Learning Center Articles

Nursing diagnosis : Risk for trauma/falls

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