Change in Mental Status

Change in Mental Status

Scenario: An 84-year-old male is admitted today after falling at home. He had a change in mental status over the last 2 months. He is oriented to person but thinks it is 1994, that he is in his home, and he is looking for his wife who died three years ago. He wears glasses and has a hearing aid in his right ear. His gait is slow and unsteady and he reports feeling weak.

Create a discussion post in response to the following using information provided in the scenario and taking the information that was read in the assignments & applying it to the scenario:

• List at least four (4) factors that place this patient at risk for falls
• Identify the nursing assessment(s) that provide(s) the data to determine the appropriate nursing diagnoses for this patient
• List two nursing diagnosis statements for this patient

Actual: NANDA-I diagnosis, an etiology and the defining characteristics (nursing diagnosis + related to + as evidenced by).

Risk: NANDA-1 diagnosis + etiology(related to)

• Identify the data cluster (grouping of significant data that points to the existence of the patient health problem) used to select the nursing diagnosis. o Identify one patient outcome (realistic, measureable and contains a time frame).
• List at least four (4) interventions the RN would implement to ensure the patient remains free from falls during the hospitalization.
  • Label each intervention as independent nursing action (intervention) or interdependent nursing action (intervention)
  • Provide a rationale for each action (intervention)
  • Provide a reference for each of your rationales
• Compare your identified risk factors to a developmental stage other than the elderly (such as infant, toddler, school age child, adolescent, young adult or middle age adult). Are they alike or dissimilar?
• How does the RN know the patient understands the teaching provided about a safe environment was effective?