ASSESSMENT NURSING RATIONALE PLANNING/GOAL INTERVENTION JUSTIFICATION

DIAGNOSIS

Risk for injury R/T After 3 days of nursing Independent:

muscle weakness interventions, the client will
be able to:
Definition:
The risk of injury as a - to identify risk
result of the a. Verbalize understanding - Assess client's for injury
interaction of of individual factors that muscle strength
environmental contribute to possibility gross and fine motor
conditions with of injury coordination
individual adaptive - minimize falls,
response and b. Demonstrate behaviors, - provide a safe and injury
defense sources. lifestyle changes to reduce environment (side rails,
risk factors and protect self remove obstacles in the
Source: from injury room)
Nurse's Pocket
Guide: Diagnoses, - It can contribute
c. be free from injury - Discuss importance to
Prioritized
of self monitoring occurrence of
Interventions, and
of conditions or injury (fatigue,
Rationales; 13th
emotions anger, irritability)
edition by Doenges,
Moorhouse, Murr
- The patient
- Thoroughly conform must get used to
patient to surroundings. the layout of the
Teach how to call for environment to
assistance; respond avoid accidents. I
immediately. tems that are too
far from the
patient may
cause hazard.

- This is to
- Ask family or significant prevent the
others to be with the patient from
patient to prevent her from accidentally
accidentally falling or falling or pulling
pulling out tubes. out tubes.

- This is to
- Eliminate or drop all prevent the
possible hazards in the patient from
room such as razors, any unpleasant