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Subjective
Data:
Pt stated I
feel
dizziness
all the
time
Objective
Data:
72 yearold, white
female
patient,
Laryngeal
cancer,
Dizziness,
weakness
generalize,
gastrostom
y
NURSING
DIAGNOSIS
Risk for fall
R/t age,
dizziness and
weakness
secondary to
chemotherap
y and
radiology.
GOAL &
OBJECTIVES
NURSING
INTERVENTIONS
RATIONALES
EVALUATION
Patient will
remain free of
falls during shift
1. Screen pt for
balance and mobility
skills
It is helpful to
determine the
clients
functional
abilities and then
plan for ways to
improve
problem areas or
determine
methods to
ensure safety
(Gray-Miceli,
2008)
2. Use a high-risk
fall
armband/bracelet
and fall risk room
sign to alert staff for
increased vigilance
and mobility
assistance
Stretching to get
items from
bedside tables
that are out of
reach can
disrupt the
patients
balance and
contribute to
falls (Perry,
2013)
4. Remove excess
future and
equipment and
make sure that
patients wear rubber
soled shoes or
slippers for walking
Provide a space
clear for
abundant using
equipment, have
patient wear
rubber soled
shoes or slipper,
Priority #
Patient will
verbalize
understand
necessary
physical
changes in
environment to
ensure increased
safety within
first week of
returning home
or transferring, lock
bed and wheel chair.
Interventions to
improve home
safety were
shown to be
effective to
reduce falls
(Tinetti, 2003)
Patient
verbalized will
make changes at
home to ensure
safety