Nursing Diagnosis Rationale Intervention Rationale Evaluation

Risk for fall r/t impaired -Vulnerable to increased •Assess severity of sensory or -Assessment factors will help After 3hrs of nursing
physical mobility susceptibility to falling, motor deficits, environmental identify appropriate interventionthe patient is
which may cause physical hazards and inadequate intervention. free from fall and was able
Objective: harm and compromise lighting, medicatiuse, to explain safety
improper use of assistive
•Absence of side rails health. precaution.
devices. -A patient who is not familiar
•decreased strength in with the placement of
lower extremities •Assess the patient’s furniture in an area or who
Older age environment for factors has inadequate lighting in the
⬇ associated with an increased house increases the risk for
Physiologic changes risk for fall. falls.
⬇
Balance impairment
⬇ •Advise the patient to wear -Wearing non-slip footwear
Loss of muscle strength shoes or slippers with non- help prevents slips and falls.
⬇ slip soles when walking.
Risk for Fall
-The patient should be
•Orient the patient to the familiarized with the bed,
surroundings. Avoid re- location of the bathroom,
arranging the furniture in the furniture, and other
room. environmental hazards that
can cause older patients to
trip or fall
•Encourage the family and
other significant others to
Goal plan: After 3hrs of
stay with the patient at all -Prevents the patient from
rendering proper nursing
times. accidentally falling.
intervention the patient
will be free from fall.
Resources: sparks & taylor
nursing pocket guide page Resources sparks & taylor
167-168, Scribd.com. nursing pocket guide page
167-168, Scribd.com.
 Nursing Diagnosis
Risk for injury r/t Age-
related diminished
physiologic reserve.
S: Natumba ko pag panaog
ko sa hagdan kay daw gulpi
nag binhod tiil ko
O:
No railings
Slippers everywhere
Rationale Intervention Rationale Evaluation
Rationale Assess general status of This is to determine the Goal met:
Vulnerable to physical the patient. patient’s condition that After 4hrs of nursing
damage due to may cause injury evaluation the patient is
environmental conditions able to know the safety
interacting with the Help patient identify To increase patient’s precautions in their home
individuals adaptive and situations and hazards that awareness of potential
defense resources which can cause accidents. danger
may compromise health
Encourage patient to make to decrease possibility of
Aging repairs and remove injury
potential safety hazards
⬇ from environment.
Poor balance
⬇ Educate patient about Patient’s knowledge about
safety ambulation at his or her condition is vital
Environmental home, including the use of to safety and recovery.
hazards safety measures such as
⬇ handrails in bathroom.

Goal: after 4hrs of nursing
intervention the patient
will take safety precautions
in and out of home
Risk for Injury Refer patient to
appropriate community
resources for more
information about
identifying and removing
safety hazards.
This enables patient and
family to alter
environment to achieve
optimal safety level.

Resources: Sparks & Taylor

Resources: Sparks & Taylor
nursing pocket guide page
nursing pocket guide page
210-213, Scribd.com.
210-213, Scribd.com.
 Nursing Diagnosis
Disturbed sleep pattern r/t
insomia
S: “nd ko mayo katulog kisa
bisan linong ang balay”
O: Insufficient energy
GOAL :
After 4hrs of nursing
intervention the patient
will be able to sleep
properly.
Rationale Intervention
Rationale: Assess patient daytime
activity and work pattern
Time-limited interruptions such as travel history,
of sleep amount and qualify normal bed time, sleeping
due to disruptions and environment, Use of
difficulty initiating sleep. alcohol and caffeine.
Provide patient sleep aid
such as pillow, bath before
Interruptions sleep, food or drink.
⬇ Teach patient in relaxation
Endogenous techniques such as guided
disturbance imagery, deep breathing,
meditation &
⬇ aromatherapy.
Trouble falling
asleep Instruct patient to
eliminate or reduce
⬇ caffeine and alcohol intake
Dissatisfaction and avoid foods that
Feeling unrested interfere with sleep.
Rationale Evaluation
- Assessment information Goal met:
will assist in selecting After 4hrs of nursing
appropriate intervention. intervention the patients
reported feeling well rested
- to promote ease in falling
asleep
- for purposeful relaxation
efforts to help promote
sleep
- it disrupts normal sleeps
especially when ingested
immediately before retiring

⬇ Instruct patient to provide - Exposure to bright lights,

Disturbed sleep a calm and quiet
environment and lessen
pattern
interruptions during nap
hours.
unnecessary noises, snoring
roommates, and loud
talking can result to sleep
deprivation.

Resources: Sparks & Taylor

Resources: Sparks & Taylor
nursing pocket guide page
nursing pocket guide page
99-102, Scribd.com.
99-102, Scribd.com.