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(Ackley, Betty),

Nursing Diagnosis
Handbook 10th ed1.

2.
GOAL/OUTCOME

3. INTERVENTIONS

4. SCIENTIFIC
RATIONALE

5. IMPLEMENTATION

For each Intervention:

Implementation of
plan/interventions: The
nurse performed (Column
3)
1. Assessed patient for
factors known to increase
fall risk such as history of
falls, mental status changes
and sensory deficits.

6. EVALUATION

NURSING DIAGNOSIS
NANDA:
Risk for falls

Related to(etiology/cause
of problem):

Client-Centered Goal:
What the client/ needs to
accomplish

Therapeutic Nursing
Interventions: What the
nurse plans to do

1. Within 2 to 3hours
of rendering proper nursing
intervention, the patient
will be free from falls.

1. Identify factors that


affect safety needs.

Impaired physical mobility

2. Modify environment as
indicated to enhance safety.

3. Assess vision and


provide adequate lighting
to clearly see the pathway.

Subjective data:
"Sometimes I'm weak"
"I've been sleep all day."
Objective data:
Decreased strength
Weak in appearance
R/t leg cast
Absence of side rails

1. To know the intervention


that will be established.
(Gary-Miceli, 2008) pg 332

2. Patients who are not


familiar with the placement
of furniture and equipment
in the room are more likely
to experience a fall.
(Gary-Miceli, 2008) pg 332

2. Assessed and modified


patient's environment for
factors known to increase
fall risk.

3. To provide welllighted environment and


avoid the occurrence of
injury.

3. Assessed patient's
environment and provided
adequate lighting.

Evaluate Outcomes:
(Column 2)
Goal met.
After 2 to 3 hours of
rendering nursing
interventions the
patient was free of
falls and safety was
ensured.

(Gary-Miceli, 2008) pg 332

Outcomes:
Be free of injury.
Demonstrate behavior,
lifestyle changes to reduce
risk factors and protect self
from injury.

4. Instruct the patient to


call for assistance when
moving.
5. Put side rails up.

4. To prevent the patient


from falling on bed.
(Gary-Miceli, 2008) pg 332

5. Patients who are


disoriented or confused
have been known to climb
over side rails and fall.

4. Placed call light within


patients reach.
5.Raised side rails.

(Gary-Miceli, 2008) pg 332

6. Place items used by the


patient within easy reach.

6. Stretching to get items


from bedside tables that are
out of reach can disrupt
patient's balance and
contribute to falls.

6. Placed bedside table


within patients reach.

(Gary-Miceli, 2008) pg 332

7. Encourage the patient to

7. Nonskid footwear reduces


risk of falls when walking.

7. Oriented the patient on


the importance of using

Revisions:
Continue to monitor

DATA SUPPORTS NSG DX


AND IS COMPLETE
R/T causes (etiology):
Reason for NANDAsupported by defining
characteristics
S data quoted from
client
O data see, hear, feel,
observe, read, lab values,
meds

Goal STATEMENT is
related to NSG DX.
Outcomes are:
-realistic/measurable
-related to client data and
stated
goal
-attainable within clientcentered
outcome time frame.

G:Nsg/pkts/general/Word/careplan.2013.8.5x11

wear shoes or slippers with


nonskid soles.

(Gary-Miceli, 2008) pg 332

nonskid slippers

THERAPEUTIC
INTERVENTIONS are based
on identified outcome.
INCLUDE:
-action to be performed
-descriptive phraseDate/time/how often

Scientific Rationale:
-Reference source by author &
page
-reflects understanding of
intervention
-reflects client data
-be specific to plan

Identify what was actually


done for each therapeutic
nursing intervention,(include
date/time)
Identify which interventions
were/were not implemented.

Evaluate each outcome


individually to determine if
it was met(date): completely,
partially, not at all State
revisions based on evaluation
of client-centered goal