Question

Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center." Which step of the nursing process does this represent?

Answer 1

The documentation that 'no further falls will occur while in the care center' is part of the planning step of the nursing process where strategies are developed to prevent future issues, such as falls.

Step-by-step explanation:

The statement "no further falls will occur while in the care center" reflects the planning step of the nursing process. In the planning step, nurses develop strategies to prevent or minimize the possibility of future problems, such as falls. It is a proactive measure that involves setting patient-specific goals or expected outcomes, similar to how a surgical team might review procedures, counts of instruments, and labeling of specimens to ensure a safe and effective procedure followed by a careful recovery period.

The documentation that no further falls will occur is part of creating a care plan that is designed to keep the patient safe. This mirrors how a surgical team, including the surgeon, nurse, and anesthesia professional, would review aloud the key concerns for a patient's postoperative care and recovery, ensuring that any potential issues are addressed proactively.