Public Display of Affection

Nursing Care Plan Student Name/Date: __Nicole Reinke/ Week 5_____________ | 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. . , |teaching) |described) | | |action verbs) | | | |Risk for injury r/t seizures amb gait and balance |Client will remain free from falls while in the |Nurse will make sure that the call light is always in reach so |This outcome of remaining fall 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 will place a â€Å"High Risk for Falls† sign above client’s bed so|and the walker was next to the bed.Client also | | | |that any person that comes into the room to help assist is aware |reported no falls. | | | |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 to|falls, this will also help promote activity and will give the |met. When reminded the clien t would use the | | |get to the bathroom in order to maintain safety. client 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 asked 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 wasn’t 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 | | | | |identified hazards to make sure everything that could cause a | | | | |fall is prevented. | |