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Vince John B.

Sevilla N21 Butuan Medical Center OB Ward

Assessment Diagnosis Planning Intervention Rationale Evaluation
Short term: Independent: Short term:
Subjective Cues:SO stated -Risk for injury Within 8 hours of nursing 1. Assess general - This is to determine Within 8 hours of nursing
Hapit sya mahulog sa katri interventions the patient will status of the the patients condition interventions the patient
imaging adlaw be able to remain free of patient. that may cause injury. was able to remain free of
injuries. 2. Assess mental - Mood coping abilities injuries.
Objective Cues: status of the and style of
-Orthostatic hypotension Long term: Within 3 days of pt. , mood personality aid to Long term: Within 3 days
noted nursing interventions the coping determine the of nursing interventions
-Delay capilliary refill patient will be able to abilities, patients level of the patient was able to
approximately 3secs explain methods to prevent personality cooperation. explain methods to
-Hypotension injury. style that may -Patients experiencing prevent injury.
-Tachycardia . result in impaired mobility,
-Tachypnea carelessnes. impaired visual acuity,
-Body weakness 3. Assess the and neurological
environment dysfunction, including
for threats to dementia and other
safety such as cognitive functional
slippery floors deficits, are at risk for
unstable stairs injury from common
and stairwells, hazards.
blocked - The patient must get
entries, high used to the layout of
beds without the environment to
rails, blocked avoid accidents. Items
IV stand. that are too far from
4. Ask or the pt the patient may cause
to conform hazard.
about the -This is to prevent the
environment\\ patient from
5. Assist patient accidentally falling or
in doing pulling out tubes.
activity such This is to prevent the
(waking up in patient from
bed, drinking any unpleasant
water, Eating experience due to
and etc.) dangerous objects.
6. Eliminate the
hazard to pt -Reduces defensive responses,
such as hot promotes trust and enhances
water, sharp cooperation.
objects, and
etc. -to provide assessment about

-to provide comfort which is also

a diversional activity
1. Administer analgesics, as
indicated to maximum
dosage as needed.
-To divert patients feeling of
pain with the use of music or
-to promote healing
2. Cooperate with the family
-to promote wound healing and
of the client to document
to relief pain discomfort
the health of the patient
-Pain result in fatigue, which
lead to exaggerated pain.

-to maintain acceptable level of