NURSING CARE PLAN

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Review the patient’s Risk factors for Checked the patient’s
Subjective Cues: At the end of 8 hours medications. falls also include chart and patient’s After 8 hours of
 Risk for fall
of nursing medication use medications. nursing
related to post-
intervention, the such as intervention, the
 Patient verbalized surgery (hip
arthroplasty) patient will be able to: antihypertensive patient was able to
“nag ingun si dok agents, ACE- remain free of fall
dili pa daw pwede inhibitors, and demonstrate
maglihuk kay bag-  Remain free of fall
diuretics, tricyclic preventive
o pa gi-operahan” and will
antidepressants, measures to
demonstrate
 Patient verbalized preventive alcohol use, decrease the risk
“mugamit lang mig measures to antianxiety agents,
bedpan para sa pag decrease the risk opiates, and
libang ug pag ihi” hypnotics or
tranquilizers.

Checked the patient’s

Evaluate the patient’s A fall is more environment including
Objective Cues: environment. likely to be
experienced by an the bed, the placement
individual if the of the things he
 Status post- surroundings are frequently uses.
amputation of the unfamiliar, such as
right leg furniture and
 Post-total hip equipment
arthroplasty placement in a
 Impaired physical certain area.
Placed the items beside
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mobility Place items the patient Items that are too the patient’s bed for
uses within easy reach, far may require the easy reach.
such as call light, water, patient to reach
and phone. out or ambulate
unnecessarily and
can potentially be
a hazard or
contribute to falls.

Raised the side rails of

According to the bed up and locked
Raise side rails on beds, it. Informed the SO to
research, a
as needed. keep it locked and
disoriented or
confused patient is secured to prevent fall.
less likely to fall
when one of the
four rails is left
down.

Nurses respond to Provided patient with

Respond to call light as
fallers’ call lights call light to alarm the
soon as possible. Helps
more quickly than nurse or significant
prevent the patient from
they do to lights others whenever he
moving without any
initiated by non- needs help.
assistance.
fallers. The
nurses’
responsiveness to
call lights could be
a compensatory
mechanism in
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responding to the
fall prevalence on
the unit (Tzeng &
Yin, 2010).

References:
Nursing Diagnosis List | Nanda Nursing Diagnosis List. (n.d.). http://www.nandanursingdiagnosislist.org/

Bsn, G. W., RN. (2023, January 10). Risk for Falls Nursing Care Plan. Nurseslabs. https://nurseslabs.com/risk-for-falls/
 NURSING CARE PLAN

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE

Subjective Cues: After 8 hours of Observe for nonverbal Patients may not Observed for non- After 8 hours of
 Ineffective
nursing intervention, signs of stress. be forthcoming verbal cues of patients nursing
coping related
to sudden the client will be able with their while conversing. intervention, the
 Patient verbalized
change in to: stressors. Patients client was able to
“wa nako gi expect
health may become verbalize
kay ma aksidente  Verbalize distant, irritable, appropriate coping
mi” appropriate fidgety, or easily strategies to
coping distracted. prevent ineffective
strategies to coping.
prevent Assess how the patient Through Asked the patient about
Objective Cues: copes with everyday conversation, the things he does to
ineffective
coping stressors. assess hobbies, cope up with stress to
 Shows signs of support systems, which he answered
denial when or beliefs that watching TV and
assist the patient in browsing through social
talking about his
coping with media.
condition
everyday stress
 Status post- such as exercise,
amputation of the crafting, religion,
right leg music, etc.
 Post-total hip
arthroplasty Evaluate the patient’s The patient may Evaluated the patient’s
 Impaired physical perception of the not have a realistic perception of his
mobility situation. understanding of situation.
 History of car the stress-inducing
situation. They
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accident may be
experiencing an
overly dramatic
response or may
not fully grasp the
magnitude of their
condition. It is
important for the
nurse to provide
factual
information and
guide the patient
in coping.

Use therapeutic Using techniques Talked to the patient

communication. such as active therapeutically, asked
listening, open-ended questions
reflecting, open- and avoided giving false
ended questions, hopes/assurance.
and even silence,
nurses can foster
trusting
relationships with
patients and
further explore
barriers to their
ability to cope.

Encourage rest as well Stress has a Encouraged rest,

as exercise. physiologic effect exercise and relaxation
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on the body techniques to the

causing increased patient.
blood pressure,
heart rate, and
blood sugar, and
can worsen health
conditions.
Patients should be
instructed to rest
and try relaxing
activities such as
meditating. On the
other hand,
exercise is also
stress-relieving by
decreasing cortisol
and increasing
endorphins.

References:
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Nursing Diagnosis List | Nanda Nursing Diagnosis List. (n.d.). http://www.nandanursingdiagnosislist.org/

Ineffective Coping Nursing Diagnosis & Care Plan. (2022, October 28). NurseTogether. https://www.nursetogether.com/ineffective-coping-nursing-diagnosis-care-plans