Fall Prevention and Nursing Diagnosis Statement Order Instructions: Topic: Fall Prevention Scenario: An 84-year-old male was admitted to the hospital today after falling at home.
He currently lives alone, his wife passed away three years ago. He has one (1) daughter who lives nearby. He wears glasses and has a hearing aid in his right ear. His gait is slow and unsteady and reports feeling weak. Two months ago, the patient was alert and oriented to person, place and time and living independently. Today, he is oriented to person, but thinks that it is 1994, that he is in his home, and he is looking for his wife. Due to his change in mental status his daughter has decided when he is released from the hospital he will move into her house. She works at home and will be able to care for him during the day.
Fall Prevention and Nursing Diagnosis Statement Questions
1- Develop a teaching plan to address the patient’s safety needs upon discharge. Be sure to include the patient and family in the plan. Consider the patient’s safety needs to develop a plan of care for discharge.
2- Write one (1) nursing diagnosis statement (3 parts) with corresponding outcome and provide two (2) interventions (one independent and one interdependent). Provide a rationale to support your nursing diagnoses statement.
Required Textbooks and chapters for this paper:
Brunner & Suddarth’s Textbook of medical-surgical nursing**
• Chapter 73: Terrorism, Mass Casualty, and Disaster Nursing
Pharmacology: A nursing process approach**
• Chapter 29: Penicillins and Cephalosporins
Nursing Diagnosis
• Use your chosen Nursing Diagnosis Guidebook to review the nursing diagnoses specific to the content covered in this module.
Maternal and child health nursing**
• Chapter 29: Nursing Care of a Family with an Infant (Section on Infant Safety, Bathing, and Diapering)
• Chapter 37: Nursing Care if a Family When a Child Needs Diagnostic or Therapeutic Modalities (section on “Use of restraints” only)
Basic nursing: concepts, skills & reasoning**
• Chapter 23: Safety
• Chapter 31: Sensory perception
Fall Prevention and Nursing Diagnosis Statement Sample Answer
Fall prevention
Among old adults, falls are common and preventable sources of morbidity and mortality. They often threaten the health and quality of life of an individual. The normal and pathological effects of aging such as changes in vision, reduced light accommodation as well as the loss of perception is the major contributor of increased falls (Brunner, Smeltzer, Bare, Hinkle, & Cheever, 2014). Others include cognitive changes such as confusion and loss of judgment and musculoskeletal changes including altered posture and reduced muscle strength.
The following items should be included in the discharge teaching plan for a patient with a history of a fall. The relatives should be educated on safety environmental measures at home such as removal of rugs and obstacles help prevent falls and encourage good lighting. Also, family members should be encouraged to familiarize the patient to the layout of the room and limit rearranging of furniture. The patient must get used to the layout of the room to avoid tripping over furniture. The patient should be informed to put on hearing aids and wear sunglasses all the time and have them checked regularly. It will help reduce the occurrence of the falls by promoting visual and auditory orientation to the environment. Visual impairment is the major cause of falls (Brunner et al., 2014).
The most appropriate nursing diagnoses for the patient is, disturbed thought process related to age related changes as evidenced by disorientation of the patient to time and place. The outcomes for the diagnoses will be, patient will interpret the environment appropriately and maintain orientation to time place and situation to the best of his cognitive ability (Brunner et al., 2014).
The patient should be encouraged to check calendar and the clock more often to get oriented to time. It will help in orientation and aid in memory and recognition. This in turn will ensure a great degree of safety. The above stated diagnoses best fit the patient due to the presenting symptoms of disorientation to time and situation.
Fall Prevention and Nursing Diagnosis Statement References
Brunner, L. S., Smeltzer, S. C. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s Textbook of Medical-surgical Nursing: Suzanne C. Smeltzer…[et Al.]: Wolters Kluwer Health.
