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Medical Diagnoses: Risk for Falls, Anti-hypertensive medications,Diminished mental status, Hxn of seizures

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

 

Pt stated that she was experiencing feelings of weakness and pain in her legs and back.

 

Objective:

       

Pt demonstrates difficulty with ambulation

       

Pt is up with assist 1X

       

Pt’s MAR states that she is currently taking anti-hypertensive medications that state dizziness, weakness, and light-headedness as possible side effects.

       

Pt has a hxn of seizures

       

Pt is over the age of 65

       

Pt has a diminished mental status

       

Pt has right-sided hemiparesis r/t a left sided stroke.


Problem:

 

Risk for falls

Long Term:

Pt will verbalize appropriate interventions to take to minimize the risk for falls by discharge.

*Teach the pt the importance of wearing supportive low-heeled shows with good traction when ambulating.

       

Rationale: “Supportive shoes provide better balance and protect the client from instability on uneven surfaces.” (Ackley & Ladwig, 2008, p. 344)

 

*Educate pt about certain medications that may affect her balance or increase her risk for falls.

       

Rationale: Rationale: “Polypharmacy has been associated with increased falls.” (Ackley & Ladwig, 2008, p. 341)

       

       

I

Goal met. Pt was able to verbalize understanding of needed interventions to reduce her risk for falls. She restated the information back to the staff after her educational lesson on the topic. She clearly remembered what she was taught and stated “I feel like I know now better now how to prevent myself from falling at home.” 

Continue interventions. Continue to reinforce the importance of appropriate shoes for the pt at home. Continue to educate the pt about her medications that could potentially increase dizziness and risk for falls.

R/T

 

Anti-hypertensive medications

 

Diminished mental status

 

Hxn of seizures

 

Short Term:

Pt will remain free of falls during this shift.

*Identify the pt with “falls precautions” protocols such as armbands, HOB signs, and chart notes.

 

Rationale: “These steps alert the nursing staff of the increased risk of falls.” (Ackley & Ladwig, 2008, p. 341)

 

*Evaluate the pt’s medications prior to administration to determine whether they increase the risk of falling.

 

Rationale: “Polypharmacy has been associated with increased falls.” (Ackley & Ladwig, 2008, p. 341)


 

I

Goal met. Pt was able to remain free of falls throughout the course of today’s shift. Pt did not demonstrate any signs of dizziness or light-headedness during ambulation. Pt did not verbalize any complaints of dizziness or unsteadiness during ambulation.


Continue interventions as listed. Continue to make sure that the pt is thoroughly identified as falls precautions pt with the appropriate protocols. Continue to evaluate the pt’s medications before administration to determine if it will increase their risk for falls.

AEB

 

Pt demonstrates some difficulty with ambulation.

 

Anti-hypertensive medications that have dizziness, weakness, and light-headedness as possible side effects.

 

Use of assistive device

 

Pt is over the age of 65

 

 

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*I = Implementation.  Check those interventions/actions/orders that were implemented.

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.

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