Nursing diagnosis
Risk for trauma/falls
Due to impaired physical mobility, Loss of muscle strength, disorientation, presence of illness, use of medications
Hypothermia
Age-related changes in thermoregulation and environment exposure
Reduction in body temperature below the normal range
Shivering
Cool skin
Pallor
Tachycardia
Decreased cardiac output
Can lead to reduced brain oxygenation, and age-related diminished cardiac functions
Disturbed sleep pattern
Unfamiliar surroundings and hospital routines/interruptions
Risk for infection
Age-related changes in immune and integumentary systems and/or suppressed inflammatory response occurring with long-term medication use (e.g., steroids, analgesics, anti-inflammatory agents), slowed ciliary response, or poor nutrition
Risk for impaired Skin integrity
Reduced subcutaneous fat and decreased peripherally capillary network in the integumentary system
Constipation
Changes in diet, decreased activity, and psychosocial factors
Depression
Loss of independence, loss of functional ability, cognitive impairment
Outcome
Outcomes should be measurable, concise, and time limited
The patient will not experience any falls.
The patient will not experience any falls in the facility for the remainder of their stay.
Planning and Interventions
Care is aimed at protecting the person from injury caused by physiologic changes or altered thought processes.
The nurse must however be mindful to protect the dignity and self-esteem of the older person
Reminiscence therapy is encouraged among the elderly to preserve memory
Evaluation
This is based on the accomplishment of the previously established outcome criteria
