Syncope - Nursing Care Plan

Nursing Care Plan Patient’s Initials: N. S Assessment Data Subjective: Pt denies any pain, SOB, dizziness Pt verbalizes “I’ve had no dizziness since the incident … it came out of nowhere and then I was waking up” Objective: T: 36.4 P: 70 R: 16 SpO2: 96% on R/A BP: 136/85 Cap refill: < 3sec Morse fall risk assessment: Pt scored 20, equals low risk Medical Diagnosis: Syncope Nursing Diagnosis and Related Goals Risk for falls related to previous syncope incident. STG: Pt will be free from any falls during my 12-hour shift on Tuesday June 1st, 2021. Followed by q1h checks on mental status and motor functions. LTG: Pt and caretaker will implement strategies in the hospital to increase safety and prevent falls at home by Tuesday June 15th, 2021. Nursing Interventions and Rationale STG 1 Intervention: Assess and Transfer Pt to a room near the nurses’ station. Followed by q1h checks on mental status and motor functions. Rationale: By moving the Pt to a nearby room it provides more constant observation and quick response to call needs. Also, by checking Pt’s mental status and motor function it helps decrease the risk of falls by ensuring the patient is of normal findings. STG 2 Intervention: Respond to the call light as soon as possible and that the bed is at the lowest position possible. Pt is able to ambulate Rationale: These actions prevent the Pt from going out of bed without any assistance, especially if the Pt has an altered mental status reducing the risk of falling. Head to toe assessment: no abnormal findings STG 3 Intervention: Discuss No mobility aids used Activity level decreased Evaluation STG: MET June 1st, 2021, Pt was free from any falls during my 12-hour shift. Pt was successful by having nurses assess and Transfer Pt to a room near the nurses’ station. Followed by q1h checks on mental status and motor functions. Along with nurses responding to the call light as soon as possible and that the bed is at the lowest position possible. Also, nurses discussed with other health care team members to assess and evaluate Pt’s medications that could contribute to falling. LTG: MET June 15th, 2021 Pt and caretaker implemented strategies in the hospital to increase safety and prevent falls at home. Pt was successful by having appropriate room lighting, hallway lighting and nightlights installed for during the night at Pt’s home. Along with encouraging the Pt to don shoes or with other health care team members to assess and evaluate Pt’s medications that could contribute to falling. Rationale: By reviewing the Pt’s medications, the health care provider and the pharmacist can identify side effects and drug interactions that increase the patient’s fall risk. Ensuring the Pt is being extra mindful when taking these medications. LTG 1 Intervention: Guarantee appropriate room lighting, hallway lighting and nightlights installed for during the night at Pt’s home. Rationale: Lighting an unfamiliar environment or if the patient has an altered mental status helps increase visibility if the patient must get up at night. LTG 2 Intervention: Encourage Pt to don shoes or slippers with non-skid soles when walking. Along with familiarizing Pt with the layout of the room. Avoid rearranging the furniture in the room. Rationale: Non-skid footwear slippers with non-skid soles when walking. Also, with familiarizing Pt with the layout of the room. And avoid rearranging the furniture in the room. Additionally, the furniture is heavy and will not tip over when used as support for the Pt ambulating. And the pathways are clear and as straight as possible by removing or avoiding clutter on the floor surface. provides sure footing for the Pt and increases the safety to help prevent falls. Along with the Pt getting used to the layout of the room helps decrease the risk of tripping over furniture. LTG 3 Intervention: Ensure furniture is heavy and will not tip over when used as support for the Pt ambulating. Make the pathways clear and as straight as possible by removing or avoiding clutter on the floor surface. Rationale: Pt’s having difficulty in balancing are not skilled at walking around. When the Pt is losing their balance, heavy furniture can help support the Pt or help reduce the fall impact.