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Fall Risk Nursing Care Plan

The document outlines a nursing care plan for a patient experiencing occasional lightheadedness and bleeding gums. The plan includes an assessment noting the patient's symptoms, a diagnosis of risk for falls, short and long term nursing goals to reduce fall risk, and primary and secondary nursing interventions. The interventions include teaching safe ambulation, asking family to assist the patient, implementing safety devices, performing a home visit, and practicing patient safety. The goals are for the patient to understand their risk factors, identify behaviors to reduce risk, and promote their safety from injury.

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2K views2 pages

Fall Risk Nursing Care Plan

The document outlines a nursing care plan for a patient experiencing occasional lightheadedness and bleeding gums. The plan includes an assessment noting the patient's symptoms, a diagnosis of risk for falls, short and long term nursing goals to reduce fall risk, and primary and secondary nursing interventions. The interventions include teaching safe ambulation, asking family to assist the patient, implementing safety devices, performing a home visit, and practicing patient safety. The goals are for the patient to understand their risk factors, identify behaviors to reduce risk, and promote their safety from injury.

Uploaded by

kaimimiya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME

Assessment Diagnosis Mutual Planning Interventions Actual Evaluation


(Goal attainable within the shift) (with Rationale & Source)
Subjective: Short Term Goal: PRIMARY INTERVENTIONS Subjective:
Patient states that she feels Risk for falls related to occasional After 8 hours of nursing Promotive:
occasional lightheadedness after lightheadedness interventions, the patient will be I: Teach client how to safely ambulate at home,
lying in bed for a long time. She able to: including using safety measures such as handrails in
also said that her gums slightly  Verbalize understanding of bathroom.
bled after brushing individual risk factors that R: This will help relieve anxiety at home and
Theoretical basis: contribute to the possibility of eventually decreases the risk of falls during
Lightheadedness is feeling as if falls ambulation.
one might faint. The body may  Identify the behaviors and S: Wayne, G. (2017) Objective:
feel heavy while the head feels as lifestyle changes that reduce
if it is not getting enough blood. risk factors and protect self I: Ask family to stay with the patient.
Another way to describe from injury R: This is to prevent the patient from accidentally
lightheadedness is as a “reeling  Modify environment to falling or pulling out tubes.
sensation.” Lightheadedness may enhance safety S: Wayne, G. (2017)
be accompanied by clouded
vision and a loss of balance. Preventive:
Lightheadedness can sometimes Long Term Goal: I: Recommend or implement needed interventions
indicate an underlying medical After 32 hours of nursing and safety devices
condition and can increase the interventions, the patient will be R: to manage conditions that could contribute to
risk for experiencing a fall. For able to: falling and to promote safe environment for individual
this reason, one should take  Be free of injury and others
caution when one feels  Know what situations that S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
lightheaded.(Nall, 2019) may lead to experiencing (2016).
falls
 State actions that promote I: Perform home visit when appropriate. Determine
her safety that home safety issues are addressed, including
supervision, access to emergency assistance, and
client’s ability to manage self-care in the home.
R: This may be needed to adequately determine
client’s needs and available resources
S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
(2016).

SECONDARY INTERVENTIONS:
Curative:
I: Practice client safety.
R: This demonstrates behaviors for client/caregiver(s)
to emulate.
S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
(2016).

Bibliography:
Doenges E.M., Moorhouse M.F., & Murr. A.C. (2016). Fatigue. Nurses’ Pocket Guide pp.310-316. Philadelphia, PA: F.A. Davis Company
Nall, R. (2019). Lightheadedness. Retrieved by November 18, 2020 from https://www.healthline.com/health/lightheadedness.
Wayne, G. (2017). Risk for Falls. Retrieved by November 18, 2020 from https://nurseslabs.com/risk-for-falls/

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