The top priority nursing diagnosis for patient S is risk for falls related to impaired balance as evidence by leaning to the left while walking, left sided weakness, and unfamiliar environment. An outcome for this diagnosis is the patient will remain free of falls by discharge.
The nurse will assist the patient when ambulating. Be sure to lock the bed, wheelchair, or recliner when standing up. When rising, have the patient change positions slowly, dangle the legs, and stand by the bed before walking to avoid orthostatic hypotension. The patient will be required use a walker and gait belt while ambulating and walking with one person at all time because of left-sided weakness. The nurse must walk behind the patient and monitor his balance …show more content…
Communicate with staff to also alert staff for the increase risk of falls. This will allow other staff such as nurses, physical therapy, occupational therapy, or certified nursing assistants (CNAs) to ambulate the patient safely and knowledge that there is risk for falls. A chair alarm and bed alarm will also be used. This will alert the staff if the patient tried to ambulate by himself. The patient should be encouraged to ‘call, don’t fall’ and allow staff to assist with ambulation to prevent falls. Although the goal the patient wishes to reach is independence, the patient must be educated that falls can result in injury to the patient and sometimes to caregivers, as well as increase health care costs through management of those injuries and potential for increased length of stay (Bergman & Papendick, …show more content…
According to Ruggiero, Smith, Copeland, and Boxer, before discharge, the nurse should check medications to “identify discrepancies, such as medication omission, duplication, change in frequency, change in dose, adjustments, new medications not accompanied by a prescription, or omission of core measures.” This is referred to as a discharge time out. If the nurse is not confident about medications, the nurse can ask a pharmacist to help. This discharge time out ensures that patients are discharged to home with the correct medications list (Ruggiero, Smith, Copeland, & Boxer, 2015).
Success will be determined if the patient uses handrails and grab bars as needed, use an assistive device such as a walker correctly, clutter and spills from the floors, and correctly transfer while using safe transfer procedures. These procedures will keep the patient safe and prevent the patient from falling (Ackley & Ladwig,
The nurse will assist the patient when ambulating. Be sure to lock the bed, wheelchair, or recliner when standing up. When rising, have the patient change positions slowly, dangle the legs, and stand by the bed before walking to avoid orthostatic hypotension. The patient will be required use a walker and gait belt while ambulating and walking with one person at all time because of left-sided weakness. The nurse must walk behind the patient and monitor his balance …show more content…
Communicate with staff to also alert staff for the increase risk of falls. This will allow other staff such as nurses, physical therapy, occupational therapy, or certified nursing assistants (CNAs) to ambulate the patient safely and knowledge that there is risk for falls. A chair alarm and bed alarm will also be used. This will alert the staff if the patient tried to ambulate by himself. The patient should be encouraged to ‘call, don’t fall’ and allow staff to assist with ambulation to prevent falls. Although the goal the patient wishes to reach is independence, the patient must be educated that falls can result in injury to the patient and sometimes to caregivers, as well as increase health care costs through management of those injuries and potential for increased length of stay (Bergman & Papendick, …show more content…
According to Ruggiero, Smith, Copeland, and Boxer, before discharge, the nurse should check medications to “identify discrepancies, such as medication omission, duplication, change in frequency, change in dose, adjustments, new medications not accompanied by a prescription, or omission of core measures.” This is referred to as a discharge time out. If the nurse is not confident about medications, the nurse can ask a pharmacist to help. This discharge time out ensures that patients are discharged to home with the correct medications list (Ruggiero, Smith, Copeland, & Boxer, 2015).
Success will be determined if the patient uses handrails and grab bars as needed, use an assistive device such as a walker correctly, clutter and spills from the floors, and correctly transfer while using safe transfer procedures. These procedures will keep the patient safe and prevent the patient from falling (Ackley & Ladwig,