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West Visayas State University

COLLEGE OF NURSING

La Paz, Iloilo City

 NURSING CARE PLAN

 Name of Patient: G.L. Atten!in" P#ysi$ian: %r. &.

A"e: '( years ol! War!)*e! N+mer: &&SW no. ( Im-ression ) %ia"nosis: o$al seiz+re /it# !ys$o"nitive

feat+res0 #y-ertensive $ar!iovas$+

!isease

Clustered Cues Nursing Diagnosis Rationale Outcome CriteriaNursing

InterventionsRationale Evaluation

07/07/!

"#00 $% Ris& 'or in(ur) related

to disorientation to

time and *lace+

'orget'ulness and

muscle strengt, o' -/.

%efinition:

At ris1 of in2+ry as a

res+lt of

environmental

$on!itions intera$tin"

/it# t#e in!ivi!+al3s

a!a-tive an!

!efensive reso+r$es.

4#e -atient /ill e

ale to re!+$e ris1 of

in2+ry as evi!en$e! y

free!om from

imalan$e or falls

after #o+rs of n+rsin"

intervention.

5. Assess level of 

$ons$io+sness

an!$o"nitive

level.

(. re6+ently

reorient of

time, -la$e,

5. Assists in

!eterminin"

 -atient3s ailityto -rote$t self an!

$om-ly /it#

re6+ire!self7-rote$tive

a$tions

(. 4#ese meas+res

are ne$essary in

en#an$in" $lient3s

memory.

07/07/!

0#00 $%

Goal met.

4#e -atient /as ale

to re!+$e ris1 of

in2+ry as evi!en$e!

free!om from

imalan$e or falls

after #o+rs of n+rsin

intervention.

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!ate an!

 -erson0 allo/

#im to

reminis$e0 an!

re-eat

instr+$tions asne$essary.

8. Provi!e

assistan$e as

nee!e! for

am+lation

an! in "ettin"

in an!

o+t of e!.

9. Re-la$e s#ar-

o2e$ts

razors; /it#

safer items.

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an! ta1in" $are of 

t#e $lient.

St+!ent3s Name: ========================================== 

Clini$al Instr+$tor: =========================================