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NURSING CARE PLAN

CUES

NURSING
DIAGNOSIS

No subjective cues

Risk for falls


related to unsteady
gait and old age.

Objective cues;
-impaired physical
mobility
-head injury
manifested by
profuse bleeding

GOALS/ OUTCOME
CRITERIA

NURSING
RESPONSIBILI
TIES

After 8 hours of
nursing intervention, no
incidence of fall will
occur, patients safety
will be ensured.

RATIONALE

EVALUATION

INDEPENDENT
Assess the person for
factors known to increase
fall risk such as history of
falls, mentall status changes
and sensory deficits

Evidence indicates that a


person who has sustained
one or more falls in the
past year is more likely
to fall again

After 8 hours of
rendering nursing
interventions the
patient will have no
incidence of fall and
safety is ensured

Assess patients
environment for factors
known to increase fall risk
such as unfamiliar setting
and inadequate lighting

Patients who are not


familiar with the
placement of furniture
and equipment in the
room are more likely to
experience a fall

Place items used by the


patient within easy reach

Stretching to get items


from bedside tables that
are out of reach can
disrupt the patients
balance and contribute to
falls
Patients who are
disoriented or confused
have been known to
climb over siderails and

Use siderails on beds as


needed.

fall
Encourage the patient to
participate in a program of
regular exercise

Evidence suggests that


people who engage in
regular exercise and
activity will strengthen
muscles

DEPENDENT
Encourage the patient to
wear shoes or slippers with
nonskid soles when
ambulating

Nonskid footwear
provides sure footing for
the patient with
diminished foot and toe
lift when walking

Orient the patient to the


layout of the room.

The more familiar the


patient is with the layout
of the room, the less
likely the patient is to trip
over furniture

Provide the patient with a


chair that has a firm seat
and arms on both sides

This chair style is easier


to get out of,especially
when the patient
experiences weakness
and impaired balance
when transferring from
bed to chair

Educate the patient and


family caregivers about the

Incorrect use or improper


maintenance of canes,

correct use and maintenance


of mobility assisted devices

walkers and wheelchairs


can increase the risk for
falls

COLLABORATIVE
Refer the person for
diagnostic masculoskeletal
evaluation

Physical therapy
evaluation can identify
problems with balance
and gait that can increase
a persons fall risk

Collaborate with other


health care team members
to evaluate the patients
medications that contribute
to falling

A review of the patients


medication by the
prescribing health care
provider and the
pharmacist can identify
side effects and drug
interaction

Refer the family to


community resources for
assistance in making home
safety modifications

Many community service


organizations provide
financial assistance to
help older alults make
safety improvements