Public Display of Affection

Nursing Care Plan Student Name/Date __Nicole Reinke/ Week 5_____________ Nursing Diagnosis Expected Outcomes Nursing Interventions/ precept Outcome Evaluation (Dx, related to, & as evidenced by) (Short term (8-48 hr. ) reasonable expectations List on the whole interventions for each nsg. dx (include patient/family (Patient outcome noted as met or unmet/responses stated in measurable, behavioral terms, i. . , teaching) described) action verbs) Risk for injury r/t seizures amb gait and balance Client testamenting remain free from locomote while in the Nurse pass on correct sure that the c altogether fallible is always in reach so This outcome of remaining slip away free was met while disorders. hospital. that the client does not have to be concerned about not knowing I was at the hospital. Everytime I went into the where the call light is when needing help. room I made sure the call light was on her table Nure go out place a High Risk for Falls grade abov e clients bed soand the footer was next to the bed.Client also that any person that comes into the room to help assist is aware report no move. of the safety measures that need to be taken. Nurse will determine risk for falls using the evaluation tool which includes client history of atrial fibrillation. Nurse will place the walker near the bed to remind client to use walker when getting up to go to the bathroom. Nurse will explain how to use the walker, by moving walker first and then move body to make sure client knows how to use the walker. Nurse will also teach the client the importance of using the walker when walking through the halls in order to prevent future This outcome of using the walker was partially Client will use a walker while in the hospital tofalls, this will also help promote activity and will give the met. When reminded the client would use the get to the bathroom in order to maintain safety. cli ent something else to do instead of laying in bed all day. walker but admitted not using it all the time. After teaching her the importance of using the walker and what could happen if she fell she said she would try to make it a habit. Nursing Diagnosis Expected Outcomes Nursing Interventions/Rationale Outcome Evaluation (Dx, related to, & as evidenced by) (Short term (8-48 hr. ) reasonable expectations List all interventions for each nsg. dx (include patient/family(Patient outcome noted as met or unmet/responses stated in measurable, behavioral terms, i. e. teaching) described) action verbs) 3. Client will be educated on how to reduce Nurse will assess for additonal factors leading to risk for This outcome was not fully met. I holded about risk of falls at home. falls because sometimes medications can increase risk for her house and the hazards that were there for falls. falls but I wasnt able to talk about using 2.Nurse will teach the client the benefit of using nonskid nonskid rugs or bathroom devices. But she rugs and safety devices in the bathroom. This is important to understands the importance and will ask her teach so that the client can recognize clutter and slippery daughter and physican when she is discharged. floors. 3. Nurse will instruct client and daughter how to correct determine hazards to make sure everything that could cause a fall is prevented.