Cues Nursing Diagnosis Goals and desired Nursing interventions Nursing Evaluation

outcomes implementation

Subjective: Risk for fall Within the 4 Independent: After the 4 hours of
related to hours of nursing nursing intervention
“Untes maga musculoskeletal the intervention, 1. Conduct a patient 1. Assess patient’s the patient will be
2018 gaha kel ya disorder as the patient will be assessment to identify any fall risk using Fall able to:
tumba yo. Flat na evidenced by able to: physical or environmental Risk Assessment
sahig nohay yo history of previous risks for falls, such as Tool (FRAT) and 1. Patient will not
pwede levanta falls. 1. To prevent tripping hazards. Hendrich II Fall sustain a fall.
Kay deficil gayot” any further Risk Model
(Back then around falls by Rationale: To identify any (HIIFRM) and 2. Patient will
2018, I fell down, reducing the potential risks for falls, so evaluate the relate the intent
flat on the ground risk factors they can be addressed and patient’s to use safety
it was hard to and prevented. environment. measures to
stand up) implementing prevent falls.
safety 2. Provide appropriate room 2. Provide
“Untes ta duwelle measures. lighting, especially at appropriate room 3. Patient will
El de mio pies night. lighting, especially demonstrate
Hindi ya man 2. To maintain at night selective
ara” the patient's Rationale: Patients, prevention
(Back then my feet mobility and especially older adults, have measures.
would hurt but not independence reduced visual capacity.
anymore) while Lighting an unfamiliar 4. Patient and
promoting environment helps increase caregivers will
“si tumba yo Bien safety. visibility if the patient must implement
de pisil gayot get up at night. In a study, strategies to
lebanta” 3. To educate the homes with adequate increase safety
(If I fall it will be patient on fall lighting report fewer falls and prevent falls
hard for me to prevention (Ramulu et al., 2021) in the home.
stand up) strategies and
proper use of 3. Regularly review the 3. Regularly review
assistive patient's medications to the patient's
Objective: devices. ensure that they are not medications before
contributing to any administering to
T: 36.3 instability or dizziness. the patient
PR: 78
RR: 17 Rationale: Ensure that the
BP: 110/70 patient's medications are not
contributing to any instability
 Has a history of or dizziness
previous fall. 4. Prohibit
 Currently 4. Discourage rearranging rearranging the
diagnosed with the furniture. furniture within the
arthritis household
Rationale: A fall is more
likely to be experienced by
an individual if the
surrounding is not familiar,
such as furniture and
equipment placement in a
certain area.

5. Educate the patient on the 5. Educate the patient

proper use of assistive on the proper use
devices and provide of assistive devices
assistance with them if and provide
needed. assistance with
them if needed
Rationale: Ensure that the
patient knows how to use the
devices correctly and safely

Dependent
6. Encourage the
6. Encourage the patient to patient to use a
use a cane, crutch, or
 walker when ambulating cane, crutch, or
to reduce the risk of falls. walker when
ambulating to
Rationale: Providing a reduce the risk of
stable base for walking and falls
preventing the patient from
tripping or losing their
balance.

7. Encourage the patient to 7. Encourage the

wear proper footwear for patient to wear
indoor and outdoor proper footwear
activities. such as shoes
and/or nonskid
Rationale: Prevent slips and socks
falls by ensuring that the
patient's shoes provide
proper traction and support.

8. Incorporate balance and 8. Encourage patient

strength exercises into the to do Chair Rise
patient's activities of daily Exercise or Sit-to-
living and provide Stand Exercise.
assistance if needed.

Rationale: Helps improve

the patient's balance,
strength, and stability