Question

Mrs. Smith is an 88- year-old female who lives alone in her home. She walks with a walker. Last night Mrs. Smith needed to go to the bathroom. She got out of her bed and walked to the bathroom without using her walker. In the morning her daughter came to the house to check up on her. She found her mom on the bathroom floor. She called the ambulance and her mom was taken to the emergency room. In the emergency room, the patient states, “she lost her balance in the bathroom when she was washing her hands and fell to the floor.” According to the daughter, her mom has lost her balance many times but never fell. She doesn’t always use her walker in the house. Her daughter also states, “She needs help getting dressed, taking a shower and making her meals.” Mrs. Smith states her pain is an 8 out of 10 on numeric scale of 0 to 10. She also states the pain constant, worse with movement, and radiates down her leg. Her legs feel weak. The nurse performs an assessment on the patient. She is unable to stand in and apply weight to her legs. The patient is weak in the upper extremities and lower extremities. She is unable to lift her legs off the bed. She is unable to turn from on her side without assistance. She is unable to pull her body up in the bed. What subjective data and objective data do you notice in this case study? Please list the subjective and objective data. Cluster the data together that is similar and explain the significance of the data. Analyze the data by applying Maslow’s Hierarchy of Need? Why is this data significant? Create three nursing diagnoses for this patient. Problem- focused nursing diagnosis has three components: Problem, Etiology and Symptoms). What are some reasons you choose each nursing diagnosis? List three outcomes for each nursing diagnosis. Outcomes must be specific, measurable, attainable, realistic and timed. What nursing actions are you going to choose for each nursing diagnosis? Please think about the patient holistically. This should be a fairly comprehensive list. Include all necessary interventions related to each nursing diagnosis, must be measurable and specific. Provide rationales for each intervention.

1. What subjective data and objective data do you notice in this case study? Please list the subjective and objective data.
2. Cluster the data together that is similar and explain the significance of the data.
3. Analyze the data by applying Maslow’s Hierarchy of Need? Why is this data significant?
4. Create three nursing diagnoses for this patient. Problem- focused nursing diagnosis has three components: Problem, Etiology and Symptoms). What are some reasons you choose each nursing diagnosis?
5. List three outcomes for each nursing diagnosis. Outcomes must be specific, measurable, attainable, realistic and timed.
6. What nursing actions are you going to choose for each nursing diagnosis? Please think about the patient holistically. This should be a fairly comprehensive list. Include all necessary interventions related to each nursing diagnosis, must be measurable and specific. Provide rationales for each intervention

Answer 1

1. Subjective data: The patient says that she's having pain in her legs. she states that she's feeling weakness in her lower extremities.

--Objective data : Pain in the lower extremities.

- According to Maslow's Hierarchy of needs ,the data's are very significant because many older adults are experiences multiple stresses at a time when ability to adapt is compromised by anatomic, physiologic, and psychologic alterations that occur during the aging process.

- Nursing Diagnosis:

--- Risk of falls.

--- Altered mental status

--- Disturbed sleeping pattern.

--- Impaired physical mobility

---Risk of falls due to aging above 65 years.Identifying the risk factors that decreases the level of falls.Due to aging she may feel disturbed mental status like confusion, memory loss, stress . So these can increase the risk for falls. Most of the aged people experiences a disturbed sleeping pattern due to physical and psychological issues. Due to this , their physical mobility are also affected which decreases the daily activity levels.

-- Stress is an another factor between older people.

Nursing Outcomes:

- The patient will be free from any falls during her hospitalization

- Implementing measures by patient and caregiver will increase safety and prevent falls in the home.

- Within 24 hours of interventions the patient will reports attainment of adequate rest and the mental status will remain intact for the patient.

Nursing Interventions:

-Encourage the family and other significant others to stay with the patient at all times.

- Advice the patient to wear shoes or slippers with non-slip soles when walking.

- Keep the patient's bed in the lowest position at all times.

- Provide warm oral fluids or IV fluids to warm the patient internally.

- Assess and record the patient's sleeping pattern by gathering information from patient's caregiver or family.

- Monitor patient's activity level.

- Provide calm and quiet environment during sleeping.

- Ensure to put side rails of the bed for patient while sleeping.

- Identify the patient's typical nighttime routine and try to follow it.

Rationale :

-- Emulating the typical nighttime rituals may promote sleep.

-- Exercises ans physical conditioning reduces the incidence of falls and avoids injury that is sustained when a fall happens.

-- By putting no slippery socks and shoes will reduce the risk of fall.

-- Dehydration can be avoided due to administration of oral fluids or IV fluids.

-- Supporting the patient and acknowledging that the feelings are normal and often help to lesen feelings of despair.

-- Aging individuals have a reduced sense of thirst and need encouragement to drink.

-- Glasses and hearing aids are likely to reduce sensory confusion.