Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Risk for Injury Goal I. Assess for Communication

Cues: related to impairment in problems such as
language barriers and After 8 hours of
altered Within 8 hours communication. speech and hearing nursing
“ I sit mobility as of nursing difficulties may affect intervention, the
differently. evidenced by intervention the client’s ability to goal was partially
When I play psychomotor and process information met as evidenced
the piano. factors treatment, the placing them at risk to by determining
experience an adverse factors that
And when patient will event in the hospital. increases the
I’m away determine the patient’s risk for
from the factors that I. Avoid the use Restraints can cause injury and
piano I increases their of physical and injuries such as demonstrating
occasionally risk for injury chemical strangulation, behaviors to
asphyxiation, trauma, avoid injury.
look and will restraints. or head injury. If
differently. demonstrate Obtain a health restraint is needed,
From other behaviors to care provider’s ethical principles of
people. And avoid injury. order if proportionality and
this has restraints are purposefulness should
be applied
caused. needed.
Dislike. From
people.” As I. Utilize Alternatives to
verbalized alternatives to restraints may include
the patient. restraints that alarm systems with
ankle or wrist
can be used to bracelets, alarms for
Objective prevent falls bed or wheelchairs,
Cues: and injuries. close and frequent
monitoring of the
VS: patient, locked doors
to the unit, keeping
the bed low, etc.
BP- 110/90
T- 37 I. Avoid Patients with
RR- 18 extremes in decreased cognition
O2sat- 100 temperature or sensory deficits
cannot discriminate
between extremes in
temperature.

I. Place the Moving the client’s

patient in a room closer to
the nurse station
room near the allows the health care
nurses’ station. provider to closely
observe patients at
high risk for injury and
falls and promptly
provide interventions.
I. Validate the Validation lets the
patient’s patient know that the
nurse has heard and
feelings and understands the
concerns information and
related to concerns.
environmental
risks.