11 Geriatric Nursing Care Plans (Older Adult)

Risk for Injury

One of the biggest challenges in geriatric care is the increased risk of injury. Falls are the most common cause of injury among older adults, but other types of harm can occur as well. Some of the most common types of injuries in geriatric care include falls, pressure ulcers, and medication errors.

Nursing Diagnosis

• Risk for Injury

Risk Factors

Here are the risk factors for the nursing diagnosis Risk for Injury for geriatric nursing care plans:

• Age-related diminished physiologic reserve, cardiac function, or renal function.
• Reduced brain oxygenation happening with disease condition and decreased functional tissue
• Impaired sensory/perceptual reception occurring with poor vision or hearing

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

The commonly used expected outcomes or patient goals for Risk for Injury nursing diagnosis:

• The patient’s mentation will return to normal for the patient within 3 days of therapy.
• The patient will be free from injury or harm as a result of mental status.

Nursing Assessment and Rationale

Nursing assessments play a critical role in reducing the risk of injury in geriatric care. By identifying potential hazards and implementing effective interventions, nursing staff can help prevent harm to elderly patients.

1. Monitor the baseline level of consciousness (LOC) and neurologic status of the patient upon admission. Evaluate mental status and pre-confusion functional abilities of the caregiver or significant others. Ask the patient to complete a three-step task. For example, “Put your right hand on your chest, wave with your left hand, and then raise your eyebrows”
A component of the Mini-Mental Status Examination, this assessment tool provides a baseline for succeeding evaluation of a patient’s confusion. A three-step task is complex and is a gross indicator of brain function. Because it requires attention, it can also test for delirium.

2. Utilize the confusion assessment method (CAM) to determine the presence or absence of delirium/confusion.
Delirium is a serious problem for hospitalized older individuals and usually goes not identified. The CAM tool (Waszynski, 2007) can be administered in a short period of time. CAM is a simple standardized tool that can be used by bedside clinicians and has been validated in settings from medical-surgical areas to intensive care units. If your agency does not already employ this tool, there are several online sources that describe it in detail.

3. Determine the cause of acute confusion.
Acute confusion is caused by physical and psychosocial conditions and not by age alone. For example, oximetry or arterial blood gas (ABG) values may reveal low oxygenation levels, serum glucose or fingerstick glucose may reveal high or low glucose levels, and electrolytes and complete blood count (CBC) will ascertain imbalances and/or presence of elevated white blood cell (WBC) count as a determinant of infection. Hydration status may be evaluated by pinching over the sternum or clavicle for turgor (tenting occurs with fluid volume deficit) and observing for dry mucous membranes and a furrowed tongue.

4. Test short-term memory by showing the patient how to use the call light, having the patient return the demonstration, and then waiting at least 5 minutes before having the patient demonstrate the use of the call light again. Record the patient’s actions in behavioral terms. Describe the “confused” behavior.
The inability to retain information beyond 5 minutes signifies poor short-term memory.

5. Assess the apical pulse and inform the physician of a newly discovered episode of an irregular pulse. If the patient is hooked on a cardiac monitor or telemetry, check for dysrhythmias; inform the physician accordingly.
Dysrhythmias and other cardiac abnormalities may cause poor brain oxygenation, which can result to confusion.

6. Monitor the patient’s pain using a rating scale of 0-10. If the pain scale is not possible, assess for nonverbal cues such as frowning, grimacing, rapid blinking, clenched fists, and fidgeting. Ask for some assistance from the significant other or caregiver to help in identifying pain behaviors.
Acute confusion can be a sign of pain.

7. Treat the patient for pain, as indicated, and monitor behaviors.
If the pain is the cause of the confusion, the patient’s behavior should change accordingly.

8. Monitor intake and output every 8 hours.
The output should equal intake. Dehydration can lead to acute confusion.

9. Assess kidney function by reviewing the patient’s creatine clearance result.
Renal function plays an essential role in fluid balance and is the main mechanism of drug clearance. Blood urea nitrogen (BUN) and serum creatinine are influenced by hydration status and in older individuals show only part of the picture. Hence, to fully understand and assess renal function in older patients, creatine clearance must be examined.

10. Review current medications, including over-the-counter (OTC) drugs, with the pharmacist.
High levels of some medications, such as digoxin, anticholinergic agents, and drug interaction can cause acute confusion.

Nursing Interventions and Rationales

Once a nursing assessment has been conducted, nursing staff can implement effective interventions to reduce the risk of injury. Some of the most effective interventions include:

1. If the patient has short-term memory problems, toilet or offer the urinal or bedpan every 2 hours while awake and every 4 hours during the night. Establish a toileting schedule and post it on the patient care plan and, inconspicuously, at the bedside.
A patient with a short-term memory problem cannot be assumed to use the call light.

2. Keep the patient’s urinal and other routinely used items within easy reach for the patient.
A confused patient may wait until it is too late to ask for help with toileting.

3. Have the patient wear glasses and hearing aid, or keep them close to the bedside and within easy reach for patient use.
Glasses and hearing aids are likely to aid in reduced sensory confusion.

4. Encourage the patient’s significant other to bring items familiar to the patient, including a blanket, bedspread, and pictures of family and pets.
Familiar objects may facilitate orientation while also producing comfort.

5. Check on the patient at least every 30 minutes and every time you pass the room. Place the patient close to the nurses’ station if possible. Provide an environment that is nonstimulating and safe.
A confused patient requires additional safety precautions.

6. Attempt to reorient the patient to his or her environment as needed. Keep a clock with large numerals and a huge print calendar at the bedside; verbally remind the patient of the date and day as needed.
Reorientation may lessen confusion.

7. Provide music but not TV.
Patients who are confused about the place and time usually think the action seen on TV is occurring in the room.

8. Tell the patient in simple terms what is occurring. For example, “I will take your blood pressure on your left arm,” “This food given to you is healthy,” or “I’ll help you walk towards the prayer room.”
Complex sentences may be hard to understand.

9. If the patient exhibits hostile behavior or misperceives your role (e.g., the nurse becomes a janitor or police), leave the room. Come back in 15 minutes. Introduce yourself to the patient as if it is your first time meeting. Start the conversation anew.
Patients who are acutely confused have poor short-term memory and may not retain the previous encounter or that you were involved in that encounter.

10. If the patient becomes aggressive, hostile, or argumentative while you are trying to reorient, stop this approach. Do not question the patient or the patient’s understanding of the environment. State, “I get why you may seem to think about that.”
This approach avoids the escalation of anger in a confused person.

11. If the patient has a permanent or severe cognitive deficit, check on her or him at least every 30 minutes and reorient to baseline mental status as indicated; however, do not question the patient about his or her understanding of reality.
Arguing can cause a cognitively impaired person to become hostile and combative. Note: Individuals with severe cognitive (e.g., Alzheimer’s disease or dementia) also can experience acute confusional states (i.e., delirium) and can be returned to their baseline mental state.

12. If the patient tries to leave the hospital, walk with him or her and attempt distraction. Ask the patient to tell you about the destination. For example, “That seems to be an interesting place! Can you describe it?” Keep your tone friendly and conversational. Resume walking with the patient away from doors and exit around the unit. After a few minutes, attempt to lead the patient back to the room. Offer snacks and naps.
Distraction is a proven measure of reversing a behavior in a patient who is confused.

13. Have the patient’s significant others talks with the patient by phone or come in and sit with the patient if the patient’s behavior requires checking more regularly than every 30 minutes.
These interventions by the significant other may help promote the patient’s safety.

14. If the patient tries to climb out of bed, offer a urinal or bedpan or assist to the commode.
The patient may need to use the toilet.

15. Alternatively, if the patient is not on bedrest, place him or her in a chair or wheelchair at the nurses’ station.
This action facilitates extra supervision to promote a patient’s safety while also supporting stimulation and limiting isolation.

16. Bargain with the patient. Attempt to establish an agreement to stay for a fixed period, such as until the health care provider, meal, or significant other comes.
This is a delaying approach to mitigate anger. Due to poor memory and attention span, the patient may forget he or she wanted to leave.

17. If the patient is attempting to pull out tubes, hide them. Put a stockinette mesh dressing over intravenous (IV) lines. Secure feeding tubes to the side of the patient’s face using paper tape, and drape the tube behind the patient’s ear.
Remember: Out of sight, out of mind.

18. Use medications being prescribed carefully for managing behavior.
Follow the maxim “start low and go slow” with medications because older patients can respond to a small number of drugs. Neuroleptics, such as haloperidol, can be used effectively in calming patients with dementia or psychiatric illness (contraindicated for individuals with parkinsonism). However, if the patient is experiencing acute confusion or delirium, short-acting benzodiazepines (e.g., lorazepam) are more effective in alleviating anxiety and fear. Anxiety or fear usually promotes destructive or dangerous behaviors in acutely confused older patients.
Neuroleptics can cause akathisia, an adverse drug reaction characterized by increased restlessness.

19. Use restraints with caution and according to hospital policy.
Patients tend to become more agitated when wrist and arm restraints are applied.

20. Evaluate the continued need for certain interventions.
Some interventions may become irritating stimuli. For example, if the patient is now drinking, terminate the IV line; If the patient is eating, remove the feeding tube; if the patient has an indwelling urethral catheter, remove the catheter and start a bladder training.