NURSING CARE PLAN

Assessment Cues Nursing Diagnosis (Rationale) Desired Outcome Nursing Intervention Justification Evaluation
Pathophysiologic /
Schematic Diagram
Subjective: Precipitating Factor: After 8 hours of nurse Independent Goal Met
Risk for injury patient-interaction the
“Indi na ni sa related to disease Genetic History patient will be able to:  Assess general status of  This is to determine the .
namon mapabay-an process as Environmental Factors the patient. patient’s condition that “Nainchidihan ko nurse
si Nanay dapat may evidenced by right Age SHORT TERM may cause injury. nga kinaglan ko gid na
upod nani sa sa sided weakness maghalong kay tigulang
balay kag baw ka inability to  Patient will  Assess mood coping  Mood coping abilities nako daan, ara man ang
delikado nag id purposefully move Predisposing Factor: remain in a safe abilities, personality and style of personality mga bata ko nga ma
tigulang na ni sa within the physical environment style that may result in aid to determine the alalay sakon ah.
tapos na stroke pa environment; Presses on nearby cranial with no carelessnes. patient’s level of Mangayo gid ko dapat
sya, t dapat gid na impaired nerves or brain tissue complications or cooperation. bulig kung may
halungan si Nanay, coordination; injuries obtained. kinanglan ako.” As
kai indi basta-basta limited range of  Family will be verbalized by the patient.
ginabatyag niya motion; Causing Subarachnoid able to identify  Recognize racial/ethnic  Discovering
subong. “As decreased muscle s hemorrhage and eliminate diversity at the onset of race/ethnicity issues will
verbalized by the trength/control hazards in the care. enhance “Kinanglan nag gid ni
patient’s SO patient’s communication, namon updan si tatay
Increase in ICP resulting environment establish rapport, and namon ti kay tigulang
from sudden entry of blood promote treatment nag id man sa, priority
Objective: Definition: into the subarachnoid space LONG TERM outcomes. gid ang safety ni Nany
para indi mag lala ang
Injuries have been  Evaluate the  What the patient iya nga ginabtayag
Admitting recognized as Injuries of brain tissue: or  Family will subong” as verbalized by
Diagnosis: importance of cultural considers risky behavior
unavoidable by secondary ensure safety the daughter of the
beliefs, norms, and may be based on
accidents that Ischemia of the brain precautions are patient.
CVA vs Bleed values on the patient’s cultural perceptions.
occur in our daily resulting from the reduced instituted and
perceptions of risk for
(+) right sided lives, rather than perfusion pressure followed.
injury.
weakness as a major public   Patient will
health issue. remain safe from
 Determine whether  Exposure to community
However, unlike severe headache associated environmental
exposure to community violence has been
accidents, injuries with episodes of vomiting hazards resulting
associated with
do not happen by and right sided weakness
 random, according from cognitive violence is contributing increases in aggressive
 BP – 170/80 to a large impairment. to risk for injury. behavior and depression.
mmHg epidemiological
 HR – 64bpm and medical study.  Thoroughly conform  The patient must get
 RR – 20cpm Injury risk follows Risk for injury related to patient to surroundings. used to the layout of the
 Temp – 36.5 a predictable disease process as Put call light within environment to
 O2sat - 95% at pattern, similar to evidenced by right sided reach and teach how to avoid accidents. Items
room air that of any disease, weakness inability to call for assistance; that are too far from the
making it purposefully move within respond to call light patient may cause
Creatinine 0.88 avoidable. In any the physical environment; immediately. hazard.
healthcare setting, impaired coordination;
B implementing a limited range of motion;  Avoid use of restraints.  If patients are restrained,
UN 12.55 good injury decreased muscle strength/ Obtain a physician’s they can sustain injuries,
ALT 28.50Na+ prevention control order if restraints are including strangulation,
144.50 program is an needed. asphyxiation, or head
important aspect of injury from leading with
K+ 3.11 nursing care and their heads to get out of
requires a complex the bed.
Chloride 106 strategy. Nurses  In place of restraints, .
also play an utilize the following:
important role in Alarm systems with ankle or
Strength: educating patients, wrist bracelets
Intact family families, and
support. caregivers on how
Bed or wheelchair alarms
to avoid falls after
they leave the
Increased observation
Weakness: hospital.
of patient
Current medical  These are alternatives to
condition Locked doors to unit restraints that can be
helpful for preventing
Source/Reference falls and injuries.
Bed with wheels removed to
NANDA
keep bed low (NOTE: may not
be acceptable with fire
regulations)
  Signs are vital for
 Provide medical patients at risk for
identification bracelet injury. Healthcare
for patients at risk for providers need to
injury. acknowledge who has
the condition for they
are responsible for
implementing actions to
promote patient safety.

 If patient is notably  Special beds can be an

disturbed, consider
using a special safety
bed that surrounds
patient. If patient has a
traumatic brain injury.
efficient and useful
alternative to restraints
and can help keep the
patient safe during
periods
of confusion and anxiety
.

 Ask family or  This is to prevent the

significant others to be patient from
with the patient to accidentally falling or
prevent him or her pulling out tubes.
from accidentally
falling or pulling out
tubes.

 Eliminate or drop all  This is to prevent the

possible hazards in the patient from
room such as razors, any unpleasant
medications, and experience due to
matches. dangerous objects.
 Avoid extreme hot and
cold around patients at
risk for injury (e.g.,
heating pads, hot water
for baths/showers).
 Patients with decreased
cognition or sensory
deficits cannot
discriminate extremes in
temperature.

 Place an injury-  Such placement allows

prone patient in a room regular observation of
that is near the nurses’ the patient.
station.

 Use culturally relevant The Make It Safe program is a

injury prevention bilingual, culturally sensitive
programs whenever educational presentation and
possible. working safely in a rural
environment.

 Validate the patient’s  Validation lets the

feelings and concerns
related to
environmental risks.
patient know that
the nurse has heard and
understands what was
said, and it promotes
the nurse-patient
relationship.

 Aid patients sit in a  Patients are likely to fall

stable chair with
armrests. Limit use of
wheelchairs and geri-
chairs except for
transportation as
needed.
when left in a
wheelchair or geri-chair
because they may stand
up without locking the
wheels or removing the
footrests.
 Educate patient about  Patient’s knowledge
safety ambulation at about his or her
home, including the use condition is vital to
of safety measures such safety and recovery.
as handrails in
bathroom.