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Tags/Categories: [17]
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Adjustment: lifestyle change resulting from admission.
Client needs socialization with peers of same age group to meet psychosocial needs r/t being in a geriatric environment.
Confined to a chair with safety belt or positioning pillow that prevents rising related to [specify]
Conflict between client and family is present.
Decrease in activity participation related to [specify]
Dependent on tube feeding for nutrition and hydration, and is at risk for aspiration, other complications related to tube feeding.
Difficulty in making self understood; ability is limited to making concrete requests.
Discomfort, potential for complications related to itching/burning eyes, blepharitis, dry eyes, conjunctivitis. (Specify problem)
Emotional unwillingness to participate in activity program due to
Expresses powerlessness related to [specify]
Has a feeding tube which could lead to a fluid volume deficit related to inadequate fluid intake.
High risk for aspiration, complications due to dysphagia related to: [SPECIFY]
High risk for elopement related to [SPECIFY]
Inadequate fluid intake related to [SPECIFY]
Infection related to chronic/acute UTI.
Mental function varies during the course of the day as evidenced by [specify].
Mobility impaired related to: [specify]
Must maintain nutritional status via tube feeding related to [inability to swallow/refusal to eat/low cal intake].
Needs assistance with ADLs: requires staff intervention or assistance to remain clean, neat and free of body odors due to:
Needs assistance with Bathing/Hygiene related to [specify]
Non-compliant with therapeutic diet.
Noncompliance related to [specify]
Noncompliant with therapeutic diet.
Not participating to fullest capability in some activities of daily living such as [specify].
Potential for adjustment reaction related to new admission to nursing home/long term care facility.
Potential for alteration in cardiac output related to [specify]
Potential for complications, discomfort related to sleep apnea. Contributing factors: __ Obesity __ Hypertension __ Nasopharyngeal narrowing
Potential for complications, ineffective airway clearance, discomfort related to diagnosis of tuberculosis.
Potential for drug-related movement disorder or gait disturbance related to taking [MEDICATION] and [(Parkinsons/poor balance/tardive dyskinesia/loss of limb movement/motor agitation/swallowing problem/vertigo/accidents)].
Potential for infection, complications related to dx of urinary retention.
Potential for recurrence of Urinary Tract Infection/chronic UTI.
Potential for seizure activity, injury related to seizure disorder.
Potential to develop a urinary tract infection related to frequent catheter insertion and/or client pulling on catheter.
Refuses to wear glasses.
Requires [#] siderails when in bed related to [specify]
RESPIRATORY: Impaired breathing pattern, shortness of breath on exertion related to: [specify]
Sleep cycle disturbances as evidenced by [specify].
Strong identification with past roles, sad feelings over loss of roles, and perceives facility daily routine different from prior pattern in the community as evidenced by [specify].
Teeth missing and does not have/use dentures.
Verbal communication impaired related to [specify]
Wanders in hallways and into others room uninvited.
Wears external catheter due to [specify].
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