways to improve problem areas or determine methods to ensure safety (Gray- Miceli, 2008) These steps alert the nursing staff of the increased risk of falls (Gray- Miceli Q. P., 2011) Patient did not experience fall during shift.
-
Upload
vic-robovski -
Category
Documents
-
view
7 -
download
3
description
Risk for fall nursing diagnosis with rationale
Transcript of Risk for fall nursing diagnosis with rationale
Priority #
Nursing Process: Plan of Care for your Patient
DATA NURSINGDIAGNOSIS
GOAL & OBJECTIVE
S
NURSINGINTERVENTION
S
RATIONALES
EVALUATION
Subjective Data:
Pt stated “I feel dizziness all the time”
Objective Data:
72 year-old, white
female patient,
Laryngeal cancer,
Dizziness, weakness
generalize, gastrostom
y
Risk for fall R/t age, dizziness and weakness secondary to chemotherapy and radiology.
Patient will remain free of falls during shift
1. Screen pt for balance and mobility skills
2. Use a “high-risk fall” armband/bracelet and fall risk room sign to alert staff for increased vigilance and mobility assistance
3. Place items used by the patient within easy reach
4. Remove excess future and equipment and make sure that patients wear rubber soled shoes
It is helpful to determine the
client’s functional
abilities and then plan for
ways to improve problem areas or
determine methods to
ensure safety(Gray-Miceli,
2008)
These steps alert the nursing staff of the increased
risk of falls (Gray-Miceli Q.
P., 2011)
Stretching to get items from bedside tables that are out of reach can disrupt the patient’s balance and contribute to falls (Perry, 2013)
Provide a space clear for abundant using equipment, have patient wear rubber
Patient did not experience fall
during shift.
Priority #
Patient will verbalize understand necessary physical changes in environment to ensure increased safety within first week of returning home
or slippers for walking or transferring, lock bed and wheel chair.
5.. Instruct the patient and family or caregivers on how to correct identified hazards, including clutter, slippery floors, scatter rugs
soled shoes or slipper, lock bed and wheel chair are protocols most hospitals using for pt with high risk for fall ( (Perry, 2013)
Interventions to improve home
safety were shown to be effective to reduce falls
(Tinetti, 2003)
Patient verbalized will make changes at home to ensure safety
