Family Support Assessment

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Nursing Diagnosis

Patient Goals Intervention: Rationale Implementation

(Yes or No)

Evaluation

Outcome

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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 when he had to use the bathroom during first rounding, therefore offered toileting with each visit and noted decrease in agitation. Will continue to round

frequently. Patient remained injury and fall free during this shift. Goals progressing.

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