Nursing Care Plan for Risk for falls - Please help!

  1. 0
    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.

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  2. 11 Comments...

  3. 1
    hey snowkie, i know where you are right now. i am a third sememster nursing student and i remember those days.
    first, always remember your nursing diagnosis has to be in a priority order. you know, airway first, breathing second , and circulation third. (abc)
    also, i was taught that a risk for diagnosis cannot be a priority diagnosis. try another NANDA diagnosis that has to do with his airway, breathing, and circulation. let me know what you come up with.
    the related to in your book are the reason why your patient has the problem. the as evidenced by is all your proof,like lab work, statements, and assessment data.
    ie-ineffective airway clearance ( nursing diagnosis) related to (why) increased lung secretions, as evidenced by ( proof, this must be objective data) increased wbc( give levels ), coughing, and wheezing.

    let me know if that helps. you'll get there.
    snowkei likes this.
  4. 1
    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)
    Seizure activity

    "Possibly evidenced by" is not applicable here because the presence of signs and sx establises an actual diagnosis.

    NOCs:
    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
    snowkei likes this.
  5. 0
    Quote from 425april
    hey snowkie, i know where you are right now. i am a third sememster nursing student and i remember those days.
    first, always remember your nursing diagnosis has to be in a priority order. you know, airway first, breathing second , and circulation third. (abc)
    also, i was taught that a risk for diagnosis cannot be a priority diagnosis. try another NANDA diagnosis that has to do with his airway, breathing, and circulation. let me know what you come up with.
    the related to in your book are the reason why your patient has the problem. the as evidenced by is all your proof,like lab work, statements, and assessment data.
    ie-ineffective airway clearance ( nursing diagnosis) related to (why) increased lung secretions, as evidenced by ( proof, this must be objective data) increased wbc( give levels ), coughing, and wheezing.

    let me know if that helps. you'll get there.

    Wow, thank you for reminding me about the ABC's!! With all the chaos in school, it really slipped my mind. I actually have to come up with three nursing care plans and this definitely helped me prioritize what is import. Again, thank you!
  6. 0
    Quote from Freedom42
    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)
    Seizure activity

    Freedom, thank you!! May I ask where you got the "risk factors" for injury/trauma?? I have the Nursing Diagnosis Handbook by Ackley, but I couldn't not find that anywhere under Risk for injuries. Does the r/t have to be in nanda? How did you come up with or where did you get "Inability to recognize/identify danger in environment"? My patient has poor static sitting balance and I think risk for injury r/t balancing difficulties would be appropriate.

    Is "Risk for injury r/t impaired physical mobility" a good nursing diagnosis? Or is "Risk for injury r/t balancing difficulties" more appropriate?
  7. 3
    about using "risk for" diagnoses. . .
    1. they do not have related factors. instead they have risk factors. risk factors are environmental [conditions] and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event (page 333, nanda-i nursing diagnoses: definitions & classification 2007-2008).
    2. you use a "risk for" diagnosis when you "think" a specific problem "might happen" to the patient
    3. since these are potential, or anticipated, problems there are no defining characteristics (signs and symptoms) to use as evidence to support the diagnosisas there are with actual problems. so your nursing diagnostic statement has only two parts:
      • the nursing diagnosis label
      • the risk factor(s)
    4. you have to have a very clear and defined idea of the problem you are attempting to prevent, know it's signs and symptoms and preventative measures.
    5. interventions for these nursing diagnoses are limited to:
      • strategies to prevent the problem from happening in the first place
      • monitoring for the specific signs and symptoms of this problem
      • reporting any symptoms that do occur to the doctor or other concerned professional
      • if symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis
    6. as a general rule, these types of nursing diagnoses do not have the same priority as actual nursing problems. actual problems are usually attended to first.
    i think that what your instructor meant by saying your related to must be a nanda and when you asked her for help she said you should have figured it out by now had to do with consulting the nanda taxonomy information. you will find this information directly below the title of the diagnosis in your ackley nursing diagnosis book (see page 479 of the 7th edition for risk for falls and the risk factors, not related factors, are listed in great detail right below the definition of the diagnosis). in my nanda nursing diagnosis reference, the risk factors for the diagnosis of risk for falls is very clearly listed--and it's a whopping list. "history of falls" is not listed as a risk factor for this diagnosis. you can also view information for this diagnosis here: risk for falls. risk for falls was split away from risk for injury because it was more specific in it's risk factors. if your patient has a history of falling, risk for falls would be the appropriate nursing diagnosis to use. it's definition, and you can also read this in your ackley book, is increased susceptibility to falling that may cause physical harm.
    justthe4ofus, mandajeanice, and snowkei like this.
  8. 0
    Quote from daytonite
    about using "risk for" diagnoses. . .
    1. they do not have related factors. instead they have risk factors. risk factors are environmental [conditions] and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event (page 333, nanda-i nursing diagnoses: definitions & classification 2007-2008).
    2. you use a "risk for" diagnosis when you "think" a specific problem "might happen" to the patient
    3. since these are potential, or anticipated, problems there are no defining characteristics (signs and symptoms) to use as evidence to support the diagnosisas there are with actual problems. so your nursing diagnostic statement has only two parts:
      • the nursing diagnosis label
      • the risk factor(s)
    4. you have to have a very clear and defined idea of the problem you are attempting to prevent, know it's signs and symptoms and preventative measures.
    5. interventions for these nursing diagnoses are limited to:
      • strategies to prevent the problem from happening in the first place
      • monitoring for the specific signs and symptoms of this problem
      • reporting any symptoms that do occur to the doctor or other concerned professional
      • if symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis
    6. as a general rule, these types of nursing diagnoses do not have the same priority as actual nursing problems. actual problems are usually attended to first.
    i think that what your instructor meant by saying your related to must be a nanda and when you asked her for help she said you should have figured it out by now had to do with consulting the nanda taxonomy information. you will find this information directly below the title of the diagnosis in your ackley nursing diagnosis book (see page 479 of the 7th edition for risk for falls and the risk factors, not related factors, are listed in great detail right below the definition of the diagnosis). in my nanda nursing diagnosis reference, the risk factors for the diagnosis of risk for falls is very clearly listed--and it's a whopping list. "history of falls" is not listed as a risk factor for this diagnosis. you can also view information for this diagnosis here: risk for falls. risk for falls was split away from risk for injury because it was more specific in it's risk factors. if your patient has a history of falling, risk for falls would be the appropriate nursing diagnosis to use. it's definition, and you can also read this in your ackley book, is increased susceptibility to falling that may cause physical harm.
    hi daytonite!

    thank you for your help. now i understand the "risk for" part!! so, if i use any "risk for" diagnosis, there will be no related to, but "risk factors of". is that correct?

    for example, if i do plan to use the falls as a diagnosis, would this be correct: risk for falls with the risk factors of impaired physical mobility.

    please advise, thank you!
  9. 0
    Yes.

    Your diagnostic statement will still be Risk for Falls R/T impaired physical mobility. The "impaired physical mobility" part" is implied as being a risk factor because of the way the first part of the diagnostic statement is worded as "Risk for". Don't you have some better specific information about why the patient is falling all the time than "impaired physical mobility"? There is quite a long list of risk factors listed by NANDA. Doesn't your patient have at least one of them (i.e., difficulty with gait, foot problems, impaired balance, neuropathy)? There is also age over 65, use of assistive devices and diminished mental status which you can also add. You can list more than one risk factor. I suspect that the reason your instructor may not have liked "history of falls" was because of it's vagueness. I'm thinking that "impaired physical mobility" has that same vagueness (it also is another diagnosis--arguably, if the patient has impaired physical mobility, why not just use the diagnosis of Impaired Physical Mobility?)
  10. 0
    Hi, Snowkei:

    Thanks for your note. Half of my class, including me, uses Doenges, a remarkably non-user friendly text. I could not find falls in the index, only injury/trauma. The other half of our class uses Ackley, which I think is easier to use.

    Good luck.
  11. 0
    Hi daytonite! Thank you so much for your help!! I had to do 2 care plans (I made about 6 just so I can get a hang of it!) for the patient. I ended up not using "Risk for falls", instead I used "Impaired physical mobility r/t chronic paraplegia and decrease muscle strength." Since the patient could not move his lower extremities and has a pressure ulcer at his heel, I also came up with "Impaired skin integrity r/t physical immobility and pressure ulcer stage II as evidence by disruption of epidermal and dermal tissue."

    Okay, I finally understand what you meant with the nursing diagnosis being vague. My mom kept stressing that I need to individualize each care plan and that helped. Even though I didn't use Risk for falls, I just wanted to make sure I was doing it right. I came up with, Risk for falls with the risk factors of decreased lower extremity strength, impaired balance and ineffective tissue perfusion.

    I really hope these are good, I've been working on getting better with care plans. Thank you for your help daytonite! I very much appreciate it.


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