NURSING CARE PLAN

GOALS/ NURSING
CUES NURSING SCIENTIFIC BASIS OUTCOME RESPONSIBILI RATIONALE EVALUATION
DIAGNOSIS CRITERIA TIES
No subjective cues Risk for falls Falls are a major safety After 8 hours of INDEPENDENT Evidence Goal met
related to impaired risk for adults, nursing Assess the person indicates that a
physical mobility especially older adults. intervention, no for factors known to person who has After 8 hours of
Objective cues; Evidence indicates that incidence of fall increase fall risk sustained one or rendering
-physical mobility about 30% to 40% of will occur, patients such as history of more falls in the nursing
-decreased urine older adults experience safety will be falls, mentall status past year is more interventions the
output at least one serious fall ensured. changes and sensory likely to fall again patient will have
per year. The Spedifically the deficits no incidence of
consequences of these patient will: fall and safety is
falls for the older adult >Be free of injury Assess patient’s Patients who are ensured
represent a major >Modify environment for not familiar with
health concern. Injuries environment as factors known to the placement of
sustained as a result of indicated to increase fall risk furniture and
a fall include soft tissue enhance safety such as unfamiliar equipment in the
injury, fractures (hip, >Demonstrate setting and room are more
spine, and wrist), and behaviors, lifestyle inadequate lighting likely to
traumatic brain injury. changes to reduce experience a fall
Fall-related injury is risk factors and
associated with protect self from Place items used by Stretching to get
prolonged injury the patient within items from
hospitalizations for the easy reach bedside tables
adult. The quality of that are out of
life for the adults is reach can disrupt
significantly changed the patient’s
following a fall-related balance and
injury. The death Use siderails on beds contribute to falls
ratetfrom fall-related as needed. Patients who are
injuries and their disoriented or
complications increases confused have
with the age of the been known to
patients. climb over
siderails and fall
(Gulanick, 6th Edition,
pg.59) Encourage the Evidence
patient to participate suggests that
in a program of people who
regular exercise engage in regular
exercise and
activity will
strengthen
muscles

DEPENDENT
Encourage the Nonskid footwear
patient to wear shoes provides sure
or slippers with footing for the
nonskid soles when patient with
ambulating diminished foot
and toe lift when
walking

Orient the patient to The more familiar

the layout of the the patient is with
room. the layout of the
room, the less
likely the patient
 is to trip over
furniture

Provide the patient This chair style is

with a chair that has easier to get out
a firm seat and arms of,especially
on both sides when the patient
experiences
weakness and
impaired balance
when transferring
from bed to chair

Educate the patient Incorrect use or

and family improper
caregivers about the maintenance of
correct use and canes, walkers
maintenance of and wheelchairs
mobility assisted can increase the
devices risk for falls

COLLABORATIVE
Refer the person for Physical therapy
diagnostic evaluation can
masculoskeletal identify problems
evaluation with balance and
gait that can
increase a persons
fall risk
Collaborate with A review of the
other health care patients
team members to medication by the
evaluate the patients prescribing health
medications that care provider and
contribute to falling the pharmacist
can identify side
effects and drug
interaction

Refer the family to Many community

community service
resources for organizations
assistance in making provide financial
home safety assistance to help
modifications older alults make
safety
improvements