Hi everyone! :spin: I'm in my first semester of nursing school. I'm having a problem with nursing diagnosis. I have to make a care plan for my patient. I chose risk for falls. However, I'm really having a hard time with the "related to" part of it. I followed Ackley's care plan constructor and came up with "Risk for falls related to history of falls." My professor handed back my care plan (after chewing me out) and said my "related to" wasn't NANDA. She said my related to MUST be a NANDA. I'm very confused
I asked her for help, but she said I should have figured it out by now. [big sigh].
My patient is a 63 y/o male. He's diagnosed with osteomylitis, history of chronic paraplegia (he stated he does not have feeling from his knees to toes), acute renal failure, CHF.
I was thinking my diagnosis should be "Risk for falls related to impaired physical mobility."
If I was to use impaired physical mobility as a related to, what would my interventions be? Perform ROM exercises? But how would that help reduce his risk for falls?
I'm so confused. Any help would be very much appreciated! Thank you.
NANDA lists this nursing diagnosis: risk for injury/trauma
Risk factors may include:
Inability to recognize/identify danger in environment, impaired judgment
Disorientation, confusion, agitation, irritability, excitability
Weakness, muscular incoordination, balancing difficulties, disturbed perception (e.g., missing chairs, steps)
"Possibly evidenced by" is not applicable here because the presence of signs and sx establises an actual diagnosis.
Safe home environment (recognize potential risks in the environment; identify and implement steps to correct/compensate for individual factors)
Client will be free of injury
From what I read of your post, I'd suggest risk for injury/trauma r/t balancing difficulties (if that's appropriate to what caused the falls)
Last edit by Freedom42 on Apr 2, '08