ASSESSMENT SUBJECTIVE CUES Mokupot ko sa mga butang dong padulong sa CR para dili ko matumba as verbalized by the patient.

OBJECTIVE CUES - Movement needs assistance - Age 91 years old - Presence of Deep Vein Thrombosis, Left Leg - Impaired physical mobility

NURSING DIAGNOSIS Risk for Fall related to impairment of physical mobility.

SCIENTIFIC REFERENCE Patient with Deep Vein Thrombosis commonly has impaired physical immobility. It is due to their weaknesses commonly on the lower extremities. It is due to the blockage caused by the Thrombus. Patient with DVT are also at risk for injury/falls, because it is really hard for them to move, especially in terms of just standing-up or barely walking around. They commonly need assistance in doing these activities and their activities of daily living. Source: http://www5.aaos.org/dvt /main.cfm

GOAL / OBJECTIVES Throughout the Nursing Care rendered (24 hrs./7 days a week) the patient has the privilege to be in safe at all times and be free of injury.

INTERVENTIONS 1. Greet and smile towards the patient with peace be with you and a good morning. 2. Review safety measures. 3. Remove environmental hazards. 4. Assist client reposition self on a regular schedule.

RATIONALE 1. To establish rapport and gain trust from the patient. 2. To prevent untoward accidents. 3. To have a safe free environment. 4. The patient has a weakness and needs assistance in repositioning in order to prevent falls 5. To promote wellness and prevent unnecessary movements that can alter the safety of the patient. 6. To avoid falls from bed that can lead to injury. 7. In terms of safety, the patient must be prioritized first, because she has her weakness that puts her at risk for injury.

EVALUATION

5. Provide rest and comfort to the patient.

6. Side rails up during time of sleep or resting 7. Coordinate with the SOs in maintaining the patients safety as the priority.

NURSES SIGNATURE _______________________________