Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for falls related After 8 hours of Independent After 8 hours of
Nahihilo po ako ata to hypostatic nursing - Observe -noticing factors nursing intervention,
parang sumasakit hypotension as intervention, the individual’s general that might affect the patient was able
ang ulo ko,” as evidenced by patient will be able health status, safety, such as to be free of injury.
verbalized by the headache, fainting to be free of injury. chronic or
patient when standing, debilitating con-
dizziness ditions, use of
Objective: multiple
-dizziness medications, recent
-headache trauma.
Fainting when - Assess muscle -altering coordina-
standing or strength, gross and tion, gait, and
extending neck, fine motor balance.
coordination. -Affects ability to
-Evaluate client’s perceive own
cognitive status limitations or
(e.g., brain injury, recognize danger.
neurolog-
ical disorders;
depression).
-Assess mood, - Individual’s
coping abilities, temperament,
personality styles. typical behavior,
stressors, and level
of self-
esteem can affect
attitude toward
safety issues,
resulting in
carelessness or
increased risk-
taking without
consideration
of consequences.
-