Risk for injury

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Risk for injury r/t Within my 8 hours 1. Assess mood, >To evaluate the At the end of 8 hours
bleeding decreased
- last platelet result of span of care, patient coping abilities, and degree/source risk span of care, patient
platelet count.
51 will  be free from personality styles. inherent to the was able to be free
- irritable injury as evidenced individual. from injury as
- with a actual vital by: 2. Provide information > to promote evidenced by:
signs of: regarding the awareness
Temp: 38.6 a. Demonstrate condition that may a. demonstrating
RR: 25 behaviors (lifestyle result in risk for injury. corrective measure
PR: 84 changes to such as avoid using
> An increase in
HR: 85 reduce risk 3. Monitor pulse, too much force upon
pulse with decreased
BP: 100/80 factors and protect Blood pressure. tooth brushing;
Blood pressure can
- IV: D5NSS 140 cc/hr self from injury);
indicate loss of
- few bruises in the b. Modify environment b. Modifying the
circulating blood
lower extremities to enhance safety; environment by
volume and may point
and out to bleeding. removing mess in her
c. Verbalize room that might cause
understanding of injury to her.
factors that contribute 4. Check on patient at > this is a primary
to possibility of injury. least every 2 hours. preventive measure to
ensure patient safety