Assessment Diagnosis Planning Intervention Rationale Evaluation Short term: Independent: Short term: Subjective Cues:SO stated -Risk for injury Within 8 hours of nursing 1. Assess general - This is to determine Within 8 hours of nursing Hapit sya mahulog sa katri interventions the patient will status of the the patients condition interventions the patient imaging adlaw be able to remain free of patient. that may cause injury. was able to remain free of injuries. 2. Assess mental - Mood coping abilities injuries. Objective Cues: status of the and style of -Orthostatic hypotension Long term: Within 3 days of pt. , mood personality aid to Long term: Within 3 days noted nursing interventions the coping determine the of nursing interventions -Delay capilliary refill patient will be able to abilities, patients level of the patient was able to approximately 3secs explain methods to prevent personality cooperation. explain methods to -Hypotension injury. style that may -Patients experiencing prevent injury. -Tachycardia . result in impaired mobility, -Tachypnea carelessnes. impaired visual acuity, -Body weakness 3. Assess the and neurological environment dysfunction, including for threats to dementia and other safety such as cognitive functional slippery floors deficits, are at risk for unstable stairs injury from common and stairwells, hazards. blocked - The patient must get entries, high used to the layout of beds without the environment to rails, blocked avoid accidents. Items IV stand. that are too far from 4. Ask or the pt the patient may cause to conform hazard. about the -This is to prevent the environment\\ patient from 5. Assist patient accidentally falling or in doing pulling out tubes. activity such This is to prevent the (waking up in patient from bed, drinking any unpleasant water, Eating experience due to and etc.) dangerous objects. 6. Eliminate the possible hazard to pt -Reduces defensive responses, such as hot promotes trust and enhances water, sharp cooperation. objects, and etc. -to provide assessment about 7. pain
-to provide comfort which is also
Dependent a diversional activity 1. Administer analgesics, as indicated to maximum dosage as needed. -To divert patients feeling of pain with the use of music or sounds Collaborative -to promote healing 2. Cooperate with the family -to promote wound healing and of the client to document to relief pain discomfort the health of the patient -Pain result in fatigue, which lead to exaggerated pain.