ASSESSMENT

NURSING DIAGNOSIS

OUTCOME

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Nanghihina iyong right side ng katawan ko. Hindi rin ako makagalaw masyado. as verbalized the patient. by

Risk injury

for After 8 hours of Evaluate nursing interventions, source

Assessed

client To identify risk for falls strength,

Met.

Clients

of muscle

muscle strength is 3/5

risk inherent gross and fine motor the coordination

the patient will in be able to individual situation

verbalize understanding of individual that to

* Observed for signs To determine need for Met. of injury evaluation of intentional injury injury

Signs

of are and

observed noted

factors contribute

Objective: * Weak in Appearance * Pale looking * Lying on bed althroughout *Decreased Hgb. Level; 115g/dL

possibility injury.

of Assist client * Provided healthcare To

prevent in promote

errors Met. Client was clients able to use the client given assistive

to correct or within a culture of resulting reduce individual risk factors safety: Elevated injury,

side safety and model safety devices and was able to perform activities without the occurrence of injury.

rails and placed a behavior for client. pillow beside the client

Ensured

that

pathway to the bathroom is

unobstructed and properly lighted