Public Display of Affection

Nursing Care throw Student Name/Date __Nicole Reinke/ Week 5_____________ Nursing Diagnosis evaluate Outcomes Nursing Interventions/ principle Outcome Evaluation (Dx, related to, &038 as show by) (Short term (8-48 hr. ) average expectations List each(prenominal) interventions for each nsg. dx (include patient/family (Patient essence noted as met or unmet/responses stated in measurable, behavioral terms, i. . , learn) described) accomplish verbs) Risk for injury r/t seizures amb gait and balance thickening go away remain free from falls piece in the control allow make genuine that the call light is always in reach so This outcome of remaining fall free was met while dis coiffures. infirmary. that the customer does not have to be concerned roughly not knowing I was at the hospital. Everytime I went into the where the call light is when needing help. populate I made sure the call light was on her dining table Nure will place a High Risk for Falls score above knobs bed soand the walker was coterminous to the bed. thickening also that any person that comes into the room to help assist is apprised reported no falls. of the safety measures that need to be taken. Nurse will determine risk for falls using the evaluation tool which includes client history of atrial fibrillation. Nurse will place the walker approach the bed to remind client to use walker when getting up to go to the bathroom. Nurse will explain how to use the walker, by moving walker first and then move body to make sure client knows how to use the walker. Nurse will also school the client the importance of using the walker when walking through the halls in order to prevent future This outcome of using the walker was partially Client will use a walker while in the hospital tofalls, this will also help promote activity and will possess the met. When reminded the client would use the get to the bathroom in order to represent safety. client something else to do instead of laying in bed all day. walker but admitted not using it all the time. After teaching her the importance of using the walker and what could happen if she fell she said she would gauge to make it a habit. Nursing Diagnosis Expected Outcomes Nursing Interventions/Rationale Outcome Evaluation (Dx, related to, &038 as evidenced by) (Short term (8-48 hr. ) reasonable expectations List all interventions for each nsg. dx (include patient/family(Patient outcome noted as met or unmet/responses stated in measurable, behavioral terms, i. e. teaching) described) action verbs) 3. Client will be educated on how to reduce Nurse will judge for additonal factors leading to risk for This outcome was not fully met. I asked about risk of falls at home. falls because sometimes medications can growth risk for her house and the ha zards that were there for falls. falls but I wasnt able to talk about using 2.Nurse will teach the client the benefit of using nonskid nonskid rugs or bathroom devices. exactly she rugs and safety devices in the bathroom. This is important to understands the importance and will ask her teach so that the client can recognize clutter and slippery girlfriend and physican when she is discharged. floors. 3. Nurse will instruct client and daughter how to correct set hazards to make sure everything that could cause a fall is prevented.