ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Risk for fall related Within 30mins. of nursing Independent: Goal partially met, after
“Nahihilo ako at medyo to impaired balance interventions, the patient -Raise side rails of the bed. -Reducing the risk of patients falling 30mins. of nursing
nanlalabo paningin ko” as evidenced by will be free from falls. out of bed. interventions, the
dizziness. patient was able to
OBJECTIVE: -Instruct the patient to call for assistance -To prevent the patient from falling in decrease the risk of
-Temperature- 36.6 ℃ when moving. bed. falling through
-RR- 28 cpm implementation of
-BP- 154/86 mmHg -Assess the patient ability to ambulate -It is helpful to determine the client’s safety measures such as
-PR- 78 bpm safely with or without assistive device functional abilities to plan for ways of raising the side rails of
-Urine Sample: 1,9443 improving the problem areas. the bed, assisting the
mg/dl of microalbumin patient when moving
-Hemoglobin A1c of74% -Thoroughly orient the patient to -For the client to familiarize the and keeping the area a
-Occipital Headaches environment. surroundings. well-lighted
-Polyuria and Polydipsia environment.
-Pain Scale: 8/10 -Assess vision and provide adequate -To provide well-lighted environment
lighting to clearly see the pathway. and avoid the occurrence of injury.

-Evaluate the client’s current
disorder/conditions that could enhance risk
potential for falls.
-Acute, even short term situations can
affect any client, such as sudden
dizziness, positional blood pressure
changes, new medications, change in
glasses prescription, recent use of
alcohol/other drugs, and so on.

-Assess the client’s cognitive status (brain -This affects the client’s ability to
injury, neurological disorders/depression). perceive his/her own limitation or
recognize danger.

-Ascertain the client’s/significant other’s -This may reveal a lack of

level of knowledge about and attendance to understanding, insufficient resources,
safety needs. or simple disregard for personal
safety.