STUDENT NAME:

DATE: 2/24/2015

COURSE: Nursing fundamentals

DATE OF ADMISSION:
5/5/2006

AGE:
74

WT: 152

CODE STATUS:

Chandra Carr
CLIENT INITIALS:
MS
HT:
53
RACE/ETHNICITY:

DNR
CULTURAL CONSIDERATIONS:

Hispanic
RELIGION/SPIRITUAL CONSIDERATIONS:
Catholic

OCCUPATION/HOBBIES/RECREATIONAL ACTIVIES:

Home Maker
LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc)
Assisted Living
SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics)
Tobacco

ALLERGIES:
Fish and apisol

ADMITTING MEDICAL DIAGNOSIS:

Obstructive chronic bronchitis with exacerbation
Definition:
condition that causes difficulty in breathing as a result of constant blocking of the airways
Etiology/pathophysiology:
Likely due to patients H/O tobacco use - can also be related to CHF

Common signs/symptoms:
Dyspnea, fluid retention

*Symptoms you assessed on your client*

Potential complications:
Respiratory infections, hypoxia, hypertension, cardiac problems, lung cancer, depression

SECONDARY MEDICAL DIAGNOSIS: (include pertinent preexisting diagnoses

such)
CHF

Definition:
Decreased function and strength of heart muscle

Etiology/pathophysiology:
CAD, MI, Cardiomyopathy, valve diseases, hypertension, DM, thyroid or kidney
disease, birth defects

Common signs/symptoms:
Congestion in lungs, fluid retention, weakness

*Symptoms you assessed on your client*

Potential complications:
Death, kidney failure, congestion, arrhythmias

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (What led up to this

admission?)
Why is the client in rehab or skilled nursing facility? What prevents them from
being home?
COPD, pt is unable to ambulate without assistance

PAST MEDICAL/SURGICAL HISTORY:

Tubal ligation and tonsillectomy

SURGERIES/MEDICAL PROCEDURES THIS ADMISSION: (include date performed

and explanation)
TL and tonsilectomy

COMPLICATION R/T TO ABOVE:

None
CONSULTS: (include date and reason for consult)
2/5/2015 Routine follow up

DIAGNOSTIC TESTS: (CT, MRI, CXR, U/S, EKG, etc.; include date, reason for test,
and results)

LABS:

Lab Test

Purpose

Normal Values

Client Results

Interpretation of Labs especially

Abnormal

*CBC* Complete Blood Count - evaluate hematologic system ad possible health problems
White Blood
Cell Count

4.1-10.4

8.7 Normal

Hemoglobin
Hgb (g/dL)

11.8-15.1

12.3 Normal

Hematocrit Hct
(%)

34.0-44.0

38.8 Normal

Platelet count
(L)

150-450

228 Normal

WBC (L)

*CBC* Complete Blood Count w/ Differential - specific white cell counts

Baso

40-100

Eos

100-300

Monos

40-100

Neutro

2,500-7,000

Lymph

1,700-3,500
*CMP* Complete Metabolic Panel-organ function/damage, electrolyte levels

Glucose (mg/dl)

74-106

155 High- but pt is diabetic so this may be

a normal value for her - probably
relatively controlled

Urea Nitrogen
(mg/dL)

7-18

31 High - sometimes increased in older

adults, or due to dehydration, related
to DM, use of diuretics or
antihypertensives

Creatinine (mg/
dL)

0.6-1.3

1.1 Normal

Sodium (mEq/L)

136-145

139 Normal

Potassium
(mEq/L)

3.5-5.1

4.2 Normal

Chloride (mEq/
L)

98-107

104 Normal

CO2 (mEq/L)

21.0-32.0

28.0 Normal

Albumin (g/dL)

3.4-5.0

2.8 Low - prolonged immobilization,

cirrhosis of liver, renal disorders,
malabsorbtion

Protein (Total)
(g/dL)

6.4-8.2

6.5 Normal

Bilirubin (mg/
dL)

0.2-1.0

0.30 Normal

Lab Test

Purpose

Normal Values

Client Results

Interpretation of Labs especially

Abnormal

Calcium (mEq/
L)

8.5-10.1

9.0 Normal

Alkaline
phosphatase
(ALP) (unit/L)

50-136

186 High - may be contributed to asthma

or perhaps drug or food allergy

AST (SGOT)
(unit/L)

15-37

12 Low - possible diabetic ketoacidosis

or due to use of aspirin

ALT (SGPT)
(unit/L)

12-78

28 Normal

GFR

52^2

Anion Gap
(mEq/L)

2-12

Osmolarity
(mOsm/kg)

280-300

7 Normal
298 Normal
Other Pertinent Labs

HbA1C

4.3-6.3

12.7 High - Uncontrolled DM

MEDS:

Medication (Brand
and Generic

Prescribed
Classification

Names)
Benzonatate

Dose, Freq,
Route

anti-tussive

Tessalon Perles

100mg one by
mouth twice
daily as
needed for
cough

Mechanism of
Action

Patient
Specific
Indications

Suppresses
cough through
a peripheral
action,
anesthetizing
cough
receptors also,
may suppress
transmission of
the cough
reflex

Cough

Depression

Side effects/Nursing
Implications
drowsiness, nausea,
constipation
Lung sounds, sputum
amount, swallow whole

Citalopram

SSRI

20mg one by

Inhibits CNS

Hydrobromide

Antidepressant

mouth once

neuronal

Monitor mental stability,

daily

reuptake of

suicidal thoughts HR and

serotonin

BP, LFT, CBC, sodium and

Celexa

N/V/D, dry mouth, insomnia

lithium Avoid alcohol

Clobetasol

clobetasol, bind Rash

to the
antiinflammatory topically to
glucocorticoid
perinatal area
receptor, which
complexes,
twice daily until
enteres the cell
rash has
nucleus and
modifies
resolved
genetic
transcription

skin thinning, impaired

Clonidine HCL

Anti-

0.1mg one by

Hypotension, dry mouth,

Duraclon

hypertensive,

mouth three

analgesic

times daily not

stimulates
Hypertension
alphaadrenoceptors
in the brain
stem. This
action results in
reduced
sympathetic
outflow from
the CNS
stimulates
enteric nerves
to cause
colonic mass
movements

nausea, diarrhea, fluid and

Propionate
Temovate

Corticosteroid

0.05% applied

to be
administered if
systolic
pressure is

wound healing, pigment

changes, dermatitis, edema
Hazard of toxicity in smaller
children,

constipation, drowsiness
Monitor BP, I&O, weight,
and for depression. Hold
OTC, do not consume
alcohol, stay hydrated

below 110
Dulcolax

Stimulant

10mg

Bisacodyl

laxative

suppository
one every 24
hours as

Constipation

electrolyte disturbances
Evaluate need, monitor for
Vitamin K absorption in pts

needed for

on anticoagulants, increase

constipation

fiber and fluid intake

Fentanyl patch

Analgesic,

50mcg/hour

Duragesic

narcotic

one patch
every 72 hours
applied to skin
as needed for
pain
management

Guaifenesin-

Expectorant

Binds with
Pain
stereospecific
receptors at
many sites
within the CNS,
increases pain
threshold,
alters pain
reception,
inhibits
ascending pain
pathways.

Sedation, circulatory
depression, cardiac arrest,
N/V respiratory depression
Monitor VS, closely monitor
respirations

100-10mg/5mL increases the

Cough
volume and
10mL by
reduces the
mouth ever 6
viscosity of
hours as
secretions in
the trachea and
needed for
bronchi allow
cough
cilia to carry
the loosened
secretions
upward

Nausea and drowsiness

Ipratopium Bromide Anticholinergic,

0.5-3(2.5)mg/

Nausea, cough, blurred

Arovent

antimuscarinic,

3mL one

broncodilator

inhalation

codeine
Robitussin Ac

every 6 hours
as needed for

inhibit vagallymediated
reflexes by
antagonizing
the action of
acetylcholine

COPD

COPD
Lantus

Antidiabetic,

100u/mL

Insulin glargine

long acting

35units

insulin

injected SQ
every morning

Monitor for fever, rash or

headache, increase fluid
intake

vision, urinary retention

Monitor respiratory status,
report treatment failure,
monitor changes in urine
output

lower blood
Diabetes
glucose levels
by stimulating
peripheral
glucose
uptake, and by
inhibiting
hepatic glucose
production.
inhibits lipolysis
in the
adipocyte, and
proteolysis,
and enhances
protein
synthesis.

Hypoglycemia, hypokalemia
Monitor for hypoglycemia,
withhold if hypokalemic,
monitor fasting glucose and
HbA1C

Lasix

Diuretic,

40mg one by

Furosemide

antihypertensive mouth once

daily

inhibits water
reabsorption in
the nephron by
blocking the
sodiumpotassiumchloride
cotransporter

Edema

Circulatory collapse,
hypokalemia, leukopenia,
aplastic anemia,
agranulocytosis, diuresis,
water and electrolyte
depletion
Monitor BP and vitals,
monitor for hypokalemia,
muscle cramps diziness,
I&O, glucose, monitor
weight, LABS - CBC, serum
and urine electrolyte, BUN,
glucose, uric acid

Lorazpam

Benzodiazepine

0.5mg one by

Ativan

sedative-

mouth every 8

hypnotic

hours as

anxiolytic

needed for
prophylaxis of
anxiety

Losartan

Angiotensin

100mg one by

Cozaar

receptor

mouth once

agonist,

daily

antihypertensive

binds to an
Anxiety
allosteric site
on GABA-A
receptors,
which
potentiates the
effects of the
inhibitory
neurotransmitte
r GABA, which
opens the
chloride
channel in the
receptor,
allowing
chloride influx
and causing
hyperpolerizati
on of the
neuron.

Drowsiness, sedation, N/V,

competitively
Hypertension
inhibits the
binding of
angiotensin II
to AT1 in many
tissues Inhibits
angiotensin II
vasoconstrictiv
e and
aldosteronesecreting
effects and
results in
decreased
vascular
resistance and
blood pressure.

Dizziness, muscle cramps,

hyper or hypotension
Supervise
ambulation,monitor for
mood alterations, CBC and
LFT, do not consume
alcohol, do not drive while
taking medication

UR infection, cough
Monitor BP at trough,
monitor CBC, electrolytes,
hepatic and renal function,
Black box warning for
pregnancy

Milk of Magnesia

Antacid, saline

30ml by mouth

Magnesium

cathartic

every 48 hours

Hydroxide

as needed for
constipation

Nitroglycerin

Nitrate

Nitrostat

vasodilator

the osmotic
force of the
magnesia
suspension
acts to draw
fluids from the
body and to
retain those
already within
the lumen of
the intestine,
stimulating
nerves within
the colon wall,
inducing
peristalsis.

Constipation

N/V/D, coma, complete

heart block, respiratory
depression
Evaluate need, Monitor
serum magnesium and
renal function, monitor HR

0.4 mg one tab nitroglycerin is

converted to
sublingual
nitric oxide
every 5
which activates
the enzyme
minutes for
guanylate
chest pain
cyclase and
stimulates the
maximum 3
synthesis of
tabs if chest
cGMP Then a
release of
pain
calcium ions
unresolved at
results in the
relaxation of
time of 3rd
the smooth
dose call 911
muscle cells
and
vasodilation.

Angina

Potassium Chloride Electrolyte

20meq one by

Hypopotasse

N/V/D, irritability, flaccid

ER

mouth twice

mia

paralysis, respiratory

Klor-Con

replacement

daily

Potassium is
the major
cation of
intracellular
fluid and is
essential for
the conduction
of nerve
impulses;
maintenance of
normal renal
function, acidbase balance,
carbohydrate
metabolism,
and gastric
secretion

Headache, orthostatic
hypotension, circulatory
collapse, dizziness, N/V,
anaphylaxis, palpitations,
tachycardia
Monitor LOC and heart
rhythm, supervise
ambulation, baseline BP
and HR

distress, cardiac
depression, arrhythmia, or
arrest, EKG changes in
hyperkalemia, VFib, Death
Monitor I&O, monitor for GI
ulceration, monitor cardiac
status, Frequent serum
electrolytes

Prednisone

Adrenal

5mg one by

Rayos

Corticosteroid

mouth once
daily

Spiriva

Bronchodilator,

Tiotrpium Inhalation antispasmodic,

antimuscarinic,

18mcg inhale
one cap per
day

anticholinergic

metabolizes in
the liver to its
active form,
then crosses
cell membrane
and binds to
cytoplasmic
receptors
resulting in
inhibition of
leukocyte
infiltration,
interference of
inflammatory
response,
suppression of
immune
responses, and
reduction in
edema or scar
tissue.

COPD

N/V, CHF, edema,

acts mainly on
M3 muscarinic
receptors
located in the
airways to
produce
smooth muscle
relaxation, thus
producing a
bronchodilatory
effect

Chronic

Dry mouth, dyspepsia,

airway

pharyngitis, rhinitis,

obstruction

sinusitis, UR infection,

cataracts, hypokalemia,
headache, insomnia,
delayed wound healing
Baseline BP, I&O, weight,
fasting glucose, and sleep
pattern, monitor bone
density, monitor withdrawal
symptoms, watch for
changes in mood LABSglucose, electrolytes, and
routine labs

chest pain, edema,

hypercholesterolemia,
hyperglycemia
WIthhold if angioedema
occurs, monitor for
tachycardia, urinary
retention, monitor for facial
swelling.

Symbicort

Adrenal

160-4.5mcg/

Budesonide and

corticosteroid,

ACT two puffs

formoterol

glucocorticoid,

twice daily

antiinflammatory

stimulation of
intracellular
adenyl cyclase,
the enzyme
that catalyzes
the conversion
of (ATP) to
(cyclic AMP).
Increased
cyclic AMP
levels cause
relaxation of
bronchial
smooth muscle
and inhibits the
release of proinflammatory
mast-cell
mediators

Obstructive

Headache, infections,

chronic

dizziness, palpitations,

bronchitis

hypertension, chest pain,

with

hypokalemia, N/V/D

exacerbation

Monitor for hypercorticism,

periodic serum potassium
do not drink or consume
grapefruit

Vital Signs

1000

Temp

1200

1600

98.2
Oral/Auxiliary/Rectal

Pulse

80
Apical/Radial/Pedal/Rhythm

Respirations

18
Rate & Quality

Blood Pressure

137/98

Oxygen Saturation
amount/Method

95%

Pain (0-10 scale):

Pain Goal:

Intak

0700

0800

090

1000

1100

1200

1300

1400

1500

25

50

IV
Tube Feed
PEG
Other
Outp
ut

Void

Foley
Bowel
Movement
Emesis
Other

Total
s

Dietary
Intake %
PO

Totals

50

HEAD TO TOE ASSESSMENT

System

Normal

Abnormal
General Survey

Appearance Well groomed

Behavior Appropriate to situation
Mental Status Memory intact
Affect appropriate
Mood Happy Approriate to situation
Speech Clear/Logical/Understandable
Weight 138lbs
Height 64 BMI 23.69
Cognitive Perceptual Neuro
Orientation:

Person Place Time Situation

Level of
Consciousness

Awake and responsive

PERRLA
Pupils:
Equal:
Round:
Reaction:
Reactive to light:
Accommodation:

Yes
Yes
Yes
Yes
Yes
Yes
Yes Bilaterally
Pain

Pain None
Scale
Pain Goal
Location:
Onset:
Variation:
Quality:
Aggravates:

Problem
Yes/No

Relieves:

P (Provocate/
Palliative)
Q (Quality/
Quantity)
R (Region/
Radiation)
S (Severity
Scale)
T (Timing)

Pain Intervention
PCA/PCE:

None

Location
Dressing
PO Intervention:
Non
Pharmacological:
Sleep/Rest
Quality &
Rested
Quantity of Sleep
Assistive
Devices

none

Safety
Sepsis Screen
Interventions
HEENT
Head/Face

Normocephalic/symmetrical

Eye

cloudy ring around cornea OU

Hx cataract sx OS

Pupil size

R 4mm

L 4mm

"

Ear

No drainage or pain

Nose

Septum midline

Throat

Moist
Color Pink color
Trachea Midline
Present

Teeth

Hearing Aid

Missing teeth
Yellow/discolored

Mouth
Intact Moist
Color of Mucous Pink
Membranes
Odor No
Tongue

Pink Moist No lesions

Neck

Supple - adequate ROM

Respiratory

Respirations Symmetric
Pattern Even & Unlabored
Respiratory Rate: 18
Respiratory Regular
Rhythm:
Breath Sounds: Clear throughout bilaterally
Location:
Cough: None
Sputum/ None
Secretions:
Color:
Oxygen: Room air
Pulse ox: 95%

Use of accessory No
muscles
Pain No
Other
Respiratory
Treatment
Cardiac
Heart Rhythm Regular Rate

Probable trigeminal PVCs

Heart Rate 80
Heart Sounds Normal S3 S2

S1 Murmur III

Peripheral
Edema Absent
Neurovascular
Pulses

Present
Radial
Pedal
Apical

VTE Screening:
Interventions
Access/Monitoring Devices
Type of Line:

None

Insertion Site:
IV Fluids:

none

TPN/PPN:
Blood glucose:
Coverage:
Blood glucose
ranges:

None

Gastrointestinal

Abdominal shape
Bowel Sounds
Last Bowel
Movement
How often
Consistency
Continent
Nausea/Vomiting

Symmetrical flat
Bowel Sounds present in all
four quadrants
2/21/2015 at 9:40am Regular
daily BMs
Formed brown
Continent
No Nausea No Vomiting

Palpation

Soft/Non tender

Interventions

None

Tubes Insertion
Site:
Tube feeding

none

Ostomy
None
Stoma
Stoma status
Nutrition
Diet

Regular diet
Breakfast % Ate 25
Lunch % Ate 50
Dinner % Ate 50
Genitourinary

Continent

Yes

Urine color

Yellow

Urine
characteristics

Clear

Stress insentience with coughing etc

Rarely incontinent
Regularly incontinent

Interventions Voiding on own

Signs of
infection No
Urine
Reproductive
Female
Menopause: post

Male

Surgical History:
Hysterectomy
Musculoskeletal
Activity Ad Lib

Ambulates with walker and has wheelchair

Posture
Ambulation
History of Falls
Interventions

Walker /Wheelchair

ROM LUE Full

RLE Full
LLE Full
RIGHT

Strength

very limited ROM in R shoulder

LEFT

ARM

LEG

4= normal strength, grip strong or good

pressure resistance can move, lift, and hold
extremity
3= grip weak and /or poor pressure
resistance lifts and holds, can move, lift and
hold extremity
2= weak grip or pressure resistance lifts
and falls back, can move and lift extremity
but cannot hold position
1= little or no grip or pressure resistance
moves on bed, cannot lift or hold
0= no movement

Pulses: Pulses present 2+

Radial
Popiteal
Dorsalis Pedis
Posterior Tibial
Homans: Negative Bilaterally
Edema: None
Pulses: Peripheral pulses should be compared for Edema: Assess by placing thumb over dorsum of the foot
rate, rhythm, and quality.
or tibia for 5 seconds:
0
1+
2+
3+
4+

Absent =A
Weak & thread= W
Normal
Full
Bounding =B

0
1+
2+
3+
4+

No Edema
Barely discernible depression, 2mm
A deeper depression (<5 mm) w/ normal foot &
leg contours
Deep depression (5-7 mm) w/foot & leg swelling
Deeper depression (>8 cm) w/severe foot and leg
swelling

Skin
Color Color appropriate for race/pink
Intact Intact
Temperature
Moisture
Skin turgor
Capillary refill
Nail beds (color &
angle)
Hair
Other:

Warm
Dry
No tenting
Regular < 2 seconds

Hygiene

Shower

Wounds/Incision

Wound on medial LLE eschar present

no signs of infection appears to
probably be healing well

Signs/symptoms
of inflammation/
infection

none

!
Interventions
Coping
Interventions Cooperative

NURSING
DIAGNOSIS
STATEMENT:

Excess fluid volume RT decreased cardiac output

Priority 1 of 3

Maslows Hierarchy Level: physiological

NURSING

OUTCOMES

Assessment focused NOC: Electrolyte

on NSG DIAGNOSIS balance, fluid balance,
kidney function

OBJECTIVE:

S.T. Goals:

LE pitting edema

1.

Decreased O2 sat

Decreased fluid
retention - edema by
next week

Hypertension
Weight gain

SUBJECTIVE:
SOB
Polydipsia

2.

INTERVENTIONS
NIC: fluid
management and
monitoring

1. Patient will have less

complaints of SOB
within a month long
period

RATIONALEs

EVALUATION

management and
monitoring fluid
will assist in
decreasing
overload
Short Term Goal:

1a Weigh daily

to monitor fluid
retention

1b Activity to
Exercises to
promote
prevent pooling of
movement of fluids fluid in legs
1c Implement fluid
and sodium
restriction as
ordered

to prevent further
retention of fluid

1a O2 therapy PRN
as ordered

to provide
adequate oxygen
at a higher
concentration

Increase O2 sat to 95 by
next week

L.T. Goal:

Ericksons: Maturity

1bAdminister
diuretic as ordered

to rid body of
excess fluid

1c provide sodium
restricted diet

prevent fluid
retention in lungs

1a reduce fluid in
lungs with
diuretics as
prescribed

to allow more
surface area for
oxygen exchange
in lungs

1b patient must
have
understanding of
necessity for
ordered therapy
and restrictions

to promote
compliance with
interventions

1c provide
scheduled rest
periods

to allow patient to
recover from
activities and take
slower deeper
breaths

Balance I&O, stable

body weight
improvement of
pitting edema in LE

Short Term Goal:

No sob and clear
lung sounds

Long Term Goal:

patient does not
complain of SOB
nor do they show s/
s of dyspnea

NURSING
DIAGNOSIS
STATEMENT:

Constipation RT inactivity

Priority 2 of 3

Maslows Hierarchy Level: physiological

NURSING
Assessment focused
on NSG DIAGNOSIS

OUTCOMES

NOC: Bowel elimination

OBJECTIVE:

S.T. Goals:

No formed stool in 2
days

1. Patient will have

formed stool within 48
hours

SUBJECTIVE:
Slight abdominal
pain, feeling of
fullness

INTERVENTIONS

NIC:Bowel
management and
training

Ericksons: Maturity
RATIONALES
Management will
decrease
discomfort felt by
patient as well as
additional
complication that
may result due to
constipation

1a Administer
laxative and/or
suppository as
ordered

to
pharmacologically
initiate a BM

1b Increase fluid
intake

prevent
constipation due
to lack of fluid

1c Provide a fiber
filled diet

promote regular
stools

2. Patient will
1a Educate patient
demonstrate knowledge on prophylactic
medications
of prevention methods
by end of day

to allow patient
knowledge and
access to
preventative
measures

1b Educate patient
on need for
hydration and
activity

encourage activity
and promote
patient
participation

1c Explain side
effects of
medications that
may decrease
bowel activities

to possibly
consider
alternatives or limit
PRN or
medications that
may not be 100%
medically
necessary

L.T. Goal:

1a Provide
to engage activity
physical therapy or that will encourage
ROM exercises to
BM
1. Constipation will
become a risk for by the promote activity
end of the month
1b Have a stable
allow for hydration
intake of fluid and
and dietary needs
fiber
to prevent
constipation
1c Attempt to limit
need for narcotic
medication

EVALUATION

To prevent
pharmacological
causes of
constipation

Short Term Goal:

Formed stool has
been passed

Short Term Goal: Pt

able to verbalize
need for prevention
and what steps will
benefit the
resolution of this
issue

Long Term Goal:

makes regular
bowel movements

NURSING
DIAGNOSIS
STATEMENT:

Risk for falls RT hx of falls and muscle dystrophy in LE

Priority 3 of 3

Maslows Hierarchy Level: safety

NURSING

OUTCOMES

Assessment focused NOC: fall occurrence,

on NSG DIAGNOSIS injury, balance,
coordination,

OBJECTIVE:

S.T. Goals:

Has had a fall within

the past month,
needs assistance
with ambulation,
muscle atrophy of
LE, uses wheelchair

1.Patient will
demonstrate use safe
ambulation and transfer
techniques by end of
day

INTERVENTIONS
NIC:body
mechanics
promotion,
exercise therapy,
fall prevention

EVALUATION

Knowledge and
practice of better
mechanics and
strengthening will
help to prevent
future falls

1a Assist patient in to limit opportunity

transfer to
for injury or fall
wheelchair
due to patient
ambulating without
supervision or
assistance
1b teach patient
safe ambulation

to allow patient to
have knowledge in
safety and why it is
important to have
assistance with
ambulation

1c Be sure proper
footwear is
provided for
patient

to prevent slipping
or stumbling due
to inadequate
footwear

help me out of bed

2. Patient will
1a Padded corners
demonstrate knowledge of hard surfaces
of injury prevention by
next week
1b Teach how to
avoid head trauma
with fall

1. Patient will not have

any additional falls for
the duration of their
stay

RATIONALES

Short Term Goal:

SUBJECTIVE:

L.T. Goal:

Ericksons: Maturity

to limit injury from

bumping into
sharp edges
To limit or
eliminate injury if
pt does have a fall

1c Instruct patient
to wear her
prescription
glasses when
ambulating

so that patient can

see clearly an
avoid running into
or stepping on
objects

1a Physical
therapy for
strengthening

to allow patient to
participate in her
own ambulation

1b assist with
ambulation

to allow pt to
ambulate without
risk or fall

Safe ambulation is
verbally and
physically
demonstrated by
patient

Short Term Goal:

Practices safe
ambulation and can
explain ways to
prevent injury
during a fall

Long Term Goal:

Has not fallen

1c Make frequently
in use objects
easily accessible
and minimize
clutter

to prevent patient
from reaching or
requiring
unnecessary
movement that
may lead to falls

References
Beckerman, J. (2014). Heart disease and congestive heart failure. Retrieved February 21, 2015 from http://www.webmd.com/
heart-disease/guide-heart-failure?page=7
Mayo Clinic. (2014). Diseases and conditions COPD. Retrieved February 24, 2015 from http://www.mayoclinic.org/diseasesconditions/copd/basics/definition/con-20032017
McLeod, S. (2007). Maslows hierarchy of needs. Retrieved February 24, 2015 from http://www.simplypsychology.org/
maslow.html
Wilkinson, J. (2014). Nursing Diagnosis Handbook. United States of America. Pearson Education.