ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for injury related to Short term: INDEPENDENT: - Immobility increases Short term:
impaired cognition and the risk of pressure
Objective: sensory deficits After 1-2 hours of - Regularly change the ulcers due to After 1-2 hours of
effective nursing patient’s position to decreased blood flow effective nursing
1. Patient interventions, the client prevent pressure ulcers interventions, the client
disorientation to and pressure on bony
and significant other and promote prominences. and significant other
place, time and will develop and follow circulation. developed and followed
person. risk control strategies -Impaired cognition and risk control strategies
manifested by -Ensure the patient's sensory deficits manifested by
2. Decrease bed is at the lowest
sensation in the verbalization of increase the risk of verbalization of
understanding. level with side rails up falls, which can lead to understanding.
lower extremities and locked when serious injuries.
Long term: appropriate to prevent Goal Met.
falls. -This helps prevent falls
After 8 hours of by alerting staff to the
effective nursing -Provide assistive patient's attempts to
interventions, the client devices such as bed Long term:
move independently.
will have no incidents of alarms or chair alarms After 8 hours of
injury-causing events to alert staff if the -Sensory deficits may effective nursing
such as falls. patient attempts to impair the patient's interventions, the client
move without ability to navigate their has no incidents of
assistance. surroundings safely. injury-causing events
-Keep the patient's such as falls.
environment free of Goal Met
obstacles to prevent -Collaboration with the
tripping hazards. patient and family
enhances their
-Educate the patient understanding of safety
and family members precautions and
about safety measures promotes a proactive
and encourage them to approach to preventing
communicate any injuries.
concerns or changes in
the patient's condition. -Early detection of
changes allows for
-Perform frequent prompt intervention and
neurological minimizes the risk of
assessments to monitor injury.
for changes in cognition
and sensory function. -Rehabilitation
promotes functional
-Support the patient's independence and
involvement in reduces the risk of
rehabilitation activities injury by improving
to improve mobility, overall mobility and
cognition, and sensory cognitive function.
function.
-Education empowers
-Teach the family caregivers to take
members strategies to proactive measures to
prevent falls, such as prevent injuries.
using handrails,
wearing nonskid
footwear, and avoiding -Certain medications
wet floors. can increase the risk of
-Regularly review the falls, so monitoring and
patient's medications to adjusting them can help
identify those that may mitigate this risk.
contribute to dizziness
or impaired cognition
and consult with the
healthcare team for
adjustments if
necessary.
-Physical therapists
specialize in improving
mobility and can
DEPENDENT: develop individualized
-Refer the patient to exercise programs to
physical therapy for gait reduce the risk of falls.
training, balance
exercises, and mobility
assessments. -Proper nutrition is
essential for
COLLABORATIVE maintaining strength
-Collaborate with a and reducing the risk of
dietitian to ensure the falls and injuries.
patient receives -Standardized protocols
adequate nutrition to ensure consistency in
support muscle fall prevention efforts
strength and overall and improve patient
health. safety outcomes.
-Work with the
healthcare team to
implement a
standardized fall risk
protocol, including
regular assessment
and intervention for
patients at risk.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired verbal Short term: Independent: Short term:
communication related
Hirap na siyang to cerebral impairment After 3 hours of nursing - Review history of - it could affect the After 3 hours of nursing
makapagsalita as as evidenced by intervention the client neurological condition speech intervention the client
verbalized by the SO absence of responding will be able to verbalize was able to verbalized
or indicate an - Involve SO in plan of - this enhances or indicated an
understanding of the care as much as participation and understanding of the
communication possible commitment to communication
Objective: communication.
difficulty and plans for - Plan for and provide difficulty and plans for
(+) Slurring of speech ways of handling alternative methods of ways of handling
(+) Dyspnea communication
- to provides an
(+) Difficulty in use of Long term: - Advised client's SO opportunity to practice Long term:
facial or body the needed techniques skills
expression After 3 days of nursing for communication, After 3 days of nursing
intervention the client verbal or nonverbal - this reduces difficult intervention the client
will establish method of cues or alternate situation and promotes will establish method of
communication in modes of return to more normal communication in
which needs can be communication life patterns. which needs can be
expressed expressed
Partially Met
