ASSESSMENT CUES NURSING

DIAGNOSIS

PLANNING and

OUTCOME

NURSING

INTERVENTION

RATIONALE EVALUATION

S:

“Wala na akong

nararamdaman sa kanang

paa ko.. Gusto ko kasi

maglakad lakad dito sa

ward”

As verbalized by patient

O:

- (+) Gangrene

- Right foot cellulitis

- Open wound at right

foot

Risk for injury related

to altered sensory

perception at right foot

Short term:

After 6hrs of nursing

interventions the

client will able to

determine ways of

preventing further

foot injury

Long term:

After 2 days of

nursing interventions

the patient will be

able to avoid further

injury to foot

Independent

Assess general status

of the client

Assess mood coping

abilities, personality

style that may result in

carelessness

Assess environmental

factors that may lead

to injury

Provide comfort and

safety measures,

placed side rails up

Provide assistance

when client is

ambulating

To determine client’s

condition that may

cause injury

To determine level of

cooperation

To determine any

possible causes of

injury

To provide a safe

environment for client,

and to avoid further

injury or falls

To ensure safety and

avoid any possible

complications