NURSING CARE PLAN

NURSING
NURSING
ASSESSMENT PLANNING INTERVENTIO RATIONALE EVALUATION
DIAGNOSIS
N
Subjective: Risk for falls Short-term Independent: Short term:
• “Kapag related to Goal: • Assessed • To assess Goal met. The
kailangan decreased After two (2) muscle degree of risk patient has an
kong mag-C.R. lower hours of nursing strength, of falling, increased in
kailangan may extremities intervention, gross and fine altering lower
nahahawakan strength the patient will motor coordination, extremities
ako o may have an coordination gait and strength
umaalalay increased in balance as evidenced by
sakin, hindi ko lower Lovett’s Scale
pa masyadong extremities • Evaluated • To appraise of
kayang strength as client’s ability to UR = 5/5, UL =
tumayo at evidenced by cognitive perceive own 5/5
maglakad Lovett’s Scale status limitations or LR = 5/5, LL =
mag-isa”, as of recognize 5/5 (normal
verbalized by UR = 5/5, UL = danger strength)
the patient. 5/5
LR = 5/5, LL = • Furosemide
• “Nanghihina 5/5 • Reviewed causes
pa ‘yung mga medication headache,
paa at binti ko regimen and weakness,
”, as stated by how it affects confusion,
the patient. patient. balance and
Long-term Monitor gait Long term:
Objective: Goal: drug’s effects disturbances There is no
• Activity Level After two (2) or side effects noted injury
= Level III days of nursing caused by
(requires intervention, • Instructed the • To monitor falling during
assistance or the patient will relative to her stay in the
 supervision not experience intensify safety and to hospital and the
from another falling patient avoid falling patient is now
person or supervision discharged.
device
• Morse Fall • Encouraged • To help
Scale = 45 patient to strengthen
(low risk, exercise or musculoskelet
implement gradually al strength of
standard fall mobilize her the lower
precaution) lower extremities
• Lovett’s extremities
Scale(Muscle such as
strength performing
grading) : UR flexion-
= 5/5, UL = extension
5/5, exercise,
LR = 4/5, LL = sitting-
4/5 standing
(with exercise and
movement trying to
against the make few
gravity and small steps • To strengthen
when alone physical
resistance is support and
added but has help in
limited range • Assisted rehabilitation
of motion) patient in
treatment • To minimize
regimen like the risk of fall
early from the bed
ambulation

• Kept side rails

up