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EMILIO AGUINALDO COLLEGE

School of Nursing

POTENTIAL NURSING CARE PLAN

PATIENT NAME: _________________MEA________________ AGE: __71____


GENDER:______F_______

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION


Subjective: Risk for Falls r/t body Within 2 to 3 hours of  Identify factors that affect To know the intervention After 2 to 3 hours of
weakness rendering proper nursing safety needs. that will be established. rendering proper
intervention, the patient nursing intervention,
will be free from fall.  Assess the patient ability to It is helpful to determine the patient will be free
ambulate safely with or the client’s functional from fall as evidenced
without assistive devices. abilities to plan for ways by ability to explain the
of improving the safety precautions.
problem areas
 Thoroughly orient the patient
to environment. For the client to
Objective: familiarize the
>decreased strength in  Ask the significant others to surroundings.
lower extremities always stay with the client. To prevent the patient
>weak in appearance from falling on bed.
 Instruct the patient to call for
Scientific Explanation: assistance when moving. To reduce the risk of
Increased susceptibility  Put side rails. falling.
to falling that may cause
physical harm.  Provide assistive devices for For the clients support.
walking such as cane, crutches
and/ wheelchairs.

 Ensure that the patient To prevent from


wears proper shoes slippering
EMILIO AGUINALDO COLLEGE
School of Nursing