NURSING EXPECTED PATIENT ASSESSMENT ACTION TEACHING

DIAGNOSES OUTCOMES interventions: interventions: interventions:

(consider orders, (consider home
(note priority for Be sure they are S. (assess /
safety, allergies, regimens,
each below) M. A. R. T. (Specific, monitor for )
code status, fall procedures,
measureable,
(Be sure to use risk, etc.) discharge plan,
achievable/
related to and etc.)
attainable, relevant
as evidenced
and time-bound)
by)

Impaired Patient will increase 1) Assess for 1) Use gait belt 1) Teach patient
physical mobility distance walked signs of fatigue to help stabilize to walk at a
R/T age and without taking a while walking in patient and reasonable pace
decreased break by 5 feet order to prevent prevent patient in order to
muscle strength every day for the falls. from falling. stabilize gait and
AEB unstable next 3 days, ending conserve energy.
2) Monitor 2) Follow with
gait, use of 10/12/17.
distance walked wheelchair or 2) Teach patient
walker or
before needing place chairs to properly use
wheelchair,
to take a break along the way in walker when
difficulty
and record the case the patient walking and
transferring
distance so needs to rest. when changing
between sitting
anyone looking from sitting to
and standing.
for it could find standing.
the data.

Insomnia R/T Patient will fall 1) Assess for 1) Establish 1) Teach

change in asleep without need for bedtime routine relaxation
environment difficulty (within 45 Temazapam to for patient techniques that
(home to BRC) minutes of getting initiate sleep involving can be used
and decreased in bed) for 5 nights, consistent before bedtime.
2) Assess for
daily physical ending 10/14/17. bedtime and
anxiety or stress 2) Teach patient
activity AEB activities.
that could not to sleep
alteration in
impact sleep 2) Engage the during the day to
sleep pattern,
patient in help with sleep
difficulty
physical exercise during the night.
concentrating,
throughout the
insufficient
day to promote
energy, and
sleep at night.
difficulty
initiating sleep.