Nursing Diagnosis #1 (Safety): Protecting Patients from Harm

S: Alteration of the physical and cognitive status following a fall. Increased in falls in the last six months. 

O: changes in mental status leading to confusion and impaired judgment, physical changes like weakened muscles, flexibility and endurance. Sensory deficit, balance and gait and use of assistive devices like sticks ( Gulanick & Myers, 2012; C arpenito, 2013). 

Nursing Diagnosis # 1 (Psychological): 

1 Risk for falls R/T Altered Mental Status change AEB confusion 

Aetiology: Falls can cause physical harm and the risk of serious injury. Falls lead to injury and accidental death. Injuries can include fractures, soft tissue and traumatic brain injury. Such injuries can lead to lengthened hospitalization and adverse effects on the quality of life. Adults who are older than 65 years are susceptible to falls with women recording higher falls compared to men. Falls can occur in community dwellings and nursing homes 

( Carpenito, 2013; Gamino et al., 2018 ). 

STG#1: Patient will relate controlled falls by not sustaining a fall and implementing strategies to prevent falls and increase safety. 

LTG#1: Patient relates no falls by using safety measures and demonstrates selective preventive measures to prevent falls (Carpenito, 2013). 

STG #1 is met as the patient was determined to take preventive measures to reduce falls and increase safety. 

LTG#1 partially met since the patient demonstrates preventive measures aimed at reducing falls. However, the patient does not use call lights and bedside bells. 

The patient is aware of the safety measures and the location of other social amenities like bathrooms and bed controls. 

The nurses secured a wristband on the patient’s arm. The patient and healthcare professionals have developed and implemented strategies for behaviour change to reduce or prevent falls. 

The patient engages in frequent exercises and gait training with the assistance of the nurses and social workers ( Gulanick & Myers, 2012; C arpenito, 2013). 

Interventions 

Orient, the patient on the safety measures and their environment, including social amenities and bed control. –Nurses and social worker 

Secure a wristband or provide signs for identification to ensure that healthcare provider implements behaviours that will reduce or prevent falls –Nurses. 

Encourage patient to participate in regular exercises and gait training programs –Nurses and Social worker ( Gulanick & Myers, 2012; C arpenito, 2013). 

Implementations:( 6) with rationale: 

The nurses and social workers provided the patient with an orientation of safety measures, including wearing nonslip shoes, call bells, bed controls, and evaluated the bed and pathways for obstacles and hazards. 

Rationale: The patient should be aware of the safety measures and other social amenities in the hospital to enhance their stay and reduce incidences of falls 

The nurses tied a wrist band on the patient's arm to enable nurse s assistants and social workers to identify the patient and implement strategies suitable for preventing a fall. 

Rationale: Identification signs are critical for patients who are susceptible to falls. It helps healthcare providers to know patients with the condition to implement actions that can promote the safety of a patient and reduce or stop falls. 

The nurses and social workers allowed the patient to participate in regular exercises and gait training. 

Rationale: Exercises are essential for the body and health of the patient. They improve the patient’s balance, increase the density of the borne, strengthen their muscle, increase physical conditioning, reduce falls and injury if the patient falls 

( Carpenito , 2013; Gulanick & Myers, 2012).