EXPECTED

ASSESSMENT PLANNING INTERVENTION RATIONALE

OUTCOME
S: Within 2 to 3  Identify factors that affect To know the intervention that After 2 to 3 hours of
O: hours of safety needs. will be established. rendering proper
>decreased strength rendering proper nursing intervention,
in lower extremities nursing  Assess the patient ability to It is helpful to determine the the patient will be
>weak in intervention, the ambulate safely with or client’s functional abilities to free from fall as
appearance patient will be without assistive devices. plan for ways of improving evidenced by ability
>absence of side free from fall. the problem areas to explain the safety
rails precautions.
>presence of  Thoroughly orient the patient For the client to familiarize
scattered rugs to environment. the surroundings.

Nursing Diagnosis:  Assess vision and provide To provide well-lighted

Risk for Falls r/t adequate lighting to clearly see environment and avoid the
body weakness the pathway. occurrence of injury.
 Ask the significant others to To ensure clients safety.
Scientific always stay with the client.
Explanation:
Increased  Instruct the patient to call for To prevent the patient from
susceptibility to assistance when moving. falling on bed.
falling that may
cause physical  Put side rails. To reduce the risk of falling.
harm.
 Provide assistive devices for For the clients support.
walking such as cane, crutches
and/o wheelchairs.

 Ensure that the patient wears To prevent from slippering.

proper shoes