Nursing Care Plan

Student Name/Date: __Nicole Reinke/ Week 5_____________

Nursing Diagnosis
(Dx, related to, & as evidenced by)

Expected Outcomes
(Short term (8-48 hr.) reasonable expectations stated in measurable, behavioral terms, i.e., action verbs)

Nursing Interventions/Rationale
List all interventions for each nsg. dx (include patient/family teaching)

Outcome Evaluation
(Patient outcome noted as met or unmet/responses described)

Risk for injury r/t seizures amb gait and balance disorders.

1.

Client will remain free from falls while in the hospital.

1. Nurse will make sure that the call light is always in reach so that the client does not have to be concerned about not knowing where the call light is when needing help. 2. Nure will place a High Risk for Falls sign above clients bed so that any person that comes into the room to help assist is aware of the safety measures that need to be taken. 3. Nurse will determine risk for falls using the evaluation tool which includes client history of atrial fibrillation. 1. Nurse will place the walker near the bed to remind client to use walker when getting up to go to the bathroom. 2. Nurse will explain how to use the walker, by moving walker first and then move body to make sure client knows how to use the walker. 3. Nurse will also teach the client the importance of using the walker when walking through the halls in order to prevent future falls, this will also help promote activity and will give the client something else to do instead of laying in bed all day.

This outcome of remaining fall free was met while I was at the hospital. Everytime I went into the room I made sure the call light was on her table and the walker was next to the bed. Client also reported no falls.

2. Client will use a walker while in the hospital to get to the bathroom in order to maintain safety.

This outcome of using the walker was partially met. When reminded the client would use the walker but admitted not using it all the time. After teaching her the importance of using the walker and what could happen if she fell she said she would try to make it a habit.

Nursing Diagnosis
(Dx, related to, & as evidenced by)

Expected Outcomes
(Short term (8-48 hr.) reasonable expectations stated in measurable, behavioral terms, i.e., action verbs)

Nursing Interventions/Rationale
List all interventions for each nsg. dx (include patient/family teaching)

Outcome Evaluation
(Patient outcome noted as met or unmet/responses described)

3. Client will be educated on how to reduce risk of falls at home.

Nurse will assess for additonal factors leading to risk for falls because sometimes medications can increase risk for falls. 2. Nurse will teach the client the benefit of using nonskid rugs and safety devices in the bathroom. This is important to teach so that the client can recognize clutter and slippery floors. 3. Nurse will instruct client and daughter how to correct identified hazards to make sure everything that could cause a fall is prevented.

1.

This outcome was not fully met. I asked about her house and the hazards that were there for falls but I wasnt able to talk about using nonskid rugs or bathroom devices. But she understands the importance and will ask her daughter and physican when she is discharged.