Cues Nursing Goals and Rationale Interventio Evaluation

Diagnosis Objectives n
S> client Risk for fall Goal: After the shift, the client
speaks related to After the shift, was able to have
gibberish vertigo the client will reduced risk for fall
secondary have reduced related to vertigo
>client to risk for fall
said that increased related to
he intracranial vertigo
experience pressure
s headache Objective: Vertigo is a sensation of Discussion
at the right After 5mins of shift balance thus makes
parietoocci intervention, the person at risk for fall
pital region the client or
of his head his
companions
> he said will be able to
that he define vertigo
experience *Accompany client when Discussion
s difficulty After 15mins Accompany client when
in moving of interaction, going to commode
the right the client or *provide adult diapers
part of his his *provide urine bottle
body companions
will be able
O> cannot enumerate
sit without ways to Well being is a subjective Assessme
assistance prevent falls perception of a vitalit and nt
feeling well… can be
>client described as objectively,
swings side experienced and measured…
by side after 20 mins and can be plotted on a
when of continuum
trying to sit intervention, Reference: Hood and Leddy,
upright the client will 2003,. P.164
be able to
appreciate the
care rendered
by nurse as
manifested by
verbalization,
smile, or any
positive
response