Nursing diagnosis + care plan help

[shrimpchips, LPN]

Formulating a nursing diagnosis and a care plan is still pretty new to me. I had some experience with it last semester when I had to write my nursing assessment paper. We have to do a similar paper this semester but now we need to come up with a complete care plan with expected outcomes and goals.

My patient is a 77 year-old female who was admitted to my clinical site on 1/30/09 for a fall related to syncope and right hip/knee pain. She currently has congestive heart failure, hypertension, angina and degenerative osteoarthritis with "questionable rheumatoid arthritis" per chart. I decided to come up with the following nursing diagnosis:

Risk for injury r/t sensory deficit and altered mobility...then after seeing her I decided to add "aeb weakness and dizziness". Are the goal and outcomes the same thing? According to my nursing diagnosis cards, expected outcomes include:

• patient optimizes ADL's w/in sensorimotor limitations
  
  
• patient and family member or caregiver develop a strategy to maintain safety.
  

For nursing interventions, I listed:

• Conduct a close watch for patient - keep them close to the nurse station, rounds q1h
  
• Keep bed in lowest position with side rails up
  
• Assist with ambulation to decrease potential for injury
  
• Apply AROM/PROM to joints
  

I don't know if any of this is correct but I feel like it isn't...any help would be appreciated!

[Daytonite, BSN, RN]

What is the injury she is at risk for? If she is at risk for an injury due to falling just diagnose Risk for Falls. The ultimate outcome is for her not to fall. The goals, as always, are based on you want to accomplish with your interventions.

The R/Ts with "Risk for" diagnoses are risk factors--things that are what make it possible for the potential nursing problem to come about.

There are no AEBs with "Risk for" diagnoses because these problems don't exist yet. AEBs are evidence of a problem and since these problem don't exist, theoretically, there can be no evidence of them.

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. With "Risk for" diagnoses your nursing interventions will be

• 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
  

[shrimpchips, LPN]

Thanks, Daytonite!!!! That makes more sense now :)