Marquez, Caren Joy B.

BSN 2-B (Group 6)

Nursing Diagnosis Objectives Nursing Interventions Rationale

Risk for injury After 24 hours of nursing 1. Observe the individual’s general health 1. Noting multiple factors that might affect
as evidenced by interventions, the patient status. safety, such as chronic or debilitating
orthostatic will verbalize 2. Evaluate the client’s current conditions, use of multiple medications,
hypotension (pregnant understanding of disorders/conditions that could recent trauma (especially a fall within the
woman) individual risk factors that enhance risk potential for falls. past year), prolonged bedrest/immobility,
contribute to the 3. Ascertain the client’s/significant unstable balance on standing, or a
possibility of falls, other’s (SO’s) level of knowledge about sedentary lifestyle.
demonstrate behaviors and attendance to safety needs. 2. Acute, even short-term, situations can
and lifestyle changes to 4. Consider hazards in the care setting affect any client, such as sudden dizziness,
reduce risk factors and and/or home/other environment. positional blood pressure changes, new
protect self from injury, medication, change in glasses
modify environment as prescription, recent use of alcohol/other
indicated to enhance drugs, and so on.
safety, and be free of 3. This may reveal a lack of understanding,
injury. insufficient resources, or simple disregard
for personal safety.
4. Identifying needs or deficits provides
opportunities for intervention and/or
instruction.