Nursing diagnosis | Nursing homework help


Nursing Diagnosis

Fall risk factors characterize things or factors that increase the chances of an older person failing. Falling of older people is basically caused by a combination of a number of risk factors. These risk factors increase with age. The probability of falling for an old man is directly proportional to the number of fall risk factors. One of the risk factors is poor reaction time for the elderly who may not be able to synchronize their activities (Lord & Sherrington, 2001). The second risk factor is an impaired walking pattern that is commonly referred to as gait. The Old man is said to have an unsteady and slow gait. The third risk factor is reduced muscle strength; the old man reports feeling weak; this increases his chances of falling. The fourth risk factor is visual impairment, the old man wears glasses and also has a hearing aid, and at this age, it can be difficult for him. The last risk factor is the fear of falling and limitation in mobility. The old man reports feeling weak; therefore while he moves, he will fear falling and at the same time, his mobility is limited due to his weakness.

One of the diagnoses that can be detected by the doctor is Alzheimer that causes a slow decline in memory and thinking. One of the other causes of Alzheimer is confusion of time and place. The nurse can diagnose the patient with Altered Mental Status (AMS), which is caused by head injury; AMS has an effect on speech, memory, attention, and thought. Gait apraxia and loss of memory is suggestive of Normal pressure Hydrocephalus (NPH). The only symptom that the old man exhibits that is typical to Parkinson disease is unsteady and slow gait, and feeling weak. The conclusion is Alzheimer is the probable disease because the others do not pass the threshold portrayed by the symptoms

Actual: NANDA-I diagnosis: Alzheimer’s disease-related to falling and alteration of mental status as evidenced by memory loss, confusion, feeling of weakness and low and unsteady gait.
Risk: NANDA-1 diagnosis: risk of advancing age as evidenced by impairment in both sight and hearing.
To diagnose Alzheimer, the nurse will have to rule out first conditions that would have similar symptoms like thyroid deficiencies and infections. The nurse or doctor will have to inquire from a close relative or person the medical history of the old man and also ask the old man to take some test on mental abilities. Now the nurse can refer the old man to a general practitioner who can be able to diagnose the Alzheimer. Three of the patient’s expected outcome are; use of available safety measures and devices, requests’ for assistance when needed, and absence of injury during hospitalization.
The first intervention is a dependent one that may require cataract surgery for the old man or the introduction of a peacemaker to reduce the falls (, 2015). The second intervention is interdependent one that involves multi-factorial interventions, which involves accessing the old man’s risk for falling, carrying out treatment and arranges referrals to reduce the identified risks. The third intervention is interdependent one: it involves the improvement of home safety for the old man, and this can be done with the assistance of an occupational The last intervention is independent; this method involves providing supplements such as Vitamin D to the old man to increase the strength in his bones and body.

The main risk factor that is common to both the elderly and the infants is head injury or brain infections. Other risk factors for falling in children are different e.g., children who are born “preterm” and born with light birth weight are at risk of falling (Pungello et al, 2010). The other cause of falling in infants is that they are not cognitively developed. Poor communication and limited health literacy can lead to lack of understanding between the patient and the nurse.
A nurse can ensure that a patient understand if the patient is able to if they are able to fill assistance forms, ability to identify name, purpose and timing of medication, good compliance and the patient’s ability to ask relevant questions.


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