Assessment Nursing Analysis Planning Intervention Rationale Evaluation

Diagnosis

SUBJECTIVE : Risk for injury In the patients After an 8 hour shift, INDEPENDENT After an 8 hour
related to with Cushing's the patient will be shift the patient
Patient 1. Obtain patient’s muscle - To monitor risk for
decreased syndrome, excess able to: was able to
reported that strength. fall.
bone density aldosterone lead to remain free of
she had and muscle increase secretion of - Remain free of 2. Discuss with patient safety - The client needs to injuries, verbalize
developed injuries. measures for ambulation check the home and
weakness potassium that blocks understanding of
fairly profound and daily activities; work environment
calcium absorption -Verbalize individual factors
muscle encourage Use of assistive for hazards to
and cause decrease understanding of that contribute
weakness and devices during ambulation prevent falls and
bone density which individual factors fractures. These to possibility of
was unable to may be the cause of that contribute to hazards include injury
lift her 3-year- compression fracture possibility of injury loose rugs, highly
old child in the lumbar spine of waxed or wet floors,
the patient and results and stairs with poor
to muscle weakness lighting or
OBJECTIVE: that risks her for inadequate
injury handrails.
- Laboratory
testing 3. Establish a protective - Have enough
showed environment to prevent lighting in the room,
urine-free falls, fractures, and other and wear glasses
cortisol injuries to bones and soft and shoes when
values of tissues. getting out of bed,
228, 235, to reduce the
265, and chance of falls that
246
may result in
injuries.
4. Instruct the patient to To avoid pain or injury
correct body mechanics. during activities

 Bend at your hips and - This helps you

knees instead of your maintain your
waist. balance by dividing
your weight evenly
between your upper
and lower body
 Spread your feet apart - This helps you
to create a foundation maintain your
of support. balance from side to
side.
 Keep your back, neck, - Do not twist or bend
pelvis, and feet aligned at your waist
when you turn or
move.

5. Encourage patient for - Periods of rest are

rest/sit and refrain from energy saving
performing nonessential techniques and
activities or procedures. refraining non-
essential activities
helps prevent
injuries
6. Encourage the client to eat - Client with
a high-protein, potassium Cushing’s disease
diet and increase dietary develop
intake of calcium, and osteoporosis (fragile
vitamin D. bones). Calcium and
vitamin D are
 important in
strengthening
bones. High-protein
diet can help
prevent the muscle
loss

DEPENDENT DEPENDENT

1. Administer medication as
ordered.

- Mifeprestone - To block the effects of

cortisol on tissues.

COLLABORATIVE COLLABORATIVE

1. Referral to a dietician may - Reducing sodium

assist the patient in intake, Increasing
selecting appropriate foods calcium and vitamin
that helps with patient’s D intake and Eat
disorder Protein-Rich Foods