Deogracias, Andrea Patrish M.

Enriquez, Elaine Andrei D.

Group 23 B

PATIENT: Remedios Garma

ROOM: 408
CUES NURSIN ANALYSIS GOALS AND INTERVENTION RATIONALE EVALUATIO
G OBJECTIVES N
DIAGNO
SIS
SUBJECTI
VE Risk for Increased Objective >Place the necessity of >Items that are too far from the Caregiver
-The fall r/t susceptibility (Short term) the patient within her patient may cause hazard and relate the intent
relative said body to falling that 1. Patient will reach can contribute to falls. to use safety
“Gusto niya weakness may cause not sustain fall. measures to
kasi yung physical >Instruct the relative >This is to prevent the patient prevent falls
pwesto harm. 2. Caregiver to assist the patient from accidentally falling or
niyang will relate the pulling out tubes. [   ] Fully met
ganyan intent to use >Respond to call light
Falls put a
(slant safety measures as soon as possible [   ] Partially
person,
position) to prevent falls. > This is to prevent the patient met
especially
kasi mas >Use side rails of the from going out of bed without
adults and
comportable 3. Caregiver bed as needed any assistance. [   ] Unmet
older adults,
siya na will demonstrate If not, why?
at risk of
matulog ng selective >Guarantee > According to research, a ____________
serious
ganyan. prevention appropriate room disoriented or confused patient ____________
injury. Fall
Nahihirapan measures. lighting, especially is less likely to fall when one of ____________
prevention
din kasi siya during the night. the four rails is left down. ___
may not
makakuha 4. Patient and
seem like a
ng tuloy caregiver will > Patients, especially older Caregiver will
favorite
tuloy na implement adults, has reduced visual demonstrate
topic, but
tulog” strategies to capacity. Lighting an unfamiliar selective
plays a very
-The increase safety environment helps increase prevention
important
patient’s visibility if the patient must get measures of
age is 67 role in health up at night. fall
care. and prevent [   ] Fully met
OBJECTI falls.
VE [   ] Partially
-The met
necessities
of the [   ] Unmet
patient is If not, why?
out of reach ____________
-Weakness ____________
of lower ____________
extremities ___
- Lowered
side rails
Patient and
caregiver is
able to
implement
strategies to
increase safe
and prevent
falls

[   ] Fully met

[   ] Partially
met

[   ] Unmet
If not, why?
____________
____________
____________
___