Risk for Injury r/t unsteady gait s/t post lumbar puncture Reviewed by Momizat on . Cues Subjective: “Malikot talaga siya.” as verbalized by the mother. Objective: - needs assistance in walking or standing - unsteady gait - wobbles when standin Cues Subjective: “Malikot talaga siya.” as verbalized by the mother. Objective: - needs assistance in walking or standing - unsteady gait - wobbles when standin Rating:
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Risk for Injury r/t unsteady gait s/t post lumbar puncture

Cues

Subjective:

“Malikot talaga siya.” as verbalized by the mother.

Objective:

- needs assistance in walking or standing

- unsteady gait

- wobbles when standing or walking by himself

- post lumbar puncture

- with a diagnosis of status epilepticus secondary to bacterial meningitis secondary to mastoiditis

- does not want to stay at one place for a long time

Need

Health Perception/ Health Management Pattern

Nursing Diagnosis

Risk for Injury related to unsteady gait secondary to post lumbar puncture

® Patients who have unsteady gait are at risk for injury. Unsteady gait is one of the effects after lumbar puncture. It is due to light headedness felt after the procedure.

Objectives of Care

Within 8 hours span of care, the patient will be free from injury as evidenced by:

a. absence of bruises and any wound that are caused by injury;

b. demonstration by the significant others safety techniques and environmental modification to prevent injury (such as: assist patient in rising up in bed, raise side rails, provide necessary things at patient’s reach)

 

Interventions

1.  Reduce hazards such as rugs, electrical cords and cellophanes

® to assure prevention of accidental slip.

2. Wear appropriate footwear (rubber soled shoes or slippers) when out of bed or ambulating

® to ensure that the grip of the feet to the floor is tight.

3. Always keep the siderails up when in bed.

® to prevent accidental falls.

4. Place bed in the lowest possible position.

® this reduces the risk for falls and serious injury.

5. Instruct to ask for assistance as needed. (eg. Rising up in bed, and on Activies of Daily living; eating, changing clothes)

® to avoid injury and save patient’s energy.

6.  Alternate activity with periods of rest and/or uninterrupted sleep.

® to prevent fatigue and pain/headache.

Bibliography: Doenges,M.et.al.Nurses Pocket Guide.11th edition.Philadelphia :FA Davis Company.©2008.pp414-418.

Evaluation

After 8 hours span of care, the patient will be free from injury as evidenced by:

a.)   absence of bruises and any wound that are caused by injury;

b.)   demonstration by the significant others safety techniques and environmental modification to prevent injury (such as: assist patient in rising up in bed, raise side rails, provide necessary things at patient’s reach)

 

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