Priority #

Nursing Process: Plan of Care for your Patient

DATA

Subjective
Data:
Pt stated I
feel
dizziness
all the
time

Objective
Data:
72 yearold, white
female
patient,
Laryngeal
cancer,
Dizziness,
weakness
generalize,
gastrostom
y

NURSING
DIAGNOSIS
Risk for fall
R/t age,
dizziness and
weakness
secondary to
chemotherap
y and
radiology.

GOAL &
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALES

EVALUATION

Patient will
remain free of
falls during shift

1. Screen pt for
balance and mobility
skills

It is helpful to
determine the
clients
functional
abilities and then
plan for ways to
improve
problem areas or
determine
methods to
ensure safety
(Gray-Miceli,
2008)

Patient did not

experience fall
during shift.

2. Use a high-risk
fall
armband/bracelet
and fall risk room
sign to alert staff for
increased vigilance
and mobility
assistance

These steps alert

the nursing staff
of the increased
risk of falls
(Gray-Miceli Q.
P., 2011)

3. Place items used

by the patient within
easy reach

Stretching to get
items from
bedside tables
that are out of
reach can
disrupt the
patients
balance and
contribute to
falls (Perry,
2013)

4. Remove excess
future and
equipment and
make sure that
patients wear rubber
soled shoes or
slippers for walking

Provide a space
clear for
abundant using
equipment, have
patient wear
rubber soled
shoes or slipper,

Priority #

Patient will
verbalize
understand
necessary
physical
changes in
environment to
ensure increased
safety within
first week of
returning home

or transferring, lock
bed and wheel chair.

lock bed and

wheel chair are
protocols most
hospitals using
for pt with high
risk for fall
( (Perry, 2013)

5.. Instruct the

patient and family or
caregivers on how to
correct identified
hazards, including
clutter, slippery
floors, scatter rugs

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