VII.

NURSING CARE PLAN RISK FOR FALL R/T DECREASE MOBILITY AS EVIDENCE BY UNSTEADY WALKER SECONDARY TO EXTREME OF AGE NURSING SCIENTIFIC NURSING ASSESSMENT OBJECTIVES DIAGNOSIS EXPLANATION INTERVENTION Subjective Risk for fall The body of an Short Term: r/t decrease elder become 1.client will 1.identify factors States feelings mobility as weaker due to identify factors that may cause or of dizziness evidence by decrease in bone that increase contribute to injury States fear of unsteady gait mass and poor potential for from a fall falling and use of a muscle tone injury by the walker leading to end of the day secondary to unsteady gait and 2. remain free of 2. routinely assist extreme of decrease mobility falls per shift the client in toileting age that is a causative on her own schedule factor of fall Objective Extreme of age Unsteady gait Use of walker History of falls Lives alone 2.Client will make necessary physical changes in environment to ensure increased Long Term: 1. client will not experience any falls during stay 1. Orient client to environment. Assess ability to use call bell, side rails, and bed controls. 2. make changes in clients environment that may cause or contribute to injury

GAIT AND USE OF RATIONALE 1. Increase client awareness EVALUATION Client is able to verbalize an understanding of risks factors for falls Client did not experience any falls per shift

2. keep path to the bathroom clear, leave the door open, falls are often linked to the need to eliminate in a hurry 1. These measures will help the client to cope with an unfamiliar environment 2. to increase clients awareness

Client did not experience falls to current

Client verbalized a plan to make changes at home to ensure safety

safety within first week of returning home

1. DECREASED CARDIAC OUTPUT RELATED TO SYSTEMIC VASCULAR RESISTANCE AS EVIDENCED BY PALENESS AND PROLONGED CAPILLARY REFILL TIME OF 3 SECONDS NURSING SCIENTIFIC NURSING ASSESSMENT OBJECTIVES RATIONALE EVALUATION DIAGNOSIS EXPLANATION INTERVENTIONS Subjective: Decreased In DM type 2, After 1-2 hours > Monitor vital signs > To not response After 1-2 hours, > Balamu Cardiac high glucose of nursing frequently. to activities or Mrs. Sugar was mag-palpitate Output levels in the blood interventions, interventions. able to identify ku lagi related to irritate the lining the patient will signs of cardiac systemic of the arteries be able to > Keep client on bed > Decreases decompensation, Objective: vascular which then identify signs of or chair rest in position oxygen alter activities, > prolonged resistance as promotes the cardiac of comfort. consumption and and seek help capillary refill evidenced by accumulation of decompensation, risk of appropriately of 3 seconds paleness and plaque. When the alter activities, decompensation. prolonged inside of the and seek help > poor skin capillary artery is blocked appropriately > Administer fluid > To minimize turgor refill time of by plaque, the replacements. dehydration and 3 seconds blood supply to dysrhythmias. > appears pale that area is reduced or is > Monitor rate of IV > To prevent > pale completely drugs closely. overdose. palpebral blocked. conjunctiva Reduction in > Decrease stimuli; > To promote cardiac output and provide quiet adequate rest. > dry mucous oxygen delivery environment. membranes to the tissues is followed by > Instruct client to > These can cause vasoconstriction avoid or limit activities changes in cardiac that raises that may stimulate a pressures and/or systemic vascular Valsalva response like impede blood flow. resistance to bearing down during preserve systemic bowel movement.

arterial pressure while maintaining regional O2 availability.

> Provide psychological support. Maintain calm attitude, but admit concerns if questioned by the client.

> Honesty can be reassuring when so much activity and worry are apparent to the client.