NURSING CARE PLAN
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
a
Subjective: Risk for falls related Short-term Goal: Independent: Short term:
vi
“Kapag kailangan to decreased lower After two (2) hours Assessed muscle To assess degree Goal met. The
kong mag-C.R. extremities strength of nursing strength, gross of risk of falling, patient has an
d
kailangan may intervention, the and fine motor altering increased in lower
e
nahahawakan ako patient will have an coordination coordination, gait extremities strength
ar
o may umaalalay increased in lower and balance as evidenced by
sakin, hindi ko pa extremities strength Lovett’s Scale of
sh
masyadong as evidenced by Evaluated client’s To appraise ability UR = 5/5, UL = 5/5
kayang tumayo at Lovett’s Scale of cognitive status to perceive own LR = 5/5, LL = 5/5
maglakad mag- UR = 5/5, UL = 5/5 limitations or (normal strength)
as
isa”, as verbalized LR = 5/5, LL = 5/5 recognize danger
by the patient.
w
Furosemide
“Nanghihina pa Reviewed causes headache,
m e
‘yung mga paa at medication weakness,
binti ko ”, as
stated by the co rc Long-term Goal:
After two (2) days
regimen and how
it affects patient.
confusion,
balance and gait
o. ou
patient. of nursing Monitor drug’s disturbances Long term:
intervention, the effects or side There is no noted
er res
Objective: patient will not effects injury caused by
Activity Level = experience falling To monitor safety falling during her
Level III (requires Instructed the and to avoid stay in the hospital
eH y
assistance or relative to falling and the patient is
rs ud
supervision from intensify patient now discharged.
another person or supervision
device To help
t
ss
Morse Fall Scale = Encouraged strengthen
hi
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
a
Subjective: Risk for falls related Short-term Goal: Independent: Short term:
vi
“Kapag kailangan to decreased lower After two (2) hours Assessed muscle To assess degree Goal met. The
kong mag-C.R. extremities strength of nursing strength, gross of risk of falling, patient has an
d
kailangan may intervention, the and fine motor altering increased in lower
e
nahahawakan ako patient will have an coordination coordination, gait extremities strength
ar
o may umaalalay increased in lower and balance as evidenced by
sakin, hindi ko pa extremities strength Lovett’s Scale of
sh
masyadong as evidenced by Evaluated client’s To appraise ability UR = 5/5, UL = 5/5
kayang tumayo at Lovett’s Scale of cognitive status to perceive own LR = 5/5, LL = 5/5
maglakad mag- UR = 5/5, UL = 5/5 limitations or (normal strength)
as
isa”, as verbalized LR = 5/5, LL = 5/5 recognize danger
by the patient.
w
Furosemide
“Nanghihina pa Reviewed causes headache,
m e
‘yung mga paa at medication weakness,
binti ko ”, as
stated by the co rc Long-term Goal:
After two (2) days
regimen and how
it affects patient.
confusion,
balance and gait
o. ou
patient. of nursing Monitor drug’s disturbances Long term:
intervention, the effects or side There is no noted
er res
Objective: patient will not effects injury caused by
Activity Level = experience falling To monitor safety falling during her
Level III (requires Instructed the and to avoid stay in the hospital
eH y
assistance or relative to falling and the patient is
rs ud
supervision from intensify patient now discharged.
another person or supervision
device To help
t
ss
Morse Fall Scale = Encouraged strengthen
hi
