JERVIS S.

LAZARO
BSN3-C9

ASSESSMENT

NURSING
DIAGNOSIS

Subjective Data:
Tuwing tatayo ako,
sumasakit ang mga
paa ko, hirap ako
lalo na kapag
naglalakad, madalas
nahihilo rin ako
pagkatayo ko mula
sa higaan, bigla
nalang akong
napapaupo.

Risk for Falls

secondary to altered
mobility secondary
to unsteady gait as
manifested by
weakness of the
lower extremities

Objective Data:
- Lethargic
- Body
Weakness
- Weakness in
the lower
extremities

PLANNING
After 6 hrs. of
Nursing
Intervention, the
client will be able
reduced of the risk
for falls and
understand the
different
precautionary
measures to reduce
the risk for falls

INTERVENTION
-

Assess Clients general

condition
Check clients ROM
Encourage the client to
call for assistance when
needed
Explain different
precautionary measures to
the client and caregiver to
prevent injury (use of
crutches, wheelchair,
walkers, holding onto rails,
use of side rails)
Observe the client closely
when ambulating
Check for presence of
Orthostatic Hypertension,
if there is:
o Check clients BP in
different positions
(supine, sitting, and
standing)
o Tell client to change
positions slowly
o Tell client to move
from lying to an
upright position in
stages
Explain/demonstrate how

EVALUATION
After 6 hrs. of
Nursing Intervention,
the client was able
reduce of the risk for
falls and understood
the different
precautionary
measures to reduce
the risk for falls

JERVIS S. LAZARO
BSN3-C9

to do passive (active if
possible) exercises to
strengthen muscles and
prevent stiffness of the
joints and muscles
Encourage client to
ambulate if tolerated