ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Risk for injury r/t SHORT TERM  Assess risk  Help obtain Goal met.
DATA: to decreased level GOAL: factors for data to plan
of consciousness injury – lack care. SHORT TERM
"While he was as evidenced by After 30, mins of of side rails, GOAL:
casually enjoying aphasia and GCS nsg intervention, seizures, loss  Prevent fall
his favorite steak of 8/15 the patient and the of corneal and injury. After 30, mins of
meal I noticed a significant other blink reflex, nsg intervention,
blank stare in him will cooperate in invasive lines  Unconscious the patient and the
followed by ways in and client cannot significant other
inaudible words minimizing risk equipment, voice pain. was able to
from him," as for injury such as restraints, cooperate in ways
verbalized by the raising side rails, tight  Limbs in minimizing risk
patient's significant and not leaving dressings, without tone for injury such as
other the patient alone. environmenta may dislocate raising side rails,
l dressings, if they are and not leaving the
After 7 hours of environmenta allowed to patient alone.
OBJECTIVE nursing l irritants, fall
DATA: intervention the damp bedding unsupported. After 7 hours of
patient will or dressings, nursing
 Left facial manifest nail not cut.  Prevent falls. intervention the
ptosis improvement in patient was able to
 Left sided LOC as evidenced  Keep side  This is to manifest
weakness by GCS of 15. rails up and determine the improvement in
 Aphasia bed in lowest patient’s LOC as evidenced
 No control LONG TERM position condition that by GCS of 15.
of his upper GOAL: whenever the may cause
extremities client is not injury. LONG TERM
 Limited After 1 week of receiving GOAL:
nsg intervention, direct care  To prevent
movement
in his lower patient will remain him or her After 1 week of
free from injury as  use caution from nsg intervention,
 Eyes open
evidenced by when moving accidentally patient will remain
when
 verbally absence of bruises the client. falling or free from injury as
instructed to nor fractures. pulling out evidenced by
GCS: 8/15 (E-3, V-  Give adequate tubes. absence of bruises
2, M-3) support to the nor fractures.
limbs and  To establish
BP:170/90 mmHg, head when baseline data
PR:105, moving or
RR: 20, turning the  To assess the
TEMP: 36.8 unconscious level of
Celsius client. consciousnes
O2 sat:95 % s
 Always turn
the client
toward the
nurse

 Assess
general status
of the patient.

 Ask family or
significant
others to be
with the
patient

 Monitor vital
signs

 Monitor
neurological
status then
compare with
the baseline