Falls Care Plan Scenario #1
Directions: Read the scenario below and use the information to formulate an individualized care plan using the template provided. Use your Nursing Diagnosis textbook by Ackley to determine if the nursing diagnostic stem is appropriate for your patient. Remember to use a three-part nursing diagnostic statement. Use SMART goals and interventions that are specific to the patient. Use your imagination for the evaluation portion. Make use of your resources, like the nurse tutor for this assignment. This assignment is worth 10 points.
Your patient is an 84-year-old male who resides in an assisted living apartment along with her husband. Today she feels weak which caused her to fall. She has been admitted to the hospital for dehydration and a urinary tract infection. She has a past medical history of incontinence, weakness, depression, dementia, arthritis, and insomnia. She has a walker but frequently forgets to use it. The daughter states she stopped by her apartment today and found the unit very cluttered with boxes and stacks of magazines. Upon questioning, the nurse learned that her patient appears to becoming more forgetful and the daughter is wondering if her mom is still safe at home.
Question 1: What are the primary reasons your patient is falling?
Question 2: What is the key focus to preventing future falls in your patient?
Now, take this information and determine the priority nursing diagnosis.
Nursing Care Plan
| Nursing Care Plan #1 | |||||
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Assessment (Supporting data for nursing diagnosis) |
Nursing Diagnosis (Three part statement) |
Goal / Outcome (One SMART short-term & long-term goal) |
Interventions (4-6 for each goal)
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Rationale for interventions (Cite your source.) |
Evaluation (Goal met, partially met, not met and why/why not?) |
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Subjective data:
Objective data:
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Nursing Diagnosis:
Etiology (related to):
Defining characteristics (as evidenced by): |
A.
B. |
A 1:
A.2:
A.3:
A.4:
B.1:
B.2:
B.3:
B.4: |
A.1:
A.2:
A.3:
A.4:
B.1:
B.2:
B.3:
B.4:
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A.
B. |
