Sample Nursing Assessment

Great Essays
Nursing Diagnosis:
Risk for impaired mobility related to arthritic pain, activity intolerance, and anxiety as evidenced by patient pain score of 5 out of 10 and patient fatigue score of 8 out of 10 on worst days, and patient verbalization of fear of falling.

Measureable Outcomes:
1. Arthritis pain reduced to a maximum 2 out of 10 on pain scale
2. Fatigue between transfusions reduced to a maximum 3 out of 10 on pain scale
3. Performs resistance and strength training exercises for 8 muscle groups devised by a physical therapist at least two times each week.
4. At minimum, patient will maintain Katz, Lawton, and TUG scores measured after three month intervals to indicate a maintenance of functional ability.
5. Eliminate incontinent episodes
…show more content…
Age-related changes increase the risk of falls, disability, injury, and osteoporosis. In order to reverse this problem or maintain remaining strength, an increase in routine physical activity as guided by a specialist is crucial (Smith, 2012).
2. Environmental modifications like minimizing clutter, installing grab bars in the shower or tub or near the toilet and installing non-slip decals on slippery surfaces, improving light, and adding color contrast between steps are affective household measures that can be taken to help prevent falls in older adults (Moylan, 2007).
3. Older adults who have had a previous fall, with or without sustained injury, may develop a fear of falling. This can lead to a decrease in participation in activities, leading to further reduced mobility and physical fitness, which in turn, increases their risk of falling and injury. A fall risk assessment should be performed, alteration of environment, and education on safe mobility should made in order to reduce the fear and risk of falls in the older adult (CDC, 2008). The Falls Efficacy Scale-International (FES-I) measures the level of concern an individual has about falling during various activities The level of concern is measured on a four point Likert scale and can be used to develop a baseline measure and manage aspects of concern (Yardley et al.,

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