ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for injury Short term goal: 1. Assess the 1. To determine the Short term:
“Nahihirapan akong related to After 2 hours of patient ability patient’s 1. After 2
igalaw ang kaliwang ischemic stroke nursing to ambulate functional hours of
kamay at paa ko” as as evidence by intervention the safely without abilities to plan nursing
verbalized by the left sided patient will be assistive for ways of interventio
patient. hemiparesis able to: devices improving n the goal
1. Identify problem areas was
Objective: factors that 2. Assess vision 2. To provide well partially
 Patient feels increase risk and provide lighted met;
uncomfortable for injury like adequate environment and 2. The patient
when moving left attempting to lighting to avoid the was able
upper and left get up from clearly see the occurrence of to identify
lower extremities bed without pathway injury. factors that
 Absence of side assistance 3. Ask the 3. To ensure the increase
rails 2. Explain relatives or safety of the risk for
 Left sided methods to significant patient injury
hemiparesis prevent injury others to Long term:
like having an always stay The goal was
assistance with the client met; the
when moving, 4. Put side rails 4. To reduce the patient does
and the use of risk of falling not acquire
side rails 5. Instruct the 5. To prevent the any injury
patient to call patient from during
Long term goal: for assistance falling on bed hospitalization
The patient will be when moving
free from injury
during his
hospitalization