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.

List at least four (4) interventions the RN would implement to ensure the patient remains free from falls during the hospitalization.

                        Label each intervention as independent nursing action (intervention) or interdependent nursing action (intervention)

                        Provide a rationale for each action (intervention)

                        Provide a reference for each of your rationales

Compare your identified risk factors to a developmental stage other than the elderly (such as infant, toddler, school age child, adolescent, young adult or middle age adult). Are they alike or dissimilar?

How does the RN know the patient understands the teaching provided about a safe environment was effective?

Explanation / Answer

patients symptoms ;

In general the pateint may be suffering with a menengioma in the brain . menengioma are beneign tumors which are present in the frontal lobe of the brain . the menegiomas are extra axial tumors arise form the archaniod cells which are present in the brain and skull within ventricles and along the spinal cord .hypomania and schizopherina .the most common symptoms include mental change . they are misbehaved as the depression symptoms and are diagnized accordingly .

the 4 interventions that RN could do will be ;

1.mental state examination; pateint seem to alert ,oriented or vague and confused , decline in mental state may indicate for the cause for the falls or it may be result in head injury has caused a chronic subdural hematoma

2. visual impairement ; if there is a suggestion or poor sight examination of eyes . macular degeneration and visual field defects should be considered

3.cardiovascular examination ; bradychardia or trachycardia ,record blood pressure in sitting and standing

4.neurological and locomotory symptoms ; assement of sensory system, muscle tone , loss of vibration sensation, try to reproduce the vertrebrobasilar symptoms ,checking the nystgamus and brefiely for cordination . the proximal myopathy ,is gait normal , they may indicate the parkinsons disease ,some gait abnormalities due to arthiritis .

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