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Visit Nrsngcomcriticalthinking For Additional Help With Care Plans Visit Nrsngcomcriticalthinking For Additional Help With Care Plans Visit NRSNG.com/CriticalThinking for additional help with Care Plans and Critical Thinking Nursing Diagnosis Patient Goals Intervention: Rationale Implementation (Yes or No) Evaluation Outcome Visit NRSNG.com/CriticalThinking for additional help with Care Plans and Critical Thinking EXAMPLE: Nursing Diagnosis Patient Goals Intervention: Rationale Implementation (Yes or No) Evaluation Outcome Diagnosis: High risk for falls related to confusion as evidenced by disorientation to place, time, situation, unsteady gait, generalized weakness Subjective Data: Patient asking, “who are you again?” Multiple family stated, “he doesn’t seem right” Patient stated, “I feel weak when I get up” Objective Data: History of dementia Set off bed alarm continually during night Requires walker for ambulation Patient will remain free from injury during this admission. Patient will remain free from falls during this admission. Patient will wear non-skid socks when out of bed: to provide stability during ambulation Patient’s bed alarm will be on at all times: to alert staff if patient is attempting to get out of bed independently Patient will be relocated to a room closer to the RN station: to enable staff to visualize patient on a more frequent basis Nurse will increase frequency of rounding: to assess needs more frequently, toilet more often, reorient. Yes Yes No Yes Patient utilized non-skid socks during all periods of ambulation, did need to be continually reminded, as he does not like socks, per his report. Will continue to promote. Patient’s bed alarm was on consistently throughout shift and patient did set alarm off approximately 4-6 times. Will continue to have bed alarm on. Another confused patient occupied the room closest to RN station; will move if room becomes available. Patient rounded on q 30 min or q 1 hour. Noted that patient became agitated w

Dr. Jack HW Helper · Accepted Answer

Visit Nrsngcomcriticalthinking For Additional Help With Care Plans Visit Nrsngcomcriticalthinking For Additional Help With Care Plans Visit NRSNG.com/CriticalThinking for additional help with Care Plans and Critical Thinking Nursing Diagnosis Patient Goals Intervention: Rationale Implementation (Yes or No) Evaluation Outcome Visit NRSNG.com/CriticalThinking for additional help with Care Plans and Critical Thinking EXAMPLE: Nursing Diagnosis Patient Goals Intervention: Rationale Implementation (Yes or No) Evaluation Outcome Diagnosis: High risk for falls related to confusion as evidenced by disorientation to place, time, situation, unsteady gait, generalized weakness Subjective Data: Patient asking, “who are you again?” Multiple family stated, “he doesn’t seem right” Patient stated, “I feel weak when I get up” Objective Data: History of dementia Set off bed alarm continually during night Requires walker for ambulation Patient will remain free from injury during this admission. Patient will remain free from falls during this admission. Patient will wear non-skid socks when out of bed: to provide stability during ambulation Patient’s bed alarm will be on at all times: to alert staff if patient is attempting to get out of bed independently Patient will be relocated to a room closer to the RN station: to enable staff to visualize patient on a more frequent basis Nurse will increase frequency of rounding: to assess needs more frequently, toilet more often, reorient. Yes Yes No Yes Patient utilized non-skid socks during all periods of ambulation, did need to be continually reminded, as he does not like socks, per his report. Will continue to promote. Patient’s bed alarm was on consistently throughout shift and patient did set alarm off approximately 4-6 times. Will continue to have bed alarm on. Another confused patient occupied the room closest to RN station; will move if room becomes available. Patient rounded on q 30 min or q 1 hour. Noted that patient became agitated w

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