Name: Caitlyn M Wegner Date: Client (M.M.

) Room #7103

NORMAL LINE OF DEFENSE/REQUIRED DATA STRESSORS (TYPE) RESPONSES TO STRESSORS

 85-year-old Caucasian female admitted June 12, 2020 1. Physiological 1. Physiological
 DIAGNOSIS:
Ht: 5’4” (162.56 cm), 189 lbs (85.729 kg) R/T: AEB:
 Patient has no known allergies 1A. Diabetes Mellitus type 2 1A. poor self-care/health
Patient is at risk for falls History of falls, use of assistive devices, unsteady gait, Patients fall this morning (7/17) at 0816. Patient
 Psychiatric Diagnoses: severe anxiety, major depressive disorder with psychotic and catatonic episodes. 1B. Hypertension maintenance
Patient initially diagnosed with major depressive disorder following antianxiety agents,
husband’s deathdiminished mental
20 years ago, status,
patient had states that she forgot that she couldn’t walk
been in remission until son’s death in September. antihypertensive agents, and impaired physical mobility 2. Psychological
unassisted and thought 1B. she
medication noncompliance
was getting ready for
 Medical Diagnoses: bilateral pulmonary embolism, essential hypertension, diabetes mellitus type 2, obesity, work.
2A. Severe Anxiety Patient needs a walker to ambulate
2. Psychological and care
and fall history staff to assist as she is unsteady on her feet.
 Patient previously admitted for major depressive disorder and generalized anxiety disorder May 22 nd to June 2B. Son’s death 8 months 2A. Sleeps and avoids conversation
Patients medication list also contains fall risk
th
10 , 2020. She had 7 previous psychiatric hospitalizations between 2007 and Oct 2019 (after son’s death), ago medications. 2B. Denial and avoidance
none until May of this year as she had been doing well with outpatient therapy.
3. Sociocultural 3. Sociocultural
 PREVENTIONS
Assessment Data (LEVEL): RATIONALE OUTCOMES/GOALS:
o Objective 3A. No family close by 3A. Difficulty communicating,
 BP: 130/64, HR: 84, RR: 18, 96%
1. Safety guidelines. Complete a fall-risk assessment for SpO2 on room air following fall
1. The Hendrich II Fall Risk Model is quick to administer 1. Clientlives
will remainavoids
free ofconversation
falls for remainder of
(daughter in Florida),
 1100
older adults VS care
in acute BP: 134/98, HR: 76,
using a valid and95% SpO2
reliable onsuch
tool room airand provides a determination of risk for falling based on my shift (1400).
 Patient had fallRecognize
in bathroom in nursing home 3B. Sleeps a lot and avoids
as the Hendrich II Model. thatatrisk
0816 factors for gender, mental and emotional status, symptoms of
 Neurological Assessments done every 4 hours post fall. Patients mental status intact, A&0 x4 2. Client will explain methods to prevent injury
falling include recent history of falls, confusion, depression, dizziness, and known categories of medications increasing. 3B. Self isolates conversation
during both assessments. Patient slightly confused following fall, forgot that she couldn’t walk on and falls to care staff after post fall teaching and
altered elimination
her ownpatterns, cardiovascular/respiratory
and thought that she was getting ready for work. This tool screens for primary prevention of falls and is
4. Developmental 4. Developmental
disease impairing repeat at the end of my shift (1400).
 Patientperfusion
had heador CToxygenation,
following fall, postural
negative results integral in a post-fall assessment for the secondary 4A. Outlived spouse and son 4A. 20 years since husband and 8
hypertension, dizziness
 Patient or vertigo,
is having primary
ECT for cancer
treatment diagnosis, prevention of falls.
of depression
o Subjective
and altered mobility (Gray-Miceli, 2008). 4B. None found months since son
 Facility patient was sent from complains patient has2.not These
beensteps alert
eating, the nursing
refusing to getstaff
out of increased
bed, risk of
5. Spiritual 4B. N/A
and hasfall”
2. Use a “high-risk beenarmband/bracelet
incontinent (patient and usually
Fall Riskis continent) since returning from last hospital
falls.
room sign to admission
alert staff for increased vigilance and mobility 5A. Grieving 5. Spiritual
assistance.  Patient stated her “anxiety is sky high” and that she was
3. “not good”
Polypharmacy, or taking more than four medications, has
5B. No religious or spiritual 5A. Situational depression
 Complaints of nervousness and not sleeping well been associated with increased falls. Medications such as
affiliation 5B. No longer identifies with a
3. Evaluate thePatient appears
client’s very anxious
medications and worrisome
to determine whether about
the recent fall
benzodiazepines and antipsychotic and antidepressant
 Lab Results – RBC: 3.41 (low), Hgb: 9.5 (low), Hct: 31.5 (low), K: 3.2 (low) religion
medications increase the risk of falling; consult with medications given to promote sleep actually increase the
 CT Results: Negative, all normal findings. Small remote posterior left cerebellar infarct
physician regarding the client’s need for medication if rate of falls.
 SPICES (yes for all assessments) and Mental Status Assessment completed (below)
appropriate.
o Patient appears her stated age and overweight. Slightly disheveled appearance but appears clean and
4. Clients are likely to fall when left in a wheelchair
is in clean clothing that is appropriate for season. No scars or tattoos present. Slouched and relaxed
4. Help clients
posturesitwith
in a stable chair with
an unsteady gait. arm rests.
Patient Avoid use and
is cooperative because they
friendly may
with standAlert
writer. up without locking
and oriented x 4the wheels or
of wheelchairs except for transportation as needed. removing the footrests. Wheelchairs
with a normal speech rate. Affect is appropriate but is sad at times, rating 3/10 for sadness/happiness. do not increase
(Ackley & Ladwig, 2011, pp. 355-362)
No suicidal ideation noted. No delusional though content or hallucinations. Patients thoughts are of the time.
mobility; people just sit in them the majority
usually organized and logical but was confused following fall believing that she was getting ready
for work and forgot that she could not walk unassisted. No evidence of memory impairment. No
evidence of distraction during conversation or activities. Patient has fair judgement and insight.
 Patient is on antihypertensives, antidepressants and anxiolytics: Clonazepam (0.5 mg TID), Ativan (1 mg Q4
PRN), Seroquel (50 mg @ HS), Venlafaxine ER, Diltiazem, Enoxaparin, and Escitalopram
 Patient attends groups intermittently
 Patients only family is a daughter who lives in Florida for support system
EVALUATION AND REVISIONS:

Goals were met: Patient successfully remained free of falls for the remainder of my shift (ending at 1400). In addition, the patient successfully reiterated what was dangerous
regarding her fall and how to avoid future falls and injury such as, never getting up with help and always utilizing the call light when assistance is needed.

DIAGNOSIS: R/T: AEB:

Patient is at risk for impaired skin integrity
Excretion and/or secretions, extremes of age, humidity,
mechanical factors (friction, shearing forces, pressure),
moisture, physical immobilization, chronic disease,
alterations in skin turgor, and altered nutritional state.
Patient has history of incontinence during severe
episodes of depression, is elderly, friction may
happen from incontinence device utilization,
physical immobile (needs 2-person assistance
for transfers and ambulation), altered in skin
turgor (decreased nutritional intake and age) and
altered nutritional state.

PREVENTIONS (LEVEL): RATIONALE OUTCOMES/GOALS:

1. Monitor skin condition at least once a day for color or
texture changes, dermatological condition, or lesions.
Determine whether the client is experiencing loss of
sensation or pain.
2. Identify clients at risk for impaired skin integrity as a
result of immobility, chronological age, malnutrition,
incontinence, compromised perfusion, immunocompromised
status, or chronic medical condition, such as diabetes
mellitus, spinal cord injury, or renal failure.
3. Monitor the client’s continence status and minimize
exposure of the site of skin impairment and other areas to
moisture from incontinence, perspiration, or wound
drainage. If the client is incontinent, implement an
incontinence management plan to prevent exposure to
chemicals in urine and stool that can strip or erode the skin;
refer to a physician for an incontinence assessment.
4. Limit number of complete baths to two or three per week
and alternate them with partial baths. Use tepid water
1. Systemic inspection can identify impending problems 1. Patient will report altered sensation or pain at
early. risk areas as soon as noted, will evaluate at end
of shift (1400).
2. These client populations are known to be at high risk for
impaired skin integrity. Targeting variables (such as age and 2. Patient will verbalize a personal plan for
Braden Scale Risk Category) can focus assessment on preventing impaired skin following teaching and
particular risk factors (e.g. pressure) and help guide the plan at of my shift (1400).
of prevention and care.
3. Implementing an incontinence prevention plan with the
use of a skin protectant or a cleanser protectant can
significantly decrease skin breakdown and pressure ulcer
formation.
4. Excessive bathing, especially in hot water, depletes aging
skin of moisture and increase dryness. The ability to retain
moisture is decreased in aging skin due to diminished
amounts of dermal proteins. One of the most common age-
related changes to the skin is damage to the stratum
corneum.
(Ackley & Ladwig, 2011, pp. 772-775 )
temperature (between 90 and 105 Fahrenheit) for bathing.

EVALUATION AND REVISIONS:

Goal was met: Patient’s skin remained intact for my entire shift. Patient did not report any altered sensations or pain at risk areas. Patient verbalized a personal plan for
preventing skin impairment (calling to be cleaned up as soon as she has an incontinence episode and being compliant with repositioning while seated and in bed) following
teaching on skin impairment and again at the end of my shift (1400).

DIAGNOSIS: R/T: AEB:

Imbalanced nutrition, less than body requirements
Insufficient dietary intake and psychological factors
Facility patient was sent from stated the client was
refusing meals and barely eating. At current
facility, patient is eating and drinking however
intake is very minimal. Patient lost around 40
pounds due to dietary changes from relapse of
major depressive disorder.

PREVENTIONS (LEVEL): RATIONALE OUTCOMES/GOALS:

1. Give the client a choice of nutritional supplements to
increase personal control, including a taste test. If the client is
unwilling to drink a glass of liquid supplement, offer 30
mL/hr in a medication cup.
2. Assess for psychological and mental factors that impact
nutrition. Watch for signs of depression.
1. Often the elderly will take medications when they will
not take food. The supplement is then served as a
medicine.
2. Malnutrition is commonly found with depression in the
elderly, but malnutrition may also cause depression in the
elderly.
1. Client will identify nutritional requirements at
every mealtime (0800, 1200, & 1700).
2. Client will consume adequate nourishment at
mealtimes and snack times (0800, 1200, 1700, &
2100).

3. Serve food in a restaurant-style manner if possible.
4. Provide a restful, homelike environment during meals
where the clients are treated with respect and are encouraged
to maintain autonomy as they are able.
3. Food served family style resulted in increased food
ingestion and decreased number of elderly clients with
malnutrition in a nursing home.
4. A study of dementia clients conducted in extended care
facilities found that when caregivers were given courses
on and expected to follow these guidelines – maintain
client’s integrity, interacting with the client in an attentive
manner, and providing a calmer, homelike atmosphere – (Ackley & Ladwig, 2011, pp. 575-581)
the client gained weight.
 EVALUATION AND REVISIONS:

Goals were met: The client successfully identified nutritional requirements with me at breakfast (0800) and lunch (1200) before my shift end at (1400). The patient is working
towards consuming adequate nourishment at mealtimes and at snack times. Patient ate 50% at breakfast and 75% for lunch, however she did state that pancakes she had for
breakfast were horrible which could contribute to her low intake.

Potential, actual, and wellness diagnoses (ATLEAST 10)

1. Anxiety related to changes in health status.

2. Impaired verbal communication related to psychological barriers (major depressive disorder).
3. Risk for constipation related to nutritional factors (vitamin and mineral deficiencies).
4. Ineffective coping related to inadequate level of confidence in ability to cope.
5. Grieving related to death of significant other.
6. Risk for loneliness related to social isolation.
7. Impaired physical mobility related to decreased muscle mass and muscle strength.
8. Impaired urinary elimination related to incontinence.
9. Impaired walking related to depressed mood, impaired balance, and insufficient muscle strength.
10. Self-neglect related to depression.
 References

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO, MO:
Mosby/Elsevier.