I.
LIST OF PRIORITIZED PROBLEMS
Cues
Subjective:
“Nanay at Tatay ko ang nagdala
sa akin dito” As verbalized by
the patient
Objective:
 Has lapses in memory
 Has sudden mood
changes
 Is confused or disoriented
Subjective:
“Hindi ako masyado mahilg
makipag usap sa iba, madalas
wala akong kibo.
Pinapakiramdaman ko lang
yung mga tao.”
as verbalized by the patient.
Objective:
 Spends time alone.
 Inappropriate emotional
response.
 Unable to
make eye contact, or
initiate or respond to
social advances of
others.
 Observed use of
unsuccessful social
interactions behaviors.
Subjective:
“Magsuklay lang kaya kong
gawin kasi etong isang kamay
ko lang nagagalaw ko eh.” as
verbalized by the patient.
Nursing Diagnosis Rank
Disturbed thought 1 The focus of nursing is to reduce
process related to
degenerative process
as evidenced by
memory deficit.
Impaired social 2 Social interaction for Seniors is
interaction related to
insufficient skills to
enhance mutuality
Self-care deficit 3 Self-Care Deficit is the inability
related to left sided
body paralysis as
evidenced by impaired
mobility/transfer
ability
Justification
disturbed thinking and promote
reality orientation. Often,
confusion in older adults is
erroneously attributed to aging.
Confusion in the older adult can
be caused by a single factor or
multiple factors such as
depression, dementia,
medication side effects, or
metabolic disorders.
important. Maintaining
relationships and spending time
with others is essential to a
senior's emotional and mental
well-being. It can help with
depression, which is prevalent
with seniors.
On the other hand, social
isolation has been associated
with depression, high blood
pressure, and greater risk of
death. Social interaction is
therefore an important factor in
healthy aging. ... For seniors,
socializing is often not easy and
thus, they are at risk of becoming
socially isolated.
of an individual to perform self-
care. The deficit may be the
effect of temporary limitations,
such as those one might
experience while aging, or the
Objectives: result of gradual deterioration
 Generalized body that erodes the individual’s
weakness ability or willingness to perform
 Paralysis of left upper the activities required to care for
and lower extremities himself or herself. Also, patients
 Inability to bathe, groom who are suffering from
self independently and depression may not have the
perform toileting tasks interest to engage in self-care
 Inability to put on activities.
various items of clothing
like slippers, socks,
shoes
 Inability to dry body
when the bed is wet due
to urinary incontinence
Objectives: Risk for Fall related 4 Although injury prevention is a
 Age: 79 years old to left sided paralysis concern for older adults, it is
 Left sided paralysis of the body due to considered as the least priority as
 Wheelchair bound ischemia of the right opposed to the patient’s actual
 Muscle weakness hemisphere needs.
 Poor eyesight
 Disorientation
 History of falls
 Environmental
conditions (wet
bathroom floors)
 Absence of anti-slip
material in bath and
shower

Morse Fall Risk:

- History of Falling (YES) 25
- Gait, impaired (20)
Total score: 45
Interpretation: >45 High risk
for fall