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,
-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