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Nursing Diagnosis
Handbook 10th ed1.
2.
GOAL/OUTCOME
3. INTERVENTIONS
4. SCIENTIFIC
RATIONALE
5. IMPLEMENTATION
Implementation of
plan/interventions: The
nurse performed (Column
3)
1. Assessed patient for
factors known to increase
fall risk such as history of
falls, mental status changes
and sensory deficits.
6. EVALUATION
NURSING DIAGNOSIS
NANDA:
Risk for falls
Related to(etiology/cause
of problem):
Client-Centered Goal:
What the client/ needs to
accomplish
Therapeutic Nursing
Interventions: What the
nurse plans to do
1. Within 2 to 3hours
of rendering proper nursing
intervention, the patient
will be free from falls.
2. Modify environment as
indicated to enhance safety.
Subjective data:
"Sometimes I'm weak"
"I've been sleep all day."
Objective data:
Decreased strength
Weak in appearance
R/t leg cast
Absence of side rails
3. Assessed patient's
environment and provided
adequate lighting.
Evaluate Outcomes:
(Column 2)
Goal met.
After 2 to 3 hours of
rendering nursing
interventions the
patient was free of
falls and safety was
ensured.
Outcomes:
Be free of injury.
Demonstrate behavior,
lifestyle changes to reduce
risk factors and protect self
from injury.
Revisions:
Continue to monitor
Goal STATEMENT is
related to NSG DX.
Outcomes are:
-realistic/measurable
-related to client data and
stated
goal
-attainable within clientcentered
outcome time frame.
G:Nsg/pkts/general/Word/careplan.2013.8.5x11
nonskid slippers
THERAPEUTIC
INTERVENTIONS are based
on identified outcome.
INCLUDE:
-action to be performed
-descriptive phraseDate/time/how often
Scientific Rationale:
-Reference source by author &
page
-reflects understanding of
intervention
-reflects client data
-be specific to plan