Nursing care plan

  1. hey all,
    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?
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    About Shai22

    Joined: Apr '10; Posts: 7; Likes: 1


  3. by   kenpochic
    Risk for fall r/t current living situation as evidence by poorly organized household items.

    I would work off something like that. than list all the stuff wrong that you assessed in his house under the assessment section of your care plan. oh and put the fact that he already has fallen and showed you bruises. why dont you give us a little rough draft and we can see if we can help you out.

    thats nice of them to give you a case study. in my school even in the beginning it was you do it off your own patient at the hospital not off a case study
  4. by   Shai22
    hey kenphochic,
    thanks for your help. yes will surely work on a draft and hope u guys help me throughout.
    yeh i know i can imagine how difficult that would have been, is it first year?we have not been assigned patients yet though.
    thanks again
  5. by   kcvo
    What about risk for falls related to visual and hearing difficulties evidenced by history of falls?
  6. by   Shai22
    am a little confused. the way our lecturers have told us was that in a nursing issue u use... due to or related to so i could say:
    risk of falls due to difficulty in vision and hearing.
    and nursing goal would be
    to improve mr. slyvesters vsion and hearing over a period of a month as evidenced by no further record of falls
    or another one could be:
    risk of falls due to unsafe environment and poor vision and hearing
    to promote a safe environment for mr. slyvester in a period of one week and to improve his hearing and visual within a month as eveidenced by no further incident of falls

    please give me suggestion
  7. by   rochelle03lc
    when trying to decide between nursing diagnosis, always think ABC, then Maslow for the order or to help you determine between the two. From there, aways think of your nursing care plan as documentation, like you would have to document your care when you get into the real world. That always helped me, hope that helps you!