Nursing Care Plan

Patient’s Code: F.D. Age: 74 Sex: Female Civil Status: Widowed Religion: Catholic Date & Time of Admission: N/A Room: N/A Attending Physician: N/A
Chief Complaint/s: Dizziness

Nursing Diagnosis (PES): Risk for fall related to dizziness as evidence by increase of respiration rate and blood pressure.
Definition: Vulnerable for increased susceptibility to falling that may cause physical harm, which may compromise health.

Assessment/ Cues Planning Interventions Rationale Evaluation

(Subjective/ Objective) (Goals and Objectives)
Subjective Data At the end of my 8 hours Independent Independent The planned care was
 Patient complains of shortness of nursing care, the 1. Assess the patient’s environment for 1. A fall is more likely to be met as the patient was
of dizziness. patient will be able to: factors known to increase fall risk such experienced by an individual if the able to:
as unfamiliar setting, inadequate surrounding is not familiar such as the
 Be free from any sign lighting, wet surfaces, waxed floors, placement of furniture and equipment  Be free from any
of injury. clutter, and objects on the floor. in a certain area. injury.
Objective Data
Before the Assessment:  Demonstrate 2. To determine the level of  Demonstrate some
 RR - 20 bpm selective prevention 2. Assessed mood coping abilities, cooperation. preventative methods
 BP - 140/70 mmHG method personality style that may result in to avoid any form of
 Pulse - 59 bpm carelessness. injury.
 Patient and caregiver Dependent
After the Assessment will implement Dependent 3. Studies recommend exercises to  Implement strategies
 RR - 22 bpm strategies to increase strengthen the muscles, improve that increases safety
 BP - 140/80 safety and prevent 3. Encourage the patient to participate balance, and increase bone density. and prevent fall in the
 Pulse - 58bpm falls in the home. in a program of regular exercise and Increased physical conditioning home.
gait training reduces the risk for falls and limits
 Verbalize the injury that is sustained when fall  Understand the
understanding on the transpires. factors that contribute
factors that may to the possibility of
contribute to the falling.
possibility of falling. 4. Many community service
organizations provide financial
4. Improve home support. assistance to make older adults make
safety environments in their homes.
5. This will help relieve anxiety at home
and eventually decreases the risk of
 5. Teach client how to safely ambulate falls during ambulation.
at home, including using safety
measures such as handrails in
bathroom.
6. Flip-flops, sandals, or socks can
6. Encourage wearing sturdy shoes have slippery soles that can make the
with non-skid soles.  patient fall. Solid shoes provide more
stability and help with uneven
surfaces. 

7. Instruct the patient and family on 7. Removing fall hazards, keeping the
how to maintain safety at home.  home brightly lit, and using assistive
devices help reduce the risk for falls. 

Collaborative
Collaborative
8. Refer the patient for diagnostic
evaluation. 8. Patients with musculoskeletal
problems such as osteoporosis are at
increased risk for serious injury from
falls. Bone mineral density testing will
help identify the risk for fractures from
falls.

References: Ackley, B., Ladwig, G., & Makic, M.B.F.(2016). Nursing Diagnosis Handbook an evidence-based guide to planning care (Eleventh Edition). St. Louis, Missouri :
Elsevier