Fall Risk care plan PDF

Preview

Summary

fall risk care plan...

Description

September 16, 2020 Patient Name:

Edith Jacobson

Dx/Condition: Hip fracture Reevaluation 09/16/2020 Date:

Fall Risk Goal •

The patient will not experience any falls. patient has been educated about risk for falls, safety and activities related to falls (Taylor, 2020)

Interventions •

Assess the patient's ability to self-transfer and walk. performed focused assessment of the musculoskeletal system to assess patient's mobility (Taylor, 2020)

•

Assess the patient's cognition and mental status. assessed patient's alertness and orientation by asking if she is awake, where she is, and today's date (Taylor, 2020)

•

Assist the patient with mobility (getting out of bed, ambulation). positioned the patient with the help of a second nurse for repositioning (Taylor, 2020)

•

Initiate measures to prevent falls. educated the patient about fall risk factors, safety, and activities to prevent falls in the future (Taylor, 2020)

•

Obtain a physical therapy consult, as needed. consult physical therapy for the patient after the hip surgery (Taylor, 2020)

•

Other: 1. nursing diagnosis: risk for falls r/t to age 2. short term goals: -patient will verbalize 2 methods to prevent falls -patient will demonstrate correct use of assistive device when self-transfer is needed -patient will verbalize signs of fall risk

Obj. data- tenderness in the left hip, left leg shorter than the right, patient is 85 years old 4. current meds: enoxaparin sodium 40mg/daily to prevent PE and DVT, docusate sodium 100mg/daily for constipation, morphine sulfate 4mg/4hrs for pain, LR 84ml/hr 5. vital signs: HR-87, BP-134/80mmHg, temp-99F, spO2- 97%, pulse- strong 90beats/min, respiration-15 6. evaluation goals: -goal 1 was not met, patient did not verbalize methods of fall prevention, will reeducate patient on fall risk precautions, -goal 2 was not met, patient did not need to self-transfer, educate the patient on how to use the assistive device, will consult doctor for PT/OT reevaluation -goal 3 was met, patient expressed feeling dizzy, re-educate patient on proper actions to take when experiencing signs of fall risk -goal 4 was met, patient did not fall on day of care, continue to reevaluate/educate patient 7. APA: Ackley, B. J. (2011). Nursing diagnosis handbook. St Louis, MO: Elsevier Mosby. Taylor, C., Lynn, P., & Bartlett, J. L. (2020). Fundamentals of nursing: The art and science of person-centered nursing care. Philadelphia: Wolters Kluwer. Care Plan Provider: Yun Lee

Date: 09/16/2020...