Scenario: An 84-year-old male is admitted today after falling at home. He had a

Question

Scenario: An 84-year-old male is admitted today after falling at home. He had a change in mental status over the last 2 months. He is oriented to person but thinks it is 1994, that he is in his home, and he is looking for his wife who died three years ago. He wears glasses and has a hearing aid in his right ear. His gait is slow and unsteady and he reports feeling weak.

Create a discussion post in response to the following using information provided in the scenario and taking the information that was read in the assignments & applying it to the scenario:

List at least four (4) factors that place this patient at risk for falls

Identify the nursing assessment(s) that provide(s) the data to determine the appropriate nursing diagnoses for this patient

List two nursing diagnosis statements for this patient

Actual: NANDA-I diagnosis, an etiology and the defining characteristics (nursing diagnosis + related to + as evidenced by).

Risk: NANDA-1 diagnosis + etiology(related to)

Identify the data cluster (grouping of significant data that points to the existence of the patient health problem) used to select the nursing diagnosis.

Identify one patient outcome (realistic, measureable and contains a time frame).

Explanation / Answer

Factors that place this patient at risk for falls include,

1. Severe hypertension or hypotension

2. Disturbed vestibulocochlear functioning (essential for equilibrium the patient has already reported with unstead walk).

3. Disturbed eye sight

4. Anti-psychotic drus usage: these drugs cause sedation and drowsiness, which may cause sudden falls.

5. Malnutrition and fear of falling

The data to determine the appropriate nursing diagnoses for this patient include,

1. Taking the history of his current medication

2. ECG of heart and EEG of brain

3. Assessment of eye sight and vestibular functioning

4. Taking the blood profile, and observing any signs of nutrional deficiency

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