Assessment Objective Cues: Surgical Incision at the Right Inguinal area Body weakness Measurements: Vital Signs: BP=

P= 130/70 PR= 77 bpm RR= 18 cpm T = 36.5 C

Nursing Diagnosis Risk for Injury related to intraoperative surgical procedure as manifested by Surgical Incision at the Right Inguinal area and Body weakness

Scientific Analysis At risk of injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources.

Planning

Intervention

Rationale

Evaluation Goal: Met

Short term goal: Independent: Psychomotor: After10 minutes of nursing care, client will be able to demonstrate precautions in the risk factors contributing to injury Affective: After 10 minutes of nursing care, client can demonstrate change in behaviors to reduce risk factors from injury. Maintain side rails up during the surgical procedure Place assistive devices within reach Note clients age and level of cognition or competence Assess clients muscle strength and motor coordination

Monitor Cognitive: environment for After 10 min. of potential unsafe nursing care conditions client will be able to verbalize understanding of individual factors that contribute to possibility of injury.

Prevent Client was potential injury able to: to the client demonstrat e precautions Prevent errors in risk for in occurring injuries, that may result changes in to injury behaviors that may To evaluate the contribute clients ability to injury to protect self and verbalize of understandi Identify risk ng of the for falls various risk factors that will result to injury Assess of during the potential operating hazard to the procedure client (Nurses Pocket Guide 11th Ed.,Doenges, M.E. Et. Al. pp. 415-417)