You are on page 1of 6


NSG Diagnosis
Risk for Impaired
related to extremes
of age

Plan of Action
That within my _
hours span on
nursing care
patient will be able
to remain skin dry
and intact as
Immobility, evidenced by:
which leads to
a) Capillary
and friction, is the
refill time of
factor most likely to
3 seconds
put an individual at
or less
b) Absence of
risk for altered skin
patients skin is
No redness
over bony
moisture, making
for higher risk of
skin impairment.

Nursing Interventions
1. Reassess patients skin condition
Rationale: to know the extent of the damage
2. Change the patients position frequently when at bed
Rationale: Position changes relieve pressure, restore blood flow, and promote
skin integrity.
3. Use pressure relieving beds, mattress overlays, and chair cushions
Rationale: These devices redistribute pressure when frequent position
changes are not possible
4. Apply lotion if not indicated
Rationale: These prevent friction and shear
5. Encourage to wear cotton fabric clothes
Rationale: Skin friction caused by stiff or rough clothes leads to irritation
6. Emphasize the importance of adequate nutrition and oral fluid intake.
Rationale: Improve nutrition and hydration will improve skin condition
7. Encourage ambulation
Rationale: Ambulation reduces pressure on the skin from immobility
8. Increase tissue perfusion by massaging around the affected area.
Rationale: massaging the actual reddened area may damage the skin further
9. Limit chair sitting to 2 hours at any one time and encourage patient to

shift weight every 15 minutes

Rationale: pressure ober the sacrum may exceed 100 mmHg pressure during
sitting. The pressure necessary to close skin capillaries is around 32 mmHg
any pressure greater than 32 mmHg may result to ischemia
10. Clean, dry, and moisturize skin, especially over bony prominences,
twice daily or as indicated by incontinence or sweating. If powder is
desirable, use medical-grade cornstarch; avoid talc .
Rationale: To reduce friction.

NSG Diagnosis
Risk for injury: fall
related to
decreased lower
extremity strength
By middle old age
(75-85 years),
many people have
developed some
physical disability,
and in the final
stage (very old
age, over 85
years) they

Plan of Action
That within my
3hrs span of
care, the patient
will demonstrate
safety behavior
a. Remains free
of falls
b. Changes
environment to
minimize the
incidence of falls

1. Assess home environment for threats to safety: clutter, slippery floors, scatter
rugs, unsafe stairs and stairwells, blocked entries, dim lighting, extension cords
(across pathway), high beds, pets, and pet excrement. Use antiskid acrylic floor
wax, nonskid rugs, and skid-proof strips near the bed to prevent slippage.
R: Clients suffering from impaired mobility, impaired visual acuity, and
neurological dysfunction, including dementia and other cognitive functional
deficits, are all at risk for injury from common hazards.
2. Recognize that when people attend to another task while walking, such as
carrying a cup of water, clothing, or supplies, they are more likely to fall.
R: Those who slow down when given a carrying task are at a higher risk for
subsequent falls (Lundin-Olsson, Nysberg, Gustafson, 1998).
3. Evaluate client's medications to determine whether medications increase the
risk of falling; consult with physician regarding client's need for medication if

become totally
dependent. A
typical expectation
is of 8-10 years of
partial disability,
and a year of total
dependency (5).
Strength peaks
around 25 years of
age, plateaus
through 35 or 40
years of age, and
then shows an
decline, with 25%
loss of peak force
by the age of 65
years. Muscle
mass decreases,
apparently with a
selective loss in
the cross-section if
not the numbers of
type II fibers. It is
unclear whether
there is a general
hypotrophy of
skeletal muscle, or
a selective

c. Explains
methods to
prevent injury

R: Polypharmacy, or taking more than four medications, has been associated
with increased falls. Medications increasing the risk of falls include diuretics,
hypnotics, sedatives, opiates, antidepressants, and psychotropic and
antihypertension agents (Wilson, 1998). Medications such as benzodiazapines
and antipsychotic and antidepressant medications given to promote sleep
actually increase the rate of falls (Capezuti, 1999). Use of selective serotonin
reuptake inhibitors and tricyclic antidepressants resulted in increased
incidences of falls in a nursing home setting (Thapa et al, 1998; Liu et al, 1998).
4. Thoroughly orient client to environment. Place call light within reach and
show how to call for assistance; answer call light promptly.
5. If client experiences dizziness because of orthostatic hypotension when
getting up, teach methods to decrease dizziness, such as rising slowly,
remaining seated several minutes before standing, flexing feet upward several
times while sitting, sitting down immediately if feeling dizzy, and trying to have
someone present when standing.
R: The elderly develop decreased baroreceptor sensitivity and decreased
ability of compensatory mechanisms to maintain blood pressure when standing
up, resulting in postural hypotension (Aaronson, Carlon-Wolfe, Schoener, 1991;
Matteson, McConnell, Linton, 1997).
6. If client is experiencing syncope, determine symptoms that occur before
syncope, and note medications that client is taking. Refer for medical care.
R: The circumstances surrounding syncope often suggest the cause. Use of
many medications, including diuretics, antihypertensives, digoxin, betablockers, and calcium channel blockers can cause syncope. Use of the tilt table
can be diagnostic in incidences of syncope (Cox, 2000)

hypoplasia and
degeneration of
Type II fibers,
associated with a
loss of nerve
terminal sprouting.

NSG Diagnosis
Impaired memory
related to physiological
changes of aging as
manifested by evident
remote and recent
memory loss

7. Ensure that the chair or wheelchair fits the build, abilities, and needs of the
client to ensure propulsion with legs or arms and ability to reach the floor,
eliminating footrests and minimizing problems with shearing.
R: The seating system should fit the needs of the client so that the client can
move the wheels, stand up from the chair without falling, and not be harmed by
the chair. Footrests can cause skin tears and bruising, as well as postural
alignment and sitting posture problems (Lipson, Braun, 1993).
Plan of Care
That within my 8 hours span
of care, patient will maintain
or improve usual reality
orientation as evidenced by:

1. Immediate memory
still intact
2. Recent and remote
memory is maintained
or improved; not
progressing to severe
memory loss
3. Able to identify
interventions to deal
effectively with
situation and benefits
such as using

Nursing Interventions
1. Assess physical status and psychiatric symptoms,
especially in recent change of mentation or development
of confusion. Institute appropriate interventions to
Not all mental changes are the result of aging, and it is
important to rule out physical causes before accepting
this unchangeable. Possibilities include pain that is often
not reported or underestimated, metabolic imbalances,
adverse toxic medication levels, drug induced side
effects, result of infections, cardiac and respiratory
2. Discuss happenings of the past. Place familiar objects in
room. Encourage the display of photographs and photo
albums and frequent visit from SO and friends.
Events of the past may be more readily recalled by the
elderly client because long-term memory usually

calendars, clocks,
signs and pictures
and playing mind and
memory games to
exercise the thinking
capacity of the brain

remains intact. Reminiscence or life review and

companionship are beneficial to clients.
3. Allow adequate time for client to respond to questions or
comments to make decisions.
Reaction may be slowed with aging due to changes in
metabolism and cerebral blood flow or with brain injuries
and some neuromuscular conditions.
4. Note presence of short term memory loss, and provide
with such aids as calendars, clocks, room signs, and
Short term memory loss presents a challenge for
nursing care, especially if the client cannot remember
such things as how to use call bell or how to get to the
bathroom. This problems are not in clients control but
may be less frustrating if simple reminders are used to
assist in providing continual orientation.
5. Evaluate individual stress level and deal with it
Stress level may be greatly increased because of recent
losses, such as poor health death of spouse or
companion, or loss of home. In addition, some conflicts
that occur with age come from previously unresolved
problems that may need to be dealt with now.


6. Reorient to person, place, and time as appropriate.

Helps client maintain focus.
7. Have client repeat and verbal or written instructions.
Verifies hearing and ability to read and comprehend.
8. Involve in regular exercise, activity, and diversional
Promotes release in endorphins, enhancing sense of
well-being, and can provide thinking skills.
9. Schedule at least one rest period per day.
Prevents fatigue; enhances general well-being.
10. Administer medications as indicated, such as donepezil
(Aricept), rivastigmine (Exelon), gelantamine
(Razadyne), and memantine (Namenda).
These medications are used to treat mild to moderate