NURSING EXPECTED ASSESSMEN ACTION TEACHING

DIAGNOSES PATIENT T intervention intervention

OUTCOMES intervention s: (consider s: (consider
(note priority
s: orders, home
for each Be sure they are
safety, regimens,
below) S. M. A. R. T. (assess /
allergies, procedures,
(Specific, monitor for
(Be sure to code status, discharge
measureable, )
use related fall risk, etc.) plan, etc.)
achievable/
to and as
attainable,
evidenced
relevant and
by)
time-bound)
Risk for falls Patient will Monitor for Assist with Teach the
related to remain free from safe safe patient to
impaired falls over her transfers to transfers balance on
mobility as stay at OL. ensure the from bed to one foot while
evidence by patient does wheelchair or the other
Patient will show
use of not fall. forward ankle heals
improved
assistive wheeled from surgery.
mobility after
device walker.
postoperative Teach the
Assess for
period and use Assist with patient to
fatigue level
forward wheeled movement navigate
with use of
walker without throughout through OL
assistive
assistance. OL with gait with a
device.
belt to forward
encourage wheeled
patient to walker.
practice
walking.

Risk for Monitor Auscultate Teach the

decreased Patient will blood heart for patient to
cardiac demonstrate pressure and rhythm along recognize
output adequate pulse rate. with the chest pains
related to cardiac output force. and
as evidenced by Monitor for
decreased discomfort.
lowered blood symptoms Assist patient
contractility
pressure. including into semi-
as evidence
dyspnea, Fowlers
by increased Teach the
Patient will cough, position for
blood explain actions patient to
distended comfort to
pressure. and precautions gradually
abdomen, decrease the
to prevent fatigue and work of increase
primary or weakness. breathing activity and
secondary and may take blood
cardiac disease. decrease pressure
venous afterwards.
return.