Assessment

Diagnosis

Planning
Short term:

Objective:

Ascending
paralysis
Left and
right leg
paralysis

Risk for fall

related to leg
paralysis

Within an
hour of
nursing
intervention,
the client will
verbalize
understandin
g of individual
risk factors
that
contribute to
possibility of
falls

Intervention
Independent:
Established
rapport

Long term:

After 8 hours
of nursing
intervention,
the client will
be free from
injury

Vitals were
assessed and
noted
Identified
factors that
affect safety
needs

Thoroughly
orient the
patient to
environment
Asked the
significant
others or
companion to
always stay
with the client

Side rails were

kept up

Instructed
client to push
the buzzer if
assistance is

Rationale

To gain
clients
cooperation
and trust
To provide
baseline
data

To know the
intervention
that will be
established

To
familiarize
client with
the
surrounding
s

To prevent
the patient
from falling
on bed

To reduce
risk of
falling

Evaluation
Short term
After an
hour of
interventio
n, client
verbalized
understan
ding of
risk factors
that
contribute
to
possibility
of falls
Long term:
After 8
hours of
interventio
n, client
was free
from injury
or fall

needed

To provide
clients
needs and
assistance