NURSING CARE PLAN

Pt Initials

G. C

Age:

72 years

Gender:

Female

Occupation:

Retired bus driver

Admit Date:

Physician:

Medical Diagnoses: Risk for fall, Risk for infection, Imbalanced Nutrition

FAMILY STATUS: mother of one daughter

HOME ENVIRONMENT: lives alone in her house

ALLERGIES: NKA

CODE STATUS - DNR/LIVING WILL: none

IDENTIFY 3 NURSING ISSUES IN ORDER OF PRIORITY

1. Patient fall 3 times in the past month

2.

3.

IDENTIFY 1 NANDA LABEL FOR EACH OF THE 3 NURSING ISSUES

1. Risk for fall

2. Risk for Infection

3. Imbalanced Nutrition

NURSING DIAGNOSTIC LABEL: NANDA

(Use Priority 1 issue)

Risk for fall

NURSING DIAGNOSIS (Complete Diagnosis)

(Use Priority 1 issue)

Risk for fall as evidence of hypotension previous patient fall three times

GOAL (1)

Patient will use safety measure to prevent fall.

OUTCOME STATEMENT

(Write 1 Outcome Statement, use “SMART”

Pt will be free for fall during her hospitalization

NURSING INTERVENTIONS