Cues Nursing Diagnosis Objective/Goal Nursing Interventions Rationale Evaluation

Subjective: Risk for Falls r/t body After 8 hours of 1. Identify factors that affect 1 To know the After 8 hours of
Objective: weakness nursing intervention, safety needs. intervention that will nursing
>decreased strength the be established. intervention , the
in lower extremities patient will be able 2. Assess the patient ability to patient was able
>weak in appearance to: ambulate safely with or 2. It is helpful to to:
>presence of free from fall. without assistive devices determine the client’s free from fall as
scattered rugs functional abilities to evidenced by
3. Assess vision and provide plan for ways of ability to explain
adequate lighting to clearly see improving the the safety
the pathway. problem areas precautions

4. Ask the significant others to 3. To provide well-

always stay with the client lighted environment
and avoid the
occurrence of injury.

4. To ensure clients
safety.