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    Risk For Fall

    Uploaded by

    LesValenzuela
    This nursing care plan outlines goals and interventions to address a patient's risk for falls due to impaired mobility and a head injury. The plan includes assessing fall risk factors, ensuring a safe environment, encouraging exercise, providing assistive devices, educating on device use, and collaborating with other providers to address medications and make home modifications. The goal is to prevent falls and ensure safety during the patient's 8-hour hospital stay.

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    Risk For Fall

    Uploaded by

    LesValenzuela
    2K views3 pages
    This nursing care plan outlines goals and interventions to address a patient's risk for falls due to impaired mobility and a head injury. The plan includes assessing fall risk factors, ensuring a safe environment, encouraging exercise, providing assistive devices, educating on device use, and collaborating with other providers to address medications and make home modifications. The goal is to prevent falls and ensure safety during the patient's 8-hour hospital stay.

    Original Description:

    ncp

    Original Title

    Risk for Fall

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    This nursing care plan outlines goals and interventions to address a patient's risk for falls due to impaired mobility and a head injury. The plan includes assessing fall risk factors, ensuring a safe environment, encouraging exercise, providing assistive devices, educating on device use, and collaborating with other providers to address medications and make home modifications. The goal is to prevent falls and ensure safety during the patient's 8-hour hospital stay.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    2K views3 pages

    Risk For Fall

    Uploaded by

    LesValenzuela
    This nursing care plan outlines goals and interventions to address a patient's risk for falls due to impaired mobility and a head injury. The plan includes assessing fall risk factors, ensuring a safe environment, encouraging exercise, providing assistive devices, educating on device use, and collaborating with other providers to address medications and make home modifications. The goal is to prevent falls and ensure safety during the patient's 8-hour hospital stay.

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    NURSING CARE PLAN

    CUES

    NURSING
    DIAGNOSIS

    No subjective cues

    Risk for falls


    related to unsteady
    gait and old age.

    Objective cues;
    -impaired physical
    mobility
    -head injury
    manifested by
    profuse bleeding

    GOALS/ OUTCOME
    CRITERIA

    NURSING
    RESPONSIBILI
    TIES

    After 8 hours of
    nursing intervention, no
    incidence of fall will
    occur, patients safety
    will be ensured.

    RATIONALE

    EVALUATION

    INDEPENDENT
    Assess the person for
    factors known to increase
    fall risk such as history of
    falls, mentall status changes
    and sensory deficits

    Evidence indicates that a


    person who has sustained
    one or more falls in the
    past year is more likely
    to fall again

    After 8 hours of
    rendering nursing
    interventions the
    patient will have no
    incidence of fall and
    safety is ensured

    Assess patients
    environment for factors
    known to increase fall risk
    such as unfamiliar setting
    and inadequate lighting

    Patients who are not


    familiar with the
    placement of furniture
    and equipment in the
    room are more likely to
    experience a fall

    Place items used by the


    patient within easy reach

    Stretching to get items


    from bedside tables that
    are out of reach can
    disrupt the patients
    balance and contribute to
    falls
    Patients who are
    disoriented or confused
    have been known to
    climb over siderails and

    Use siderails on beds as


    needed.

    fall
    Encourage the patient to
    participate in a program of
    regular exercise

    Evidence suggests that


    people who engage in
    regular exercise and
    activity will strengthen
    muscles

    DEPENDENT
    Encourage the patient to
    wear shoes or slippers with
    nonskid soles when
    ambulating

    Nonskid footwear
    provides sure footing for
    the patient with
    diminished foot and toe
    lift when walking

    Orient the patient to the


    layout of the room.

    The more familiar the


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

    Provide the patient with a


    chair that has a firm seat
    and arms on both sides

    This chair style is easier


    to get out of,especially
    when the patient
    experiences weakness
    and impaired balance
    when transferring from
    bed to chair

    Educate the patient and


    family caregivers about the

    Incorrect use or improper


    maintenance of canes,

    correct use and maintenance


    of mobility assisted devices

    walkers and wheelchairs


    can increase the risk for
    falls

    COLLABORATIVE
    Refer the person for
    diagnostic masculoskeletal
    evaluation

    Physical therapy
    evaluation can identify
    problems with balance
    and gait that can increase
    a persons fall risk

    Collaborate with other


    health care team members
    to evaluate the patients
    medications that contribute
    to falling

    A review of the patients


    medication by the
    prescribing health care
    provider and the
    pharmacist can identify
    side effects and drug
    interaction

    Refer the family to


    community resources for
    assistance in making home
    safety modifications

    Many community service


    organizations provide
    financial assistance to
    help older alults make
    safety improvements

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