Patient Name

Dell Stokes

Age

65

Gender

Male

Admission Date

January 10, 2050

Risk for Falls (NANDA Code: 00155)

The patient will remain free from falls during hospitalization until discharge on January 20, 2050.

1. Assess fall risk daily using a validated tool.
2. Ensure the call bell is within reach and educate the patient on its use.
3. Place non-slip mats by the bedside.

Frequent assessments reduce fall risk by identifying changes in mobility or cognition.
Accessible tools enhance patient safety.
Non-slip mats minimize slips and accidents.

By January 20, 2050, the patient successfully avoided falls, and no incidents were recorded.

Impaired Physical Mobility (NANDA Code: 00085)

The patient will demonstrate improved mobility by walking 50 feet with a walker by January 15, 2050.

1. Encourage active participation in physical therapy sessions.
2. Assist the patient with range-of-motion exercises twice daily.
3. Offer rest periods to prevent fatigue.

Guided exercises improve muscle strength and joint flexibility.
Rest prevents exhaustion and enhances recovery.

By January 15, 2050, the patient independently ambulated 50 feet with a walker.

Acute Pain related to surgical incision (NANDA Code: 00132)

The patient will report a pain level of ≤3 on a 0–10 scale by January 12, 2050.

1. Administer prescribed analgesics as needed and assess pain levels every 4 hours.
2. Use non-pharmacological methods such as guided imagery.
3. Educate the patient on proper positioning to reduce pressure on the incision site.

Timely pain relief interventions improve comfort and promote healing.
Non-pharmacological methods provide additional relief.
Education empowers the patient to participate in care.

On January 12, 2050, the patient consistently reported pain levels ≤3.

Imbalanced Nutrition: Less than Body Requirements (NANDA Code: 00002)

The patient will consume at least 75% of each meal by January 16, 2050.

1. Collaborate with a dietitian to provide nutrient-dense, appetizing meals.
2. Monitor food intake daily and address barriers like nausea.
3. Provide small, frequent meals as tolerated.

Nutritional strategies address deficiencies and promote recovery.
Frequent monitoring identifies trends and potential issues early.

By January 16, 2050, the patient consistently consumed ≥75% of each meal.