ASSESSMENT S: O: >decreased strength in lower extremities >weak in appearance >absence of side rails >presence of scattered rugs Nursing Diagnosis:

Risk for Falls r/t body weakness Scientific Explanation: Increased susceptibility to falling that may cause physical harm.

PLANNING

INTERVENTION

RATIONALE To know the intervention that will be established. It is helpful to determine the clients functional abilities to plan for ways of improving the problem areas

Within 2 to 3 Identify factors that affect hours of safety needs. rendering proper nursing Assess the patient ability to intervention, the ambulate safely with or patient will be without assistive devices. free from fall.

EXPECTED OUTCOME After 2 to 3 hours of rendering proper nursing intervention, the patient will be free from fall as evidenced by ability to explain the safety precautions.

Thoroughly orient the patient For the client to familiarize to environment. the surroundings. Assess vision and provide adequate lighting to clearly see the pathway. Ask the significant others to always stay with the client. To provide well-lighted environment and avoid the occurrence of injury. To ensure clients safety.

Instruct the patient to call for To prevent the patient from assistance when moving. falling on bed. Put side rails. To reduce the risk of falling.

Provide assistive devices for For the clients support. walking such as cane, crutches and/o wheelchairs. Ensure that the patient wears To prevent from slippering. proper shoes