Care plan diagnosis

Posted
by AmandaBeaverhausen AmandaBeaverhausen Member Student

Specializes in CMA, CNA.

I'm doing a care plan on a 70 year old man with a history of falls. He was admitted to hospital due to a recent fall wherein he lay in the floor half a day before help arrived. I'm thinking "impaired physical mobility related to sedentary lifestyle and decreased muscle strength", but don't know how to properly word the AEB part. Would I say "AEB history of falls" or "AEB fall", (referring to the most recent)? He has had 5 falls over the past 2 weeks. He has no other reason for falling aside from a cluttered house, being elderly, and his not using a cane he was given once. Vitals and other objective data doesn't indicate any other reasons for the fall. No polypharmacy to blame. Paramedics said he might have to be removed from the home, so I'm thinking it was in despair. Any advice is greatly appreciated. I have Doenges pocket guide and Gulanick and Meyers care plan book but wanna make sure this is solid, since everything is built upon it. 

JKL33

6,389 Posts

19 hours ago, AmandaBeaverhausen said:

He has no other reason for falling aside from a cluttered house, being elderly, and his not using a cane he was given once.

My comment isn't directly related to what you've chosen for your care plan so far, but just wanted to say there is mostly likely more to it than that. Age 70 might be considered by most to be somewhat old/elderly but realistically a basically healthy 70 year old isn't falling down a few times a week. They are driving cars and taking care of their affairs and some still working or helping to care for other family members. If he tripped over something and fell once, that's one thing. If he's fallen multiple times and was at some point unable to get himself up, he has more going on.

For the purposes of educational exercise you should review his health history and also then make a list of possible factors that could contribute to falling in general--not just for him specifically. This kind of exercise in thinking helps you learn to be complete rather than getting pigeonholed too early in your thought process d/t anchoring on a single aspect of something. Also the fact that there isn't polypharmacy doesn't exclude medications as a contributing factor.