RNstudent311

My patient has no skin breakdown but a incision site with staples that is approximated with no drainage. He has scrotal edema and a distended abdomen.

How about the patient will demonstrate behaviors that will decrease the risk for falls by the end of the shift. and The patient will ambulate from his bed to his chair with x2 assist by the end of the shift The only reason I am doing my NCP on risk for falls and risk for injury is bc my 2nd year instructor says she wants us to use those before say impaired skin integrity bc they are the priority bc if the pt could fall and sustain injury.

Thank you ESME12 for the links very helpful!!

My other diagnoses in my careplan were risk for falls, risk for infection, impaired skin integrity, and impaired physical mobility. My patient would try to get out of bed and stated," these rails need to be oiled bc they wont move." He had 4 episodes of diarrhea. Physical therapy evaluated him and stated that he could stand up and ambulate to his chair only with x2 assist from staff. You had to put your knee in front of his knee so he could stand up. He was wobbly when he stood. His VS were fine except for a high BP which was tx with Cozaar. Pt had a hx of HTN. The pt also has a hx of Dementia.

Well I was thinking (But not sure) 1. The patient will be free from falls caused by being unsteady by the end of the shift. 2. Strategies will be implemented to increase safety and prevent falls in the hospital room by the end of the shift. 3. The patient will be taught fall prevention techniques by the end of the shift. I use Nursing care plans: diagnoses, interventions, and Outcomes by Gulanick and Nursing Dx Handbook: An evidenced based guide to planning care by Ackley

I am in my third semester of nursing school and I need help on my plan of care. My pt was 90 yrs old and was confused and had just had surgery. I used risk for falls r/t confusion and weakness. We have to have 1 long term goal which I used Pt will remain free from falls and 3 short term goals. I am having a hard time coming up with those 3 short-term goals. Help would be much appreciated. THANKS!!