Nanda Risk of falls - Using the ATI Active Learning Medication Template and ATI text PN PHARM complete PDF

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Using the ATI Active Learning Medication Template and ATI text PN PHARM complete a
template on each medication for class...

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Nadia Louis Nurse Care Plan Nursing Diagnosis Nanda : Risk of falls Related to: Impaired physical mobility Subjective Data: “Sometimes I feel weak” Objective Data: Decreased strength, weak in appearance Goals/Outcome: Goal: Within 2 to 3 hours of rendering proper nursing interventions, the patient will be free of falls Outcome: Be free of injury, demonstrate behavior, lifestyle changes to reduce risk factors, and protect self from injury. Nurse Interventions: 1. Identify factors that affect safety needs 2. Modify environment as indicated to enhance safety 3. Instruct patient to call for assistance when moving 4. Put side rails up 5. Place items use by patient within reach 6. Assess vision and provide adequate lighting to clearly see the pathway Scientific Rationale: 1. To know the intervention that will be established 2. Patients who are not familiar with the placement of furniture and equipment in the room are more likely to experience a fall 3. To provide well-lighted environment and avoid the occurrence of injury 4. To prevent the patient from falling out of bed. 5. Patients who are disoriented or confused have been known to climb over side rails and fall. 6. Stretching to get items from bedside tables that are out of reach can disrupts patient’s balance and contribute to falls. 7. Nonskid footwear reduces risk of falls when walking Implementation: 1. Assessed patients for factors known to increase fall risk such as history of falls, mental status changes and sensory deficits. 2. Assessed and modified patients' environments for factors known to increase fall risks. 3. Assessed the patient's environment and provided adequate lighting. 4. Place call light within patients reach. 5. Raised side rails. 6. Placed bedside table within patients reach.

7. Oriented patient on the importance of using call light. Evaluation: Goals met: After 2 to 3 hours of rendering nursing interventions the patient was free of falls and safety was ensured Revisions: Will continue to monitor patient until end of shift, report any issues to charge nurse....