Assessment

OBJECTIVE:Needs assistance
in ambulation
-Headache
-dizziness
-limited motionfeeling of warm
specially in the
eye
VS taken as
follows:
T-37
RR-28 cpm
BP140/100mmhg

Diagnosis
Risk for injury r/t
multiple factors
(Headache,
dizziness, limited
motion, feeling of
warm specially in
the eye, V/ST-37
c, RR- 28cpm, BP150/100mmhg)

Planning
Short term Goal:
At the end of
Nursing
intervention, the
client will be free
from any signs of
injury.
Long Term Goal:
After nursing
intervention the
risk factors of
client from pain
will be lessen.
After nursing
intervention ,the
client will
verbalized
understanding of
individual factors
that may
contribute to
possibility of
injury

Intervention
Assess general
status of the
client

Rationale
To determined
clients condition
that may cause
injury

Assess mood
coping abilities,
personality style
that may result in
carelessness

To determine the
level of
cooperation

Assess
environmental
factors that may
lead to injury

To determine
causes of injury

Promoting client
Safety by:
Monitoring V/S
Providing
materials for
injury prevention

To lessen the risk

for injury, safe
environment and
Promote clients
comfort.

Evaluation
GOAL
:The client was
free of any signs
of injury