Risk for Falls expected outcomes PLEASE HELP!!!

Esme12, ASN, BSN, RN · Jul 20, 2014

Welcome to AN! The largest online nursing community!

We are happy to help but we need what you think might be short term goals. You are third semester you should be pretty good at this by now. What NANDA resource are you using? What are your other needs for this patient.

RNstudent311 · Jul 21, 2014

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

RNstudent311 · Jul 21, 2014

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.

RNstudent311 · Jul 21, 2014

Thank you ESME12 for the links very helpful!!

Guests · Jul 21, 2014

RNstudent311 said:
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

#2 and #3 aren't goals... they are interventions...

What are some goals that will help be the bridge between here (fall risk) and there (free of falls)? That is, what kinds of things will indicate to you that you're making progress?

I'll give you a freebie... "The patient will consistently use the call light to ask for help ambulating to the bathroom."

Esme12, ASN, BSN, RN · Jul 21, 2014

RNstudent311 said:
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 won't 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.

looking at this I would chose different ND

Quote
My pt was 90 yrs old and was confused and had just had surgery.

I would choose

Chronic Confusion

Diarrhea

Risk for Falls

Ineffective Impulse Control

Risk for Infection

Risk for Injury

Impaired Memory

Impaired physical Mobility

For impaired skin integrity...what evidence do you have to support that?

Definition: Altered epidermis and/or dermis

Defining Characteristics

Destruction of skin layers; disruption of skin surface; invasion of body structures

Related Factors (r/t)

External

Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation

Internal

Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence

Does your patient have skin breakdown?

RNstudent311 · Jul 21, 2014

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.

RNstudent311 · Jul 21, 2014

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.

Guests · Jul 21, 2014

RNstudent311 said:
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

I'll start by saying that I suck at this stuff... but...

#2 sounds pretty good but #1 is not at all concrete... what are those behaviors to which you're referring?

smf0903 · Jul 21, 2014

I don't know if this will help or not, but we were always taught that when formulating goals for patients that they should be realistic and measurable. AND, the plan of care could be given to anyone else and could be followed to the "T" without you saying "oh, I meant such-and-such when I put that there", in other words, it should be unbelievably explicit and specific.

nurseprnRN, BSN, RN · Jul 25, 2014

RNstudent311 said:
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

Losing the passive voice frees you up to take ownership of the process and to give direction to those to whom you will delegate. Outcomes are patient-based.

Instead of, "Strategies will be implemented..." (by whom??), say, "Staff will (specify at least two or three things) to decrease patient's identified fall risk factors." If she's unsteady, you might say that staff will always use a gait belt, lighting will be good, she will never walk c fewer than two people, she'll have her glasses cleaned and on, she'll wear good footwear, what else can you think of? ... get the picture?

Instead of "Patient will be taught..." (by whom again??), say, "Patient will describe at least one fall prevention technique." Oh really? Will she? Well, she might. If she can't, then you get to think of another goal or a better way to teach her so she learns.

Those are OUTCOMES, not passive-voice descriptions of actions taken by some unnamed person. Saying that "Student nurse will teach patient..." isn't a patient outcome, it's a student outcome. ?