Choose ONE of the following Nursing Diagnoses and write any.
Choose ONE of the following Nursing Diagnoses and write any… Choose ONE of the following Nursing Diagnoses and write any comprehensive nursing note incorporating the nursing process. Nursing Dx #1 Risk for InjuryNursing Dx # 2 Imbalanced Nutrition: less than body requirementsNursing Dx #3 Impaired urinary eliminationNursing Dx #4 Activity Intolerance/Fatigue Case BelowChief Complaint: Assisted living facility staff have requested a consult for resident with frequent falls. History of Present Illness: Mr. Kloo is an 83-year-old white man who lives in an assisted living facility. He was seen in the emergency department 4 days ago because he fell backwards, while getting out of bed, and bumped the back of his head on the wall. Mr. Kloo reports that he used to walk “just fine” with his cane, but now he says “I fall all the time for no reason”. Due to his more frequent falls, Mr. Kloo’s son purchased him a rollator walker to use instead of his cane about six months ago. According to the staff, Mr. Kloo has experienced numerous falls and “near falls” since moving into the facility 18 months ago. The types of falls Mr. Kloo has experienced include tripping on a carpet, loss of balance following bumping into a table in the lobby, getting out of the bath, falling backwards while attempting to get up from a chair or his bed, missed small step off front porch, as well as slips during the night when getting up to void. He has lost his balance walking as well. He reports that he sleeps well, except for having to get up to urinate several times during the night, for which sometimes he does not make it to the toilet. He used to enjoy walking but reports that he hardly ever goes outside now because he’s afraid of falling somewhere too far from staff help. The staff confirm that Mr. Kloo very infrequently ventures outside onto the porch or courtyard of the facility, but that he still enjoys going to the dining hall, the lobby, and activities room. The staff report that Mr. Kloo is very pleasant and sociable. He does have some memory impairment, and frequently forgets to wear his hearing aid. He has corrective lenses, but upon observation, his glasses appear to be ill-fitting.Past Medical History: Hypertension Systolic heart failure Osteoarthritis of hips and knees Restless leg syndrome Mild cognitive impairmentSocial History: Lives in assisted living, denies use of alcohol, tobacco or illicit substances. Has one son who visits approximately once a month.Allergies: NKDAMedications: Lisinopril 40 mg by mouth daily Metoprolol succinate 200 mg by mouth daily Furosemide 40 mg by mouth twice daily KCl 20 mEq by mouth daily Atorvastatin 40 mg by mouth every evening at bedtime Ropinirole 2mg by mouth at bedtime Aspirin 81mg by mouth daily Tylenol 500 mg by mouth every 4-6 hours as needed for pain Calcium carbonate 500 mg by mouth twice daily Vitamin D 1000 IU by mouth daily ASCPAssessment: Given this patient’s active frequent falls history and current presentation, this patient is at highest risk for a subsequent fall. Gait, Strength & Balance Assessment ordered due to patient’s active falls status and weakened state. He is in need of physical therapy; therefore, it would be safer and more appropriate to have gait, strength and balanced formally assessed during physical therapy.Review of Symptoms: Constitutional: Lack of energy, weak. Eyes: Prescribed bifocals. Describes some blurriness while wearing. Due to weight loss over time, glasses now appear to be too big and heavy, slipping down his nose. HEENT: Hearing difficulty, has a hearing aid. GI: Urinary frequency, and nocturia up to 4 times a night. Neurology: Balance problems when walking, memory problems. Musculoskeletal: Joint stiffness and pain in both knees and hips. Knees greater than hips. He wears braces on his knees to help manage the pain and reports these help. Psych: Afraid of falling, memory trouble.This is a frail, alert, very pleasant elderly man. Vitals: Supine – 129/53 mmHg, HR 59 bpm; BP Sitting – 103/40 mmHg, HR 60 bpm; Standing – 101/51 mmHg, HR 62 bpm. Height: 65 inches; Weight: 132 pounds. Head: Contusion with resolving ecchymosis and swelling at the posterior occiput on the right side. ENMT: Wearing glasses. Last eye exam, unknown. CV: Regular rate and rhythm; normal S1/S2 without murmur, rub, gallop, lift, or heave. Respiratory: Clear to auscultation throughout. GI: Normal bowel tones, soft, non-tender, non-distended. Musculoskeletal: No knee joint laxity. Trace edema bilateral lower extremities. Neurology: Alert and oriented x 3. Cranial nerves II-XII grossly intact. Muscle strength in both upper and lower extremities 4/5.Labs: Na 137 mEq/L (136-145 mEq/L) K 4 mEq/L (3.5-5 mEq/L) Cl 101 mEq/L (95-105 mEq/L) CO2 22 mEq/L (22-28 mEq/L) BUN 16 mg/dL (7-18 mg/dL) SCr 1.2 mg/dL (0.6-1.2 mg/dL) Glucose 109 mg/dL (70-99 mg/dL, fasting) Health Science Science Nursing NURS 200S
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