nursing diagnosis - Risk for falls related to difficulty with gait/ osteoarthritis
| interventions | Rationales |
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Ans) Risk of fall: Interventions with Rationale:
1) For patients at risk for falls, provide signs or secure a wristband identification to remind healthcare providers to implement fall precaution behaviors.
Rationale:
Signs are vital for patients at risk for falls. Healthcare
providers need to acknowledge who has the condition for they are
responsible for implementing actions to promote patient safety and
prevent falls.
2) Transfer the patient to a room near the nurses’ station.
Rationale:
Nearby location provides more constant observation and quick
response to call needs.
3) Move items used by the patient within easy reach, such as call
light, urinal, water, and telephone.
Rationale:
Items that are too far from the patient may cause hazard and can
contribute to falls.
4) Respond to call light as soon as possible.
Rationale:
This is to prevent the patient from going out of bed without any assistance.
5) See to it that the beds are at the lowest possible position.
Rationale:
6) If needed, set the patient’s sleeping surface as adjacent to the floor as possible.
Rationale:
Keeping the beds closer to the floor reduces the risk of falls and serious injury. In some healthcare settings, placing the mattress on the floor significantly reduces fall risk.
7) Use side rails on beds, as needed. For beds with split side rails, leave at least one of the rails at the foot of the bed down.
Rationale:
According to research, a disoriented or confused patient is less
likely to fall when one of the four rails is left down.
8) Avoid the use of restraints to reduce falls.
Rationale:
Studies demonstrate that regular use of restraints does not reduce
the incidence of falls.
9) Guarantee appropriate room lighting, especially during the night.
Rationale:
Patients, especially older adults, has reduced visual capacity. Lighting an unfamiliar environment helps increase visibility if the patient must get up at night.
10) Encourage the patient to don shoes or slippers with nonskid soles when walking.
Rationale:
Nonskid footwear provides sure footing for the patient with
diminished foot and toe lift when walking.
11) Familiarize the patient to the layout of the room. Limit rearranging the furniture in the room.
Rationale:
The patient must get used to the layout of the room to avoid
tripping over furniture.
12) Provide heavy furniture that will not tip over when used as support when patient is ambulating. Make the primary path clear and as straight as possible. Avoid clutter on the floor surface.
Rationale:
Patients having difficulty in balancing are not skilled at walking
around certain objects that obstruct a straight path.
13) Bed and chair alarms must be secured when patient gets up without support or assistance.
Rationale:
Audible alarms can remind the patient not to get up alone. The use
of alarms can be a substitute for physical restraints.
14) Provide the patient with chair that has firm seat and arms on both sides. Consider locked wheels as appropriate.
Rationale:
When patient experiences weakness and impaired balance, this chair
style will be useful and easier to get out of.
nursing diagnosis - Risk for falls related to difficulty with gait/ osteoarthritis interventions Rationales 1. 2....
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