Name: Patient C Date of Admission:

Age: 80/M Attending Physician:

DATE/ CUES DIAGNOSIS GOALS INTERVENTIONS RATIONALE EVALUATION

TIME

3/16/20 Subjective: Risk for falls Within the span of 4 INDEPENDENT INDEPENDENT: Within the span of
24 @ - Patient related to hours of care the 4 hours of care
8am shows muscle patient will be able 1. Remove clutter 1. Clear pathways the patient able
shakiness weakness and to: and obstacles reduce tripping to:
indicating impaired from pathways hazards,
muscle mobility. 1. Demonstrate to create clear promoting safer GOAL MET
weakness improve and wheelchair
stability and unobstructed navigation. 1. Demonstr
- Decrease safety. paths for ated
d activity wheelchair 2. Properly fitted improved
tolerance 2. Environment navigation. wheelchairs stability
will be enhance stability and safety.
Objective: modified to 2. Provide the and support,
- Presence reduce fall patient with reducing the risk 2. Modified
of wound risk and appropriate of falls. environme
at his right promote assistive nt
lower leg. safety. devices such 3. Ongoing resulting in
as a evaluations help reduced
3. Remain free wheelchair with detect changes fall risk
from falls proper seating in fall risk, and
support and allowing for promoted
footrests to timely safety.
enhance intervention.
mobility and 3. Remained
stability. free from
COLLABORATION: falls.
3. Regularly 1. Regular reviews
assess the with the
patient's healthcare team
 mobility, ensure
balance, and continuous
cognitive assessment and
function to modification of
identify the care plan.
changes in fall
risk over time. 2. Working together
to modify
medications
COLLABORATION: minimizes side
1. Schedule effects that could
follow-up increase fall risk
appointments while managing
with the medical
healthcare conditions
team to review effectively.
progress,
reassess fall
risk, and
modify the care
plan as
needed.

2. Collaborate
with the
healthcare
team to adjust
medications or
dosages as
needed to
minimize fall
risk while
managing
underlying
medical
conditions.