# 4 Diagnosis: Risk for injury related to altered secondary to autoimmune

dysfunction

Cues and Nee Desired Nursing Rationa evaluation

background ds outcome Intervention le
knowledge s and
indicatio
n
Subjective: “dili S Goals: • check • f Within 8 hours of
ko kalihok og A Be free vital signs or nursing care the
tarong” as F from especially base patient was able
verbalized by E injury the blood line to:
the patient T pressure data
Y Within and a.) free from
Objective: the 8 reco injury
• body A hours of rd b.) modified
malaise N nursing VS environment
• impaired D care, the for as indicated
vision in patient • ascertain docu to enhance
the right S will be knowledg men safety
eye E able to: e of t- c.) demonstrate
• impaired C safety atio d
hearing U a.)modify needs or n behaviours,li
acuity R environm injury purp festyle
• large I ent as preventio oses changes to
body T indicated n reduce risk
physique Y to motivatio • t factors and
enhance n o protected
• blood
safety prev self from
pressure
ent injury
: b.) • assess injur d.) the goals
150/100 demonstr client’s y in were met.
mmhg ate muscle hom
behaviou strength e
background rs,
knowledge: at and
lifestyle in
risk of injury as • provide
changes com
a result of healthcar
to reduce mun
environmental e within a
risk i-ty
condition culture of
factors setti
interacting with safety
and ng
the individuals protect
adaptive and self form
defensive • place • t
injury o
resources assistive
devices if iden
possible tify
risk
for
falls
• encourag • t
e use of o
relaxation prev
technique ent
s error
s
• raise side resul
rails ting
in
clien
t
injur
y

• t
• administe o
r redu
medicatio ce
n as risk
prescribe of
d by the injur
doctor y
• refer to
other • t
resources o
as redu
indicated ce
(counselli or
ng) man
age
stres
s

• t
o
prev
ent
pati
ent
from
fall

• t
o
pro
mot
e
well
ness
• f
or
self
phas
e
lear
ning