Need help with a NCP

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I am a 2nd yr nursing student, trying to create a NCP on my client. My client has lewy body dementia, and my nursing diagnosis is Risk for falls. How do I create an outcome for my client?!? I am so confused... HELP!

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Specializes in LTC, Nursing Management, WCC.
I am a 2nd yr nursing student, trying to create a NCP on my client. My client has lewy body dementia, and my nursing diagnosis is Risk for falls. How do I create an outcome for my client?!? I am so confused... HELP!

Well if your nursing diagnosis is Risk for Falls than an outcome would be that the patient would be free from injury...with a date attached. So Patient will be free from injuries r/t falls 12.15.08. Than your interventions would be things that you would try to implement to ensure that he doesn't fall. Normally, from my experience, with someone who has dementia and this type of nursing diagnosis... it would be a lot longer date. Say for the next 90 days. This patient will always be at a risk for falling so this nursing diagnosis will probably always be on his careplan.

If this patient has other things that put him at risk for hurting himself in addition to falling, then broaden the nursing diagnosis to Risk for Injury.

Some intervention regarding fall risk would be that he ambulates with assistance. That you keep a call light close to the patient. Performing a fall risk assessment. Making sure his environment is free from clutter. Using nonskid foot wear, using bed alarms while patient is in bed, checking on the patient more frequently, etc...

Good Luck!

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Specializes in med/surg, telemetry, IV therapy, mgmt.
Well if your nursing diagnosis is Risk for Falls than an outcome would be that the patient would be free from injury...with a date attached.

Incorrect! The outcome is that the patient will remain free from falls or you can explain methods to prevent falls that lead to injury. If the patient is to be free from injury use Risk for Injury. Read the taxonomy carefully.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

with lewy body dementia, risk for falls is the only problem the patient has? what about confusion, memory problems, sleep problems, ability to perform adls, and mobility? risk for falls is an anticipated problem. if this person is institutionalized there must be a reason for it and risk for falls is not it. you need to go back and assess this patient more thoroughly for the symptoms of their problems before diagnoses can be established. you really have provided nothing for us to work with.

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I am a 2nd yr nursing student, trying to create a NCP on my client. My client has lewy body dementia, and my nursing diagnosis is Risk for falls. How do I create an outcome for my client?!? I am so confused... HELP!

Lewy body dementia signs and symptoms may include:

  • Visual hallucinations. Seeing colors, shapes, animals or people may be one of the first symptoms of Lewy body dementia.
  • Movement disorders. Parkinson's-like signs may include slowed movement, rigid muscles, tremors or a shuffling walk.
  • Delusions. These may consist of false ideas about another person or situation.
  • Cognitive problems. Alzheimer's-like problems may include confusion, memory loss and reduced attention spans.
  • Sleep difficulties. A sleep disorder can cause you to physically act out your dreams while you're asleep.

Impaired physical mobility r/t neuromuscular impairment

Risk for injury r/t confusion, decreased muscle coordination

risk for falls r/t diminished mental status

Disturbed sleep pattern

Chronic confusion r/t neurological dysfunction

self care defecit:

Just some thoughts....

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