Patient Care Plan

STUDENT: MICHELLE BROOK

Michelle Brook 2/24/2011 Ms. Cohen Assignment Revised

PATIENT INITIALS: M.C AGE: 85 M/ F - F Nursing Interventions
2 Therapeutic **Install lighting throughout the home, have son install blinds over the kitchen windows (Independent) **Establish a list of priorities to modify, and have Ms. Cohens son assist in installing bathroom safety devices (Independent)

ADMITTING DIAGNOSIS CVA (STROKE) AFFECTING PATIENTS LEFT SIDE Rationales

With aging the pupils loses the ability to adjust to light causing sensitivity to glare. Glare makes it difficult to clearly see a walking path (meiner and Luechenotte, 2006). Modification of environment reduces fall risk (mcCullagh, 2006). (Perry and Potter pg 825).

Nanda Dx and Statement:

Goals: Short Term/Long Term

Short term

Evaluation: Goals met?

Evaluate each goal Short Term: Ask Ms. Cohen and family to identify risks. Reassess Ms. Cohens Visual Acuity Ms C and daughter are more knowledgeable of potentioal hazards and are able to identify risks during a walk through the home Hazards in the home have been reduced. Long Term Observe Ms. Cohens gait and posture Observe environment for elimination of hazards. Mcs vision has improved due to new corrective lenses enabling her to ambulate more safely Ms C expressed a greater sense of safety as a result of the changes made around her home.

Risk for injury related to impaired mobility, decreased visual acuity, and physical environmental hazards. AEB Subjective Ms C states that she bumps into thins and is afraid she is going to fall Objective Data Home environmental hazards Inpaired Mobility Decreased visual Acuity

**Mrs Cohen and family will be knowledgable of potential hazards for Ms. Cohens age group within one week **Ms. Cohen will be free of injury within 2 weeks.

Long Term Goal **Ms. Cohen will express greater sense of feeling safe from falls in one month **Home will be free of hazards within one month

2Educational **Discuss with Ms. Cohen and daughter the normal changes of aging, effects of recent stroke, associated risks for injurt, and how to reduce risks (Independent) ** Review findings from home hazard assessment with Ms. Cohen and Daughter (Independent)

Education regarding hazards reduces fear of falling (American Geriatrics Society, 2001).

Fall risks for homebound older adults include visual disturbances, unsteady gait, and postural changes (meiner and Leuchenotte, 2006). Home hazards

evaluation will highlight extrinsic factors that lead to falls. (Perry and Potter Pg. 825).

2 Diagnostic **Refer to a physical therapist to assess need for assistive devices for kyposis, left sided weakness, and gait(Dependent) **Encourage Daughter to schedule vision testing for new prescription within 2-4 weeks(independent) Exercise Often improves gait and balance and flexibility. Modifying gait problems by increasing lower extremity strength reduces fall risk Improved visual acuity reduces incidence of falls (Edelman and mandle 2006). (perry and potter pg. 825)