CUES

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

SELECTED INTERVENTION

IMPLEMENTED INTERVENTIONS

RATIONALE

EVALUATION

OBJECTIVE: -Needs assistance in ambulation -Headache -dizziness -limited motion -feeling of warm specially in the eye -VS taken as follows: T-37 C RR-28 cpm BP-150/100 mmhg

Risk for injury r/t multiple factors (Headache, dizziness, limited motion, feeling of warm specially in the eye, V/S T-37 c, RR- 28 cpm, BP150/100 mmhg)

The Increase o f BP and RR will result to hypertension which may affect the clients lost of balance, in relation to limitation of movements the client is unable to gain his balance and protect his self that leads to possible injury.

Short term Goal: At the end of Nursing intervention, the client will be free from any signs of injury. Long Term Goal: after nursing intervention the risk factors of client from pain will be lessen. After nursing intervention , the client will verbalized understanding of individual factors that may contribute to possibility of injury.

Assess general status of the client Assess mood coping abilities, personality style that may result in carelessness Assess environmental factors that may lead to injury Promoting client s Safety by: Monitoring V/S Providing materials for injury prevention

Assessed general status of the client. Assessed mood coping abilities, personality style that may result in carelessness. Assessed environmental factors that may lead to injury. Promoted client s Safety by: Monitored V/S Provided materials for injury prevention

To determined client s condition that may cause injury To determine the level of cooperation To determine causes of injury To lessen the risk for injury, safe environment and Promote client s comfort.

GOAL: The client was free of any signs of injury.