Below the case study are possible nursing diagnosis thatI’ve come up with, but I am having trouble narrowing it down toone. Can someone please help me and explain which and why is thebest? Thank you
Mr. O’Brien is an alert and oriented 81-year-old manadmitted to the hospital with complaints of dizziness and syncope.His blood pressure (BP) on admission is 80/43. At the long-termnursing care facility where he lives, he ambulated with a walkerindependently but, since his episode of syncope, he has complainedof weakness and needs another person to assist while walking as afall precaution.
Mr. O’Brien is admitted with prescriptions that includeassessment of orthostatic vital signs every shift and fallprecautions. The nurse explains to Mr. O’Brien how to use the calllight and instructs him to call before getting out of bed so thatsomeone can assist him with ambulation. The nurse completes a setof orthostatic vital signs. His orthostatic vital signs are lying:BP 120/84, heart rate (HR) 73; sitting: BP 114/73, HR 83; standing:BP 96/61, HR 92. When the assessment of orthostatics is complete,Mr. O’Brien is settled in bed. The nurse raises two side rails atthe head of the bed, and the bed alarm is turned on so that if Mr.O’Brien tries to get out of bed without assistance, an alarm willnotify staff. Later in the shift, Mr. O’Brien’s bed alarm sounds.The nurse quickly goes to his room to find Mr. O’Brien lying on thefloor on his right hip. He is alert and oriented and states, “I hadto go to the bathroom. I know I should have called for help but thenurses are busy. I figured I could go myself. Only two more stepsand I could have reached my walker. I just slipped is all.”Immediately following his fall, Mr. O’Brien complains of pain inhis right hip that is a “7” on a 0–10 pain scale. He describes thepain as a “dull ache” that is worse with movement of his right leg.His BP is 110/62, HR is 88, and respiratory rate (RR) is16.
Nursing Diagnosis:
Impaired physical mobility r/t dizziness
Risk for fall r/t orthostatic hypotension
Risk for fall r/t syncope
Risk for injury r/t transient loss ofconsciousness
