Date/Time Assessment Needs Nursing Diagnosis Objective of Intervention Evaluation

Care
Nov 11, 2019 Patient: Juliet H Risk for falls r/t loss of After 8 hours of 1. Identify risk factors that increases the risk GOAL MET
Danila E muscle tone and strength nursing of falling
10:00 am Age: 75 yrs A due advance of age interventions, After 8 hours of
L the patient will R – This will help in determining nursing
7am-3pm shift Subjective T It’s not uncommon for be able to: interventions necessary to decrease the risk of interventions, the
-“Makaya man H elderly patients to be at falling. patient was able to
nako mag ligo isa, risk for falls. As one’s 1. Be free from
maka laba paman P age progresses, muscle falls 2. Determine the patient’s ability to perform - Decrease the
gani ko. Pero E tone and strength ADLs, instrumental activities of daily risk of falling
panagsa madulas R significantly decreases. 2. Implement living (IADLs), and demands of daily through
ko kung man laba C This is largely due to safety measures living (DDLs). implementation
o malig. Wala pa E increase in activity of to prevent falls of safety
man ko nhulog P muscles and stiffening of R – This assess what the patient is still measures such
intawon. T joints as a result of 3. Demonstrate capable of doing and that she cannot. It can as the use of
I normal aging process. proper use of also determine activities that increases the risk corrective
Objective O When the muscles are not ambulatory of falling lenses when
-Patient is age 75 N stimulated it atrophies, devices walking, use of
years old coupled with the decrease 3. Observe the patient’s environment for ambulatory
-Loss of muscle A contractility of actin and factors associated with risk for fall device when
strength due to age N myosin filaments, muscle needed, and
-Presence of D fibers begin to decrease R – Certain areas in the patients environment keeping certain
illness (Dementia) in size. Synovial joints can increase the risk for falls. Its is important areas such as
-Does not use H that are important in to determine what these areas area to the bathroom
ambulatory E movement also stiffen implement safety measures. and laundry
devices A during aging. These room dry and
-Patient requires L entire processes is normal 4. Modify patient’s environment as free from slips.
corrective lenses T as one ages however, it necessary to decrease risk of falls
H can be countered with
V/S constant exercise and R – Areas such as the bathroom, kitchen, and
T: 36.3 M proper diet., laundry room are common places where the
P: 65 A patient can experience falling. Adding rubber
R: 22 N mats to the bathroom, or keeping the
BP: 130/90 A bathroom dry are important ways to decrease
O2 Sat: 98 G risk for falls
E
M 5. Determine need for assistive devices
E
N R – Although some elderly individuals are
T still highly capable of ambulating on their
own. An assistive devices aids those who has
difficulty or at risk of falls.

6. Advice the patient to wear slippers with

non-slip soles when walking
R – Wearing non-slip footwear decreases slips
and falls

7. Avoid re-arranging the furniture in the

room as necessary

R – Elderly patient, especially those with

dementia, should be familiarized with the bed,
location of the bathroom, and other hazards
that can cause trips or falls.

8. Encourage the patient to use corrective

lenses

R- Ailing eyesight is another sign of aging.

Elderly patient not only experience bouts of
muscle weakness but they also experiences
decrease acuity in eyesight. Both of these can
increase the risk of falls

9. Encourage patient to engage in regular

exercise and gait training

R- Exercise can improve muscle strength,

balance, and coordination. It reduces the risk
of falls and avoids injury that is sustained
when fall happens