Help with care plan

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    Ok, I am a first year nursing student and I have to do a fall risk assessment (done) and then come up with a care plan with at least 3 nursing diagnoses, at least one short term and one long term goal, and at least four interventions/rationales. I am having unusual difficulty with this so any help would be greatly appreciated. So far I have these as my diagnoses

    Activity intolerance R/T copd and emphysema AEB shortness of breath during walking and pt admitting "I do not get up any more than necessary and I am just 'no count' these days"

    Impaired physical mobility R/T arthritis in knees and decreased endurance AEB slow shuffling gait and pt stating she "is as sore as a boil"

    Risk for injury R/T long oxygen cannula cord and throw rugs AEB observing pt having difficulty navigating from room to room.

    Risk for falls R/T medications AEB patient being prescribed xanax, paxil, lotrel, lortab, and microzide which are all fall risk drugs.

    Any and all criticism and feedback is welcomed!!

    Thank you so much.
  2. 2 Comments so far...

  3. 0
    Quote from rcombs
    Ok, I am a first year nursing student and I have to do a fall risk assessment (done) and then come up with a care plan with at least 3 nursing diagnoses, at least one short term and one long term goal, and at least four interventions/rationales. I am having unusual difficulty with this so any help would be greatly appreciated. So far I have these as my diagnoses

    Activity intolerance R/T copd and emphysema AEB shortness of breath during walking and pt admitting "I do not get up any more than necessary and I am just 'no count' these days"

    Impaired physical mobility R/T arthritis in knees and decreased endurance AEB slow shuffling gait and pt stating she "is as sore as a boil"

    Risk for injury R/T long oxygen cannula cord and throw rugs AEB observing pt having difficulty navigating from room to room.

    Risk for falls R/T medications AEB patient being prescribed xanax, paxil, lotrel, lortab, and microzide which are all fall risk drugs.

    Any and all criticism and feedback is welcomed!!

    Thank you so much.

    OK- really good start

    Short term goal.... what are your goals re: falls?

    Long term goal.... identify potential risks at home, any mobility assessments (and possible PT evaluation & exercises), verbalize understanding of uses/side effects of meds,

    Interventions/rationales

    -throw rugs- whaddya gonna do about them and why?
    -skid proof socks/slippers/shoes- why?
    -possible social services home visit to check need for lift chair (Medicare will cover if MD prescribes)
    -check need for elevated toilet seat or BSC in hospital and home (knee issues)
    - social services evaluation for possible community programs (Meals on Wheels, 'helper' a few x's per week if indicated/covered- Medicare won't cover, but if she has some sort of LTC insurance, that might)
    - encourage interest in hobbies to increase sense of accomplishment/diversion (note need for sedentary activity)
    -assess ability to set up/take meds appropriately (falls, reps status...)
    -assess lighting at night at home (night lights in halls, bathroom, etc)

    Maybe that will be a start
  4. 0
    i'm thinking that this is a really good start.
    you've really put some thought into cause and effect, a functional approach.

    one suggestion: i wouldn't say "because those are fall-risk drugs," but say why. maybe something like, "... (dizziness/weakness/positional blood pressure drop/whatever side effects for each drug)."


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