Assessment Nursing Planning Intervention Scientific Rationale Evaluation

Diagnosis
Subjective Data: Risk for Injury After 2 hours of Independent: Independent: After 2 hours of
“mahadlok siya maka related to nursing intervention 1. Note client’s age, gender, 1. Affects client’s nursing
dungog ug tingog sa sensory client’s environment developmental stage, ability to intervention
razor” as verbalized integration will: decision making ability, protect self client’s
level of and/or others,
by the teacher. dysfunction  Modify environment
cognition/competence. and influences
related to environment are:
2. Assess mood, coping choice of
hypersensitivity as indicated abilities, personalities interventions  Modified
Objective Data: - to certain to enhance styles(e.g. temperament, and teaching. as
 head-banging stimuli in the safety aggression, impulsive 2. Because this indicated
behavior environment  Be free of behavior). may result in to
 Easily gitated injury 3. Assess client’s muscle carelessness or enhance
strength, gross and fine increase risk safety
motor coordination. taking without  Free of
4. Monitor environment for considerations injury
potentially unsafe of
conditions and modify as consecquences.
needed, and Orient or 3. To identify risk
reorient client to for false.
environment, as needed. 4. To prevent the
risk for injury
5. Educated parent’s about 5. To inform and
their child’s for them to
disorder/problem. understand
6. Encourage the parents to their child.
Maintain bed or chair in 6. To prevent child
lowest position with wheels risk from fall.
locked. 7. To prevent
7. Ensure that floors are clear stumbled and
of hazards and that risk for injury
pathway to bathroom is 8. To prevent
 unobstructed and properly stimulate
lighted. tantrums that
8. Provide a calm and quiet will lead to self
environment. harm.
9. Encourage parents to create 9. Because this
a safe environment by can cause
removing sharp objects, injury when not
cover sharp corners. monitored.
Collaborative: Collaborative:
1. Refer to physical or 1. To identify
occupational therapist, as high-risk tasks,
appropriate. conduct site
visits; select,
create, modify
equipment or
assistive
devices; and
provide
education
about body
mechanics and
musculoskeleta
l injuries, in
addition to
providing
therapies as
indicated.