ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

O: Risk for injury The patient is After 8 hours of - monitor vital signs - to have baseline GOAL MET
+ appears related to less responsive nursing data
confused decreased and unaware intervention, the After 8 hours of
+ lethargic level of of his own patient will be - assess for patient’s - to know if there are nursing
+ GCS of 13 consciousness environment able to: level of consciousness changes in his LOC intervention, the
due to and be able to give patient was able
decrease - be free from any appropriate to:
sensory injuries interventions
stimulation, - have no injuries
- avoid further - always raise the side - to prevent
making the
complications and rails and lower the bed unwanted events - avoided
patient
harm to appropriate height such as falls unwanted
possible and
complications and
prone to such
- have a safe - place the patient in a - to provide comfort harm
harm and
environment comfortable position
further
- had a safe
injuries. - advice the patient to - to provide environment
press the call bell immediate assistance
placed at the side of when the patient
the bed intends to move or go
to the bathroom

- eliminate possible - to decrease the risk

environmental hazards for harmful situations

- encourage the - to keep the patient

significant others to in assistance and
stay by the side of the guided
patient