Interactive Care Plan

Nursing Diagnosis: (Problem [NANADA] Statement; R/T; AEB)

Risk for falls r/t hypotension, bradycardia AEB Norco pain medication 5 mg PO for pain; Hydrocodone 5/325 mg Q3h for pain PRN (maternal)
Nursing Goal: (A patients behavior that is measurable, realistic, and specific that will occur in a specific time frame)

Mother will have no incidences of falls by discharge

DEFINING CHARACTERISTICS
Patient signs & symptoms and risk factors

NURSING INTERVENTIONS
Include the following and be specific: Assess, Do, Teach, Refer (i.e. VS every 4 hours, IS every hour, specific labs, etc.) Assess pain level prior to ambulation

NURSING RATIONALE
Explain the rationale for doing this intervention Assessing patients pain level will allow nurse to determine adequate amount of pain medication to administer to patient. By knowing the proper pain level and being able to determine which pain medication may work best; nurse will help to alleviate possibility of falls due to side effects of medications Administering pain medication 30 minutes before ambulation will help to reduce possible side effects during ambulation A gait belt is a helpful tool in preventing falls. It allows for the care giver to be able to hold on to the patient and aid in ambulation, while giving them an adequate tool to prevent a fall.

PATIENTS RESPONSE
The patients response/or findings of each nursing intervention that supports the nursing diagnosis and goal (i.e. lab values, VS values, decrease in shortness of breath, etc.) Patient pain level reduced to a 3/10. Patient shows no signs of dizziness, fatigue, or confusion.

OBJECTIVE:
Norco Pain Medication Hydrocodone Pain Medication Side effects of pain medication include dizziness, fatigue, confusion, unbalance, hypotension, bradycardia

Give pain medication 30 minutes prior to ambulation activities

Patient received pain medication 30 prior to ambulation; ambulating in hall with no signs of dizziness, or fatigue. Patient has no complaint of pain.

Do get patient up with assistance and gait belt during ambulation

Patient ambulated 30 feet with gait belt on. No signs of distress, or fatigue. Responded well to ambulating. Complains of no pain.

Explain to patient the importance of using call light when needing to get out of bed

SUBJECTIVE:
Patient stating any of the following: Feel dizzy, unsteady or tired

Assess patient VS; especially heart rate and blood pressure every 4 hours

The call light is an important tool in keeping the patient safe. When a patient needs something, or is needing to get up out of bed, the call light allows for someone to see the patient is in need of help. This will keep the patient from falling while getting in and out of bed, or ambulating or bathroom Vital signs especially heart rate and blood pressure are easy tools to help evaluate signs of hypotension, and bradycardia. Vital signs should be taken on a regular basis throughout day; usually every 4 or every 6 hours. Depending on symptoms they also may be done as soon as every 2 hours.

Patient used to call to get assistance to bathroom. Call light was returned to bedside, in reach by patient.

Assessed vital signs at 1400: HR 75, B/P 114/75; No signs of bradycardia, or hypotension. Patient is ready to ambulate hall.

Goal Evaluation: (met, partially met, not met) Met

Patient was able to control pain without showing any signs of hypotension, bradycardia, dizziness or fatigue. No new falls occurred prior to discharge of patient on 4/9/2012.