Nursing Care Plan

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Chapter 49
1. Identify nursing diagnoses relevant to patients with sensory alterations.Pg.1241- 1243
~ Risk- prone health behavior
~ Impaired verbal communication
~ Risk for injury
~ Impaired physical mobility
~ Bathing self-deficit
~ Dressing self-deficit
~ Toileting self-deficit
~ Situational low self-esteem
~ Risk for fall
~ Social Isolation 2. Develop a plan of care for patients with sensory deficits.Pg.1245-1247 Pg. 1235

Nursing Care Plan for Risk for Fall


An 82 year old patient is admitted to the medical surgical floor with altered mental status. According to the patient’s family the patient had a fall last week and you observe that the patient is unsteady on her feet. After completing the fall assessment form you determine that the pt. is high risk for falls. Pt scored 20 on 1-25 fall scale.

Nursing Diagnosis

Risk for falls related to altered mobility secondary to unsteady gait as evidence by patient unsteady on feet and Fall score of 20.

Subjective Data
Family reports patient had a fall last week

Objective Data
Pt. unsteady while standing
Fall score 20
Altered mental status

Nursing Outcomes

-The patient will be free from any falls during her hospitalization.

Nursing Interventions

-The nurse will assess every shift the patient Morse Fall Score.

-The patient will wear a fall risk bracelet and non-skid socks so other nursing staff will know the patient is a fall risk.

-The nurse will keep the patient’s bed in the lowest position at all times.

-The nurse will use the bed and chair alarm as needed.

-The nurse will assess the patient need to use the bathroom every two hours.

-The nurse will move the patient close to the nurses’ station for closer observation.

3. List interventions for preventing sensory deprivation and controlling sensory overload. Pg. 1235
~ Recognize the onset

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