Arrange the steps taken by the nurse while assessing the visual level of a client

In this nursing care plan guide are 11 nursing diagnosis for the care of the elderly (older adult) or geriatric nursing or also known as gerontological nursing. Learn about the assessment, care plan goals, and nursing interventions for gerontology nursing in this post.

Inhaltsverzeichnis Show

1. Risk for Falls
Risk for Falls
1. Risk for Falls
Recommended Resources
References and Sources
In which sequential order would the nurse assess the visual level of a client?
Which assessment technique would the nurse use to assess the hydration status of the patient?
When assessing a patient with dark skin which areas should the nurse check for physical manifestation of jaundice?
Which physical examination techniques are most helpful when assessing a patient quizlet?

Gerontology nursing or geriatric nursing specializes in the care of older or elderly adults. Geriatric nursing addresses the physiological, developmental, psychological, socio-economic, cultural and spiritual needs of an aging individual.

Since aging is a normal and fundamental part of life. Providing nursing care for elderly clients should not only be isolated to one field but is best given through a collaborative effort which includes their family, community, and other health care team. Through this, nurses may be able to use the expertise and resources of each team to improve and maintain the quality of life of the elderly.

Geriatric nursing care planning centers on the aging process, promotion, restoration, and optimization of health and functions; increased safety; prevention of illness and injury; facilitation of healing.

Here are 11 nursing care plans (NCP) and nursing diagnosis for geriatric nursing or nursing care of the elderly (older adult):

Risk for Falls
Impaired Gas Exchange
Hypothermia
Disturbed Sleep Pattern
Constipation
Adult Failure to Thrive
Risk for Aspiration
Risk for Deficient Fluid Volume
Risk for Injury
Risk for Infection
Risk for Impaired Skin Integrity

1. Risk for Falls

Risk for Falls

Nursing Diagnosis

Risk for Falls

Risk Factors

Common risk factors for the nursing diagnosis risk for falls:

Age (especially ≥ 65 years)
Impaired physical mobility
Loss of muscle strength
Altered sensory perception
Presence of illness (Alzheimer’s disease, dementia, osteoporosis)
Urinary incontinence
Use of medications
Disorientation
Dizziness
Lack of knowledge of environmental hazards secondary to confusion
Improper use of aids (e.g., canes, walkers, wheelchair, crutches)

Defining Characteristics

Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

Expected outcomes or patient goals for risk for falls nursing diagnosis:

Patient will be free from falls.
Patient and caregiver will implement measures to increase safety and prevent falls in the home.

Nursing Interventions and Rationale

In this section are the nursing actions or interventions and their rationale or scientific explanation for the nursing diagnosis risk for falls:

Nursing Interventions	Rationale
Nursing Assessment
Identify factors that increase the level of fall risk	These factors will help in determining interventions necessary for the patient. Risk factors include age, presence of an illness, sensory and motor deficits, medication use, and inappropriate use of mobility aids.
Assess the patient’s environment for factors associated with an increased risk for fall.	A patient who is not familiar with the placement of furniture in an area or who has inadequate lighting in the house increases the risk for falls.
Therapeutic Interventions
Secure a wristband identification to warn healthcare providers to implement fall precaution on the patient.	Healthcare providers need to recognize patients at high risk for falls to implement measures to promote patient safety and prevent falls.
Place assistive devices and commonly use items within reach.	Provides easy access to assistive devices and personal care items. Items such as call bell, telephone, and water should be kept close to avoid frequent reaching.
Review hospital protocols regarding transferring a patient.	Hospital facility should have clear policies and procedures during transfers that will ensure the patient’s safety.
Keep the patient’s bed in the lowest position at all times.	Keeping the bed closer to the floor prevents injury and risk of falls.
Answer call light as soon as possible.	This is to prevent an unstable patient from ambulating without any assistance.
Use side rails on bed as needed	Raising the side rails reduces the risk of patients falling out of bed during transport.
Advise the patient to wear shoes or slippers with non-slip soles when walking.	Wearing non-slip footwear help prevents slips and falls.
Orient the patient to the surroundings. Avoid re-arranging the furniture in the room.	The patient should be familiarized with the bed, location of the bathroom, furniture, and other environmental hazards that can cause older patients to trip or fall.
Ensure the patient’s room is well-lit. Consider the use of a bedside lamp that is turned on at night.	Providing lighting in key places can reduce fall risk and avoid obstacles during mobility.
Encourage the family and other significant others to stay with the patient at all times.	Prevents the patient from accidentally falling or pulling out tubes.
Ensure the patient’s eyesight is regularly checked and explain the importance of wearing eyeglasses if needed. Make sure glasses and hearing aids are always worn.	Hazard can be lessened if the patient utilizes appropriate aids to improve visual and auditory orientation to the environment. Visually impaired patients are at high risk for falls.
Instruct the patient how to ambulate at home, including using safety measures such as handrails in the bathroom.	Help relieve anxiety at home and eventually decreases the risk of falls during ambulation.
Encourage the patient to engage in a program of regular exercise and gait training.	Exercises can improve muscle strength, balance, coordination and reaction time. Physical conditioning reduces the incidence of falls and avoids injury that is sustained when a fall happens.
Collaborate with other health care team to assess and review patient’s medications that can contribute to the risk for falls. Identify the peak effects of the medications that can alter the consciousness of the patient.	A review of the patient’s prescribed medications will recognize side effects and drug interactions that may enhance fall injury risk. The more medications a patient takes, the greater the risk for side effects and interactions such as orthostatic hypotension, dizziness, confusion, urinary incontinence, and altered gait and balance. Polypharmacy in older adults is a significant risk factor for falls.
Evaluate the need for physical and occupational therapy to assist patient with gait techniques and provide the patient with assistive devices for transfer and ambulation. Initiate a home safety evaluation as needed.	The use of gait belts provides a more secure means to safely assist patients when transferring from bed to chair. Assistive aids such as wheelchairs, canes, and walkers allow the patient to have stability and balance during ambulation. High toilet seats can facilitate safe transfer on and off the toilet.

1. Risk for Falls

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

References and Sources

Here are the references and sources for this Geriatric Nursing Care Plan:

Boltz, M., Capezuti, E., Fulmer, T. T., & Zwicker, D. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice. Springer Publishing Company.[Link]
Carpenito-Moyet, L. J. (2009). Nursing care plans & documentation: nursing diagnoses and collaborative problems. Lippincott Williams & Wilkins. [Link]
Gilje, F., Lacey, L., & Moore, C. (2007). Gerontology and geriatric issues and trends in US nursing programs: a national survey. Journal of Professional Nursing, 23(1), 21-29. [Link]
Mauk, K. L. (Ed.). (2010). Gerontological nursing: Competencies for care. Jones & Bartlett Publishers. [Link]
Wold, G. H. (2013). Basic Geriatric Nursing-E-Book. Elsevier Health Sciences. [Link]

Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.

In which sequential order would the nurse assess the visual level of a client?

The first step while assessing the visual level of the client is to direct the client to stand or sit 60 cm away at eye level. Next, the nurse should ask the client to gently close or cover one eye and look at the nurse's eye directly opposite.

Which assessment technique would the nurse use to assess the hydration status of the patient?

Gently pull the skin at the back of the neck or along the spine and evaluate how long the skin takes to return to the patients body. A slow return to normal, or decreased skin turgor, indicates a loss of hydration. Conversely, increased skin turgor may be an indicator of overhydration.

When assessing a patient with dark skin which areas should the nurse check for physical manifestation of jaundice?

Jaundice—Inspect the sclera and hard palate. Erythema—Palpate the area for warmth. The localized area of skin may be purplish/bluish or violaceous (eggplant color). Edema—Inspect the area for decreased color.

Which physical examination techniques are most helpful when assessing a patient quizlet?

The nurse should use his or her fingertips to assess the texture, vibration, or pulsations. Which of the following physical examination techniques are most helpful when assessing a patient? Select all that apply. Palpation, percussion, and auscultation are all techniques the nurse uses during a physical examination.

Arrange the steps taken by the nurse while assessing the visual level of a client

1. Risk for Falls

Risk for Falls

Nursing Diagnosis

Risk Factors

Defining Characteristics

Desired Outcomes

Nursing Interventions and Rationale

1. Risk for Falls

Recommended Resources

See also

References and Sources

In which sequential order would the nurse assess the visual level of a client?

Which assessment technique would the nurse use to assess the hydration status of the patient?

When assessing a patient with dark skin which areas should the nurse check for physical manifestation of jaundice?

Which physical examination techniques are most helpful when assessing a patient quizlet?

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