5.10 Putting It All Together

Client Scenario

Mr. Olson is a 64-year-old client admitted to the medical-surgical floor with a diagnosis of pneumonia. The client has severe macular degeneration and limited visual acuity. He is alert and oriented but notes that he has suffered a “few stumbles” at home over the last few weeks. He ambulates without assistance but relies heavily on tactile cues to help provide guidance.

Applying the Nursing Process

Assessment: The nurse notes that Mr. Olson’s macular degeneration and limited visual acuity pose a significant safety risk. He has reported “stumbling” at home and uses tactile cues to establish room boundaries.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Olson.

Nursing Diagnosis: Risk for Injury AMB altered visual acuity, stumbling at home, and using tactile cues to mobility.

Overall Goal: The client will be free from falls.

SMART Expected Outcome: Mr. Olson will be free from falls throughout his hospitalization.

Planning and Implementing Nursing Interventions:

The nurse will provide the client with education regarding the room layout and tactile boundary cues. The nurse will keep the client’s room free from clutter and provide appropriate lighting. The nurse will instruct the client to utilize the call light and request assistance when ambulating throughout the room. The nurse will provide the client with nonskid footwear to enhance safety during ambulation.

Sample Documentation:

Mr. Olson is at risk for falls as a result of his decreased visual acuity and hospitalization in an unfamiliar environment. The client has been provided education and safety equipment to decrease his risk of injury. The client has received education regarding the room layout and has been encouraged to request assistance when ambulating about the room.

Evaluation:

During the client’s hospitalization, Mr. Olson utilizes the recommended safety equipment and requests assistance when ambulating and no falls occurred. SMART outcome was “met.”