NURSING MANAGEMENT (NCP)

CUES	NURSING DIAGNOSIS	SCIENTIFIC EXPLANATION	PLANNING	INTERVENTIONS	RATIONALE	EVALUATION
S> O O>conscious    >appears    weak    >irritable    and restless    at times    >(+) seizure    >with lab    results as      follows: Serum Na-101.2 mmol/l Serum K- 1.75 mmol/l    > with VS as    follows:    BP- 160/100    T- 35.9    P- 87    R-15	Risk for falls related to muscle weakness and episodes of seizures secondary to low levels of potassium in the blood	Because potassium and sodium are needed for normal nerve conduction and muscle function, low plasma potassium and sodium levels can often lead to weakness and can lead to falls or seizures Hypertension can cause deprivation of body cells of O2 secondary to decrease blood flow resulted from vasoconstriction. This can in turn causes weakness of the muscles and dizziness	After 8 hours of nurse-patient interaction, patient will be able to reduce risks of falls as evidenced by an absence of falls, bruises and seizures	1.        Establish rapport 2.        Assess general conditions 3.        Monitor VS 4.        Assist in treatments and provide information regarding patient’s present condition 5.        Discuss consequences of previously determined risk factors 6.        Discuss side effects of anti-hypertensive drugs 7.        Stress importance of monitoring conditions that may contribute to occurrence of falls 8.        Employ seizure precautions 9.        Keep bed in a low position with padded side rails up 10.     Before the client walk, clear the path of obstacles and place non-slippery shoes on the client	1.        To gain trust 2.        For baseline data 3.        To determine alterations which may indicate a need for interventions 4.        To determine individual risks 5.        For follow up instructions and interventions 6.        This can contribute to weakness and balance 7.        To reduce risks 8.        To minimize 9.        risk for injury	Goal met, patient was able to reduced risks of falls as evidenced by an absence of falls, bruises, contusions and seizures