UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
ASSESSEMENTS
(Subjective/Objective Data
pertinent to this nursing
diagnosis)
Subjective:
“I get dizzy when I
stand up.”
“My vision has
started to get blurry.”
“I have sciatica, so I
have pain in my back
and legs.”
“I get SOB when I
walk for too long.”
“I have some kind of
arthritis from being
old.”
“I use a cane, but I
can’t walk too far.”
“I am serious as a
heart attack my pain
is 11/10.”
“I can’t get any sleep
because people keep
coming in here.”
“I smoked cigarettes
for 60 years.”
Objective:
79 years old
Unstable gait
RLE:1/5
LLE: 1/5
Shallow breathing
depth.
NURSING DIAGNOSIS
NANDA diagnosis? Related
factors noted? Evidence if an
“actual” problem?
Risk for falls AEB risk
factors such as:
79 years old
“My vision has started to
get blurry.”
I get dizzy when I stand
up.”
“I have some kind of
arthritis from being old.”
“I can’t get any sleep
because people keep
coming in here.”
Use of assistive device.
Unstable gait
On many different types
of pain medications.
RLE: 1/5
LLE:1/5
Student Name: Makaela Etheridge
ADULT HEALTH NURSING
NURSING PLAN OF CARE
NURSING INTERVENTIONS EVIDENCE SUPPORTING PRACTICE
Administering, demonstrating and
performing treatments, & teachings (Cite source: Author & Page #) List full
pertinent to diagnosis)
Ongoing Assessments:
1. Assess mood, coping
abilities, and
personalities styles
during initial
assessment (a-c).
2. Evaluate the patients
muscle strength, gait,
and standing balance
using the “times get
up and goq 4 hours
(a-c).
3. Assess the patient
using a fall risk
assessment tool like
the Johns Hopkins
Hospital Fall Risk
Assessment Tool q 4
hours. (a-c).
Prioritized Interventions:
1. Review the patient’s
medication regimen
and how it will affect
them. Teach the
patient about the use
of pain medications
and how to prevent
falls while taking
them. (a-c).
2. Implement needed
interventions and
Date: 2/3/2021
IMPLEMENT
ATION
EVALUATION
Explain how
(Rationale) State outcome achievement in
interventions
behavioral terms. Note: Continue ,
were met or
reference separately. Change (specify), Discontinue POC
explain why
they were not.
1. “An individual’s temperament, Evaluate achievement of patients
typical behaviors, stressors, and goals and objectives:
level of self-esteem can affect
attitude toward safety issues,
resulting in carelessness or
increased risk taking without
consideration of consequences
(Doenges et al., 2019, p. 311).
1. “The TUG test is a simple and
quick clinical, performance-
based measure of lower
ectremity function, mobility, and
fall risk useful even with healthy
adults” ((Perry, Potter,
&Ostendorf, 2017, p. 343).
2. “Fall risk scales are widely used Evaluate the effectiveness of each
intervention:
in acute and long-term settings
and include numbered rating
scales that place the client in risk
categories (from low to high)”
(Doenges et al., 2019, p. 311).
2. “The use of certain medications
(e.g., narcotics/opiates,
psychotropics,
antihypertensives, and diuretics)
can contribute to weakness,
confusion, and balance and gait
disturbances” (Doenges et al.,
2019, p. 312).
3. “Safety begins with a patient’s
immediate environment. Always
Identify indicated changes to the
keep a need in the low positions
POC: (May write on the back of
and a bed alarm activated and
this page)
use necessary fall prevention
strategies. The call light/bed
control system allows patients to
adjust bed positions and signal
care givers for help” (Perry,
Potter, &Ostendorf, 2017, g.
340)
4. “Teach older adults about the
 UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING Student Name: Makaela Etheridge
ADULT HEALTH NURSING
NURSING PLAN OF CARE Date: 2/3/2021

COPD OUTCOME STATEMENTS safety measures like need to be aware on safety

Measurable? Realistic? Time precautions to prevent accidents
Sciatica placing the bed in the
element noted? Pertinent to such as falls…Home
Wheezing on diagnosis? lowest position with modifications may help prevent
auscultation three side rails up, falls. Collaborate with the older
By 2/5/2021 at 1800 the bed alarm on, teach adult, family, and significant
SOB all the time. patient will have a others when recommending
how to use the call
Uses assistive reduced risk for falls light, and how to use
useful changes to prevent injury”
(Ignatavicius et al., 2020, p. 57-
device. AEB: assistive devices 58.”
Acetaminophen correctly. (a-c).
650 mg q 4 hrs
3. Provide the patient
PRN a. Be free of injury.
with educational
Morphine 2 mg/mL b. Verbalize resources like a home
q 6 hrs PRN understanding of safety checklist,
Norco 200 mg q 6 ways to prevent equipment directions
hrs PRN fall and understand
for use, and webs
of the risk factors
Percocet 1 tab 5- that cause falls. sites for review and
325 mg q 4 hrs c. Patient will reinforcement of
PRN implement learning(a-c).
measures to
increase safety and
prevent falls in the
home.

List a minimum of two references to indicate interventions are derived from and supported by evidence-based practice. References are to be documented in APA format.
 UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING Student Name: Makaela Etheridge
ADULT HEALTH NURSING
NURSING PLAN OF CARE Date: 2/3/2021

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. (15th

ed.). F. A. Davis.

Ignatavicius, D. D., Workman, L. M., Rebar, C. R., Heimgartner, N. M. (2020). Medical-Surgical Nursing: Concepts of Interprofessional and
Collaborative Care. (10th ed.). Elsevier.

Perry, A. G., Potter, P. A., & Ostendorf, F. A. (2018). Clinical nursing skills and techniques. (9th ed.). Elsevier.