Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

States feelings of dizziness

States fear of falling

Objective

Extreme of age

Unsteady gait

Use of walker

History of falls

Lives alone

Problem

Risk for falls

Long Term:

1. client will not experience any falls during stay

2.Client will make necessary physical changes in environment to ensure increased safety  within first week of returning home     

1. Orient client to environment. Assess ability to use call bell, side rails, and bed controls.

1. These measures will help the client to cope with an unfamiliar environment

2. make changes in client’s environment that may cause or contribute to injury

2. to increase client’s awareness

*

*

Client did not experience falls to current

Client verbalized a plan to make changes at home to ensure safety

R/T

Decreased mobility

Short Term:

1.client will identify factors that increase potential for injury by the end of the day

2. remain free of falls per shift

1.identify factors that may cause or contribute to injury from a fall

1. Increase client awareness

2. routinely assist the client in toileting on her own schedule

2. keep path to the bathroom clear, leave the door open, falls are often linked to the need to eliminate in a hurry

*

*

Client is able to verbalize an understanding of risks factors for falls

Client did not experience any falls per shift

AEB