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Care Plan 6 - Coggle Diagram
Care Plan 6
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Actions to prevent:
Perform fall assessment to assess pt's history of falls, mobility, mental status, etc.
Assist pt with mobility and provide assistive equipment as necessary (gait belt, walker, etc.)
Monitor for signs of respiratory distress (cyanosis, anxiety, labored breathing, etc.)
Monitor vital signs Q4H (RR, SpO2, breath sounds)
Nursing Interventions:
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Nurse will educate the patient about safety and risk for falls, and how to prevent falls.
Nurse will place the call light within reach and instruct patient to call for help when getting out of bed or chair.
Discharge:
Pt can verbalize importance of fall safety precautions and utilize safety measures at home (non slip shoes, free of clutter, etc.)
Pt will have stable vital signs (SpO2 >95%, RR 12-20, HR 60-100)
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Outcomes:
Pt will achieve adequate ventilation and respiratory assessments will remain stable (SpO2 >95%, RR: 12-20, HR: 60-100, no SOB)
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Avoid:
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Avoid leaving the patient laying or sitting for extended periods of time to optimize tissue perfusion
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