Physical injury risk condition: fall nursing care plan

Physical injury risk condition: fall nursing care plan

<Definition>
A physical injury risk condition is a condition in which the person is at high risk of being impaired due to sensory impairment, physical disability, inability to recognize the danger, or premature age. Physical injury risk conditions include physical trauma, falls / falls, aspiration, and choking.

<Nursing care plan>

Target
You can spend time without falling

Observation plan
1. Consciousness level
2. Mental state
3. Understanding and cognition
4. Presence or absence of fluctuations in circulatory function and respiratory function
5. Presence / absence and degree of paralysis and movement disorders
6. Walking situation
7. Use and status of assistive devices and prosthetics
8. Presence / absence and degree of visual, auditory, and sensory neuropathy (glasses, hearing aids, etc.)
9. Presence or absence of dizziness and nystagmus
10. Presence or absence of light-headedness or discomfort
11. Understanding the excretion pattern
12. Living environment (bed position and height, bed and table conditions, floor head stand position, etc.)
13. Clothes, footwear
14. Inspection data
15. Presence or absence of dehydration and bleeding tendency
16. Drain and route parts and conditions
17. The drug you are using

Care plan
1. Adjust the bed and the environment around the bed
2. Place the nurse call within the reach of the patient
3. Choose athletic shoes that have heels, are non-slip, and are hard to trip over.
4. Choose clothes that are easy to work with
5. Respond to excretion assistance at an early stage
6. Adjust to get closer to the living environment and rhythm before hospitalization
7. If walking is unstable, adjust to move with an attendant or a wheelchair.
8. Consider using headgear if there is a possibility of seizures or loss of consciousness
9. If there is a drain or route, adjust it so that it is easy to move.
10. If it is unavoidable, consider installing a bed leaving sensor to prevent falls.

Education plan
1. Explain the factors that are prone to falls and preventive measures
2. Explain shoes that are hard to fall
3. Explain clothes that are easy to work with
4. Explain the drugs that are prone to falls
5. Explain to call a nurse whenever you have anxiety
6. If the environment changes, explain the situation in advance.


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