Nursing Care Plan: Assessment, Diagnosis, Interventions, Evaluation

This assignment presents a comprehensive nursing care plan designed to address three key patient needs: risk of falls, fatigue, and self-care deficits encompassing bathing, toileting, hygiene, grooming, and dressing. The care plan meticulously outlines the assessment findings, relevant nursing diagnoses, and specific, measurable, achievable, relevant, and time-bound (SMART) goals for each identified issue. It further details a range of nursing interventions tailored to each diagnosis, along with the rationale behind each intervention, explaining how it contributes to achieving the set goals. The plan concludes with an evaluation component, which describes how the effectiveness of the interventions will be measured and assessed to ensure optimal patient outcomes. References support the evidence-based practice outlined in the plan.

Assessment Nursing
diagnosis
Plan Intervention Rationale Evaluation
Risk of fall
Age related
physical changes.
Older people
are more
likely to
experience
fall due to
decreased
muscle
strength,
reduced
visual
function,
unsteady gait,
delayed
response or
reaction time
and many
others.
The main
goal is to
reduce the
risk of fall
and fall
related
injuries.
 Ensuring a bed
and chair
alarm
 Using side
rails on beds.
 Familiarizing
the patient to
the layout of
the room and
not changing
the
arrangement of
the furniture
without reason
(Young,
Landstrom,
Rosenberger,
Guidroz &
Albu, 2015).
Use of audible
alarms will
alert others
about the
needs of the
patients and it
will also help
the patient in
reminding not
to get up alone.
The side rails
and familiar
room will help
the patient to
avoid tripping
over furniture.
Patient will be
more
comfortable
and the
caregivers will
be more alert.
The side rails
and familiar
room will
reduce the risk
of fall and
injury related
to it.
Fatigue
Inadequate
amount of sleep.
Insufficient
sleep or
change in the
sleeping
pattern,
which occurs
due to any
emotional
distress, drug
side effects
and other
reasons may
contribute to
the
development
of fatigue.
The prime
goal will be
to ensure an
adequate
amount of
sleep of the
patient.
 Restricting
all kinds of
environme
ntal stimuli
during the
planned
times of
sleeping.
 Providing
comfort,
such as
massage or
cool
showers.
 Assisting
the patient
in
developing
a schedule
for daily
activity
and rest
(Caruso et
al., 2017).
Vivid noise,
lighting and
other
distraction
from the
surrounding
can hamper the
relaxation of
the patient and
contribute to
fatigue.
Physical
comfort can
provide
relaxation to
the patient and
with the help
of a schedule a
patient can
effectively
maintain the
balance
between the
time of
working and
sleeping.
Patient will
sleep
peacefully
without any
kind of
external
distractions
and will also
be able to
manage the
time of
relaxing in
between a busy
schedule of
work which
will help to
reduce fatigue
and its affects.
Self-care deficit
including
bathing,
Different
types of
etiological
Patient will
identify all
the useful
 Ensuring the
proper privacy
of the patient
Privacy of the
patient is
extremely
The patient
will be
motivated to

toileting,
hygiene,
grooming and
dressing
Cognitive
impairment
factors may
require
explicit
nursing
interventions
to enable the
practice of
self-care and
management.
resources
required in
optimizing
independence
. Also, the
patient will
safely
execute the
self-care
activities.
during
dressing and
toileting.
 Implementing
some measures
to promote
independence,
however,
intervening if
the patient is
unable to
perform the
activities
properly
(Guirguis-
Blake,
Michael,
Perdue,
Coppola &
Beil, 2018).
 Rendering
close
observation for
all the
activities until
the patient
exhibits all the
skills
efficiently
(Shah, 2015).
important and
the patient’s
ability of
performing
any self-care
measure will
change often
over time.
Also, an
optimum level
of assistive
care will help
the patient in
avoiding harm
while
performing the
activities
without
causing any
disappointment
.
perform daily
activities
without
depending on
the external
assistance
which will
decrease
his/her
disappointment
of being
dependent to
others. The
patient will be
more confident
in performing
different types
of self-care
tasks.

References
Caruso, C. C., Baldwin, C. M., Berger, A., Chasens, E. R., Landis, C., Redeker, N. S., ... &
Trinkoff, A. (2017). Position statement: Reducing fatigue associated with sleep
deficiency and work hours in nurses. Nursing outlook, 65(6), 766-768. Retrieved from
https://www.nursingoutlook.org/article/S0029-6554(17)30600-0/fulltext
Guirguis-Blake, J. M., Michael, Y. L., Perdue, L. A., Coppola, E. L., & Beil, T. L. (2018).
Interventions to prevent falls in older adults: updated evidence report and systematic
review for the US Preventive Services Task Force. Jama, 319(16), 1705-1716.
Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2678103
Shah, M. (2015). Compare and Contrast of Grand Theories: Orem’ s Self-Care Deficit
Theory and Roy’ s Adaptation Model. International Journal of Nursing
Didactics, 5(01), 39-42. Retrieved from
http://innovativejournal.net/index.php/ijnd/article/download/1780/1432
Young, J., Landstrom, G., Rosenberger, S., Guidroz, A. M., & Albu, A. (2015). Leading
Nursing Into the Future: Development of a Strategic Nursing Platform on a System
Level. Nursing administration quarterly, 39(3), 239-246. Retrieved from
http://www.academia.edu/download/45032346/Leading_Nursing_Into_the_Future201
60423-31261-1vv7g5k.pdf