Subjective: Disturbed thought 1 The focus of nursing is to reduce “Nanay at Tatay ko ang nagdala process related to disturbed thinking and promote sa akin dito” As verbalized by degenerative process reality orientation. Often, the patient as evidenced by confusion in older adults is memory deficit. erroneously attributed to aging. Objective: Confusion in the older adult can Has lapses in memory be caused by a single factor or Has sudden mood multiple factors such as changes depression, dementia, Is confused or disoriented medication side effects, or metabolic disorders. Subjective: Impaired social 2 Social interaction for Seniors is “Hindi ako masyado mahilg interaction related to important. Maintaining makipag usap sa iba, madalas insufficient skills to relationships and spending time wala akong kibo. enhance mutuality with others is essential to a Pinapakiramdaman ko lang senior's emotional and mental yung mga tao.” well-being. It can help with as verbalized by the patient. depression, which is prevalent with seniors. Objective: On the other hand, social Spends time alone. isolation has been associated Inappropriate emotional with depression, high blood response. pressure, and greater risk of Unable to death. Social interaction is make eye contact, or therefore an important factor in initiate or respond to social advances of healthy aging. ... For seniors, others. socializing is often not easy and Observed use of thus, they are at risk of becoming unsuccessful social socially isolated. interactions behaviors. Subjective: Self-care deficit 3 Self-Care Deficit is the inability “Magsuklay lang kaya kong related to left sided of an individual to perform self- gawin kasi etong isang kamay body paralysis as care. The deficit may be the ko lang nagagalaw ko eh.” as evidenced by impaired effect of temporary limitations, verbalized by the patient. mobility/transfer such as those one might ability experience while aging, or the Objectives: result of gradual deterioration Generalized body that erodes the individual’s weakness ability or willingness to perform Paralysis of left upper the activities required to care for and lower extremities himself or herself. Also, patients Inability to bathe, groom who are suffering from self independently and depression may not have the perform toileting tasks interest to engage in self-care Inability to put on activities. various items of clothing like slippers, socks, shoes Inability to dry body when the bed is wet due to urinary incontinence Objectives: Risk for Fall related 4 Although injury prevention is a Age: 79 years old to left sided paralysis concern for older adults, it is Left sided paralysis of the body due to considered as the least priority as Wheelchair bound ischemia of the right opposed to the patient’s actual Muscle weakness hemisphere needs. Poor eyesight Disorientation History of falls Environmental conditions (wet bathroom floors) Absence of anti-slip material in bath and shower
Morse Fall Risk:
- History of Falling (YES) 25 - Gait, impaired (20) Total score: 45 Interpretation: >45 High risk for fall