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Nursing Care Plan

Nursing Care Plan

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Published by jopearl18

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Published by: jopearl18 on Feb 21, 2010
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08/17/2014

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NURSING CARE PLAN
CUESNURSINGDIAGNOSISSCIENTIFIC BASISGOALS/OUTCOMECRITERIANURSINGRESPONSIBILITIESRATIONALEEVALUATION
 No subjective cuesObjective cues;-physical mobility-decreased urineoutputRisk for fallsrelated to impaired physical mobilityFalls are a major safetyrisk for adults,especially older adults.Evidence indicates thatabout 30% to 40% of older adults experienceat least one serious fall per year. Theconsequences of thesefalls for the older adultrepresent a major health concern. Injuriessustained as a result of a fall include soft tissueinjury, fractures (hip,spine, and wrist), andtraumatic brain injury.Fall-related injury isassociated with prolongedhospitalizations for theadult. The quality of life for the adults issignificantly changedfollowing a fall-relatedAfter 8 hours of nursingintervention, noincidence of fallwill occur, patientssafety will beensured.Spedifically the patient will:>Be free of injury>Modifyenvironment asindicated toenhance safety>Demonstrate behaviors, lifestylechanges to reducerisk factors and protect self frominjuryINDEPENDENTAssess the personfor factors known toincrease fall risk such as history of falls, mentall statuschanges and sensorydeficitsAssess patient’senvironment for factors known toincrease fall risk such as unfamiliar setting andinadequate lightingPlace items used bythe patient withineasy reachEvidenceindicates that a person who hassustained one or more falls in the past year is morelikely to fall againPatients who arenot familiar withthe placement of furniture andequipment in theroom are morelikely toexperience a fallStretching to getitems from bedside tablesthat are out of reach can disruptthe patient’s balance andGoal metAfter 8 hours of renderingnursinginterventions the patient will haveno incidence of fall and safety isensured
 
injury. The deathratetfrom fall-relatedinjuries and their complications increaseswith the age of the patients.(Gulanick, 6
th
Edition, pg.59)Use siderails on bedsas needed.Encourage the patient to participatein a program of regular exerciseDEPENDENTEncourage the patient to wear shoesor slippers withnonskid soles whenambulatingOrient the patient tothe layout of theroom.contribute to fallsPatients who aredisoriented or confused have been known toclimb over siderails and fallEvidencesuggests that people whoengage in regular exercise andactivity willstrengthenmuscles Nonskid footwear  provides surefooting for the patient withdiminished footand toe lift whenwalkingThe more familiar the patient is withthe layout of theroom, the lesslikely the patient
 
Provide the patientwith a chair that hasa firm seat and armson both sidesEducate the patientand familycaregivers about thecorrect use andmaintenance of mobility assisteddevicesCOLLABORATIVERefer the person for diagnosticmasculoskeletalevaluationis to trip over furnitureThis chair style iseasier to get outof,especiallywhen the patientexperiencesweakness andimpaired balancewhen transferringfrom bed to chair Incorrect use or improper maintenance of canes, walkersand wheelchairscan increase therisk for fallsPhysical therapyevaluation canidentify problemswith balance andgait that canincrease a personsfall risk 

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