EXPECTED

ASSESSMENT PLANNING INTERVENTION RATIONALE

OUTCOME
S: Within 2 to 3  Identify factors that affect To know the intervention that After 2 to 3 hours of
“umalis po yung hours of safety needs. will be established. rendering proper
lolo ko “as rendering proper nursing intervention,
verbalized by the nursing  Assess the patient ability to It is helpful to determine the the patient will be
patient intervention, the ambulate safely client’s functional abilities to free from fall as
O: patient will be plan for ways of improving evidenced by ability
>no relative beside free from fall. the problem areas to explain the safety
the bed precautions.
 Thoroughly orient the patient For the client to familiarize
Nursing to environment. the surroundings.
Diagnosis:
Risk for Fall related  Assess vision and provide To provide well-lighted
to VAC application adequate lighting to clearly environment and avoid the
as manifested by see the pathway. occurrence of injury.
broken side rails  Ask the significant others to To ensure clients safety.
always stay with the client.

 Instruct the patient to call for To prevent the patient from

assistance when moving. falling on bed.

 Ensure that the patient wears To prevent from slippering.

proper shoes