can someone help me with a nursing care plan
. am doing first semester nursing
my case study is:
Mr Sylvester is a 78 year old gentleman who presented at the facility accompanied by his daughter (Mrs Martin). He appears to be well dressed though his clothes are creased and there are some stains down the front of his shirt. He has bruises on his forehead and on questioning about these states he had a fall at home yesterday. When asked if he has any other injuries, he shows you bruises on his elbow and knees. He said he has had a "few falls lately" but recovers from them quickly. He lives in his own, three bedroom house by himself.
His daughter lives out of town and is concerned about his safety at home. She rings him once a week but finds conversation is difficult over the phone, sometimes he doesn't even answer. She is thinking about the need to have him admitted to a nursing home.
As part of your assessment, you visit his house and find a free standing two story house with three steps up to the front veranda. There is a long hall with the living room and kitchen at the end. He states he doesn't use the "formal lounge and dining rooms" except when the family come to visit. The kitchen has a table in the middle of the room. There is a pile of papers, still folded on the table. When asked about these, Mr Sylvester states he can't see well enough to read them anymore. In the family room, his chair is close to the TV and the volume is set at maximum level. The laundry is off the kitchen and there are six stairs down to the back yard. The clothes line is in the middle of the large back yard.
The stairs within the house are carpeted and his bedroom has a polished floor with a carpet square beside the bed. He has a bedside table and two chairs in the room and multiple boxes that seem to be full of books, magazines and old papers
i was thinkng :
1. visual and auditory sensory disturbed
can i use both?
2. falls, risk
3. is there impaired physical mobilty?
thanks and any tips for writing a scoring plan?