Anoxic brain injury nursing diagnosis

Anoxic encephalopathy, or hypoxic-ischemic brain injury, is a process that begins with the cessation of cerebral blood flow to brain tissue, which most commonly results from poisoning (for example, carbon monoxide or drug overdose), vascular injury or insult, or cardiac arrest.

Anoxic brain injury nursing diagnosis. 11125 MDS 3.0 Chapter 3 Section I v1.17.1. Intent: The items in this section are intended to code diseases that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to ...

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If you have a bike, you need a helmet, whether you’re 8 years old or 88 years old. Head injuries are common in bike accidents, and they can lead to brain damage and even death. In ...Anoxia is defined by the total absence of oxygen to the tissues or a particular organ such as the brain. The term anoxic brain injury (ABI) is frequently used synonymously in the literature with terms hypoxic-ischemic, anoxic-ischemic, hypoxic, or cerebral anoxia.. One of the earliest documented cases of ABI was in 1945 with eight …8 Tracheostomy Nursing Care Plans. Updated on April 30, 2024. By Paul Martin, BSN, R.N. Utilize this comprehensive nursing care plan and management guide to provide nursing care for patients with tracheostomy. Enhance your knowledge of nursing assessment, interventions, goals, and nursing diagnosis, all meticulously tailored to …Dec 1, 2009 · Anoxic brain injury (AnBI) is defined as a gross deterioration in brain function after disruption or cessation of the brain's vascular supply, thereby leading to inadequate oxygenation of the brain [1]. The symptomatology and clinical outcome after an anoxic episode depend on the degree and duration of oxygen deprivation. In this article we’ll discuss nursing diagnosis for respiratory disorders. Namely, COPD (Chronic Obstructive Pulmonary Disease) ARDS (Acute Respiratory Distress Syndrome) Pneumonia. PE (Pulmonary Embolism) Pneumothorax/ Hemothorax/ Tension Pneumothorax. Mechanical Ventilation. In future articles, we’ll discuss NANDA …Diagnosis and risks of hypernatremia in brain injury At present, the commonly used diagnostic criterion for hypernatremia is serum sodium > 150 mEq/L ( 6 , 15 ). In general, hypernatremia is defined as chronic when it persists for more than 48 h and acute when it lasts for < 48 h ( 17 ).Anoxic/Hypoxic brain injury (ABI/HBI) can be defined as a global disturbance related to brain function with resultant loss (Anoxic) or decrease (Hypoxic) in oxygen supply to the brain. The term anoxia is used to refer to a complete loss of tissue oxygenation. 33. Tissue oxygenation is affected by deliverable blood oxygen content and blood flow.MRI scans may be carried out for a variety of reasons, and will be accordingly targeted at specific zones of the body. Scans of the brain and spinal cord, for instance, not only lo...

Paroxysmal sympathetic hyperactivity (PSH) is a pattern of recurrent bursts of dysregulated sympathetic activity, resulting from severe brain injury. These episodes of sympathetic activation are short, dramatic, and often triggered by stimulation. PSH can be a challenging diagnosis, which may easily be confused with seizure, respiratory failure ...Nursing Diagnosis. Ineffective healing. Deficient knowledge. Impaired mobility. Acute pain. Altered sensory perception. Impaired swallowing. Go to: Causes. Brain trauma may result from anything …Disorders of consciousness (DoC) are characterized by alterations in arousal and/or awareness, and common causes of DoC include cardiac arrest, traumatic brain injury (TBI), intracerebral ...To confirm the diagnosis, they’ll order a few tests to check for brain function and to see how serious the damage may be. ... But if you have a severe anoxic brain injury and are in a vegetative ...Jan 17, 2022 · The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to impaired verbal communication. 1. Assess for conditions that affect speech. An example is seen in prolonged cardiac arrest causing diffuse anoxic brain injury. The basis for prognosis in milder forms is usually the diagnosis and underlying cause (i.e., tumor, stroke, traumatic brain injury, infection, etc.) and early recognition and treatment. ... Nursing care must pay close attention to changes in neurologic status ...After brain injury, both noxious and non-noxious stimuli then have the ability to drive a positive feedback loop that produces PSH. These stimuli may include common nursing interventions, such as suctioning, turning, repositioning, and bathing, as well as physiologic triggers such as constipation, urinary retention, and pain.

When you have aches and pains, you might reach for an ice pack or heating pad. But which is better? That depends on the type of injury or health problem you’re dealing with. Whethe...Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its ...A Pennsylvania nurse who prosecutors say administered excessive doses of insulin to nursing home patients, 17 of whom died, pleaded guilty Thursday. ... who had …The opioid epidemic has led to the creation of a new term: Toxic Brain Injury. This type of brain injury occurs from prolonged substance misuse and nonfatal overdose. This encompasses two forms of brain injury resulting from a lack of oxygen – hypoxic and anoxic brain injury. Hypoxic brain injury occurs when the brain does not receive …Anoxic brain injury, also known as global hypoxic-ischemic injury, is seen in all age groups (from antenatal to the elderly) as a result of numerous etiologies. The pattern of injury depends on a number of factors including: age of the patient (brain maturity) neonatal hypoxic-ischemic encephalopathy. hypoxic-ischemic injury in older …

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Nursing Diagnosis. The nursing diagnosis for anoxia brain injury may include: impaired physical mobility, altered nutrition, altered cognitive function, potential infection, impaired communication, impaired bowel and bladder function, altered self-care, impaired memory, risk for injury, and pain associated with the injury. Outcomes.A neurological exam is a series of tests that check for disorders of the brain and spinal cord. These disorders cause serious health problems. The exam can help lead to diagnosis a...If you have a bike, you need a helmet, whether you’re 8 years old or 88 years old. Head injuries are common in bike accidents, and they can lead to brain damage and even death. In ...Nov 5, 2023 · Apneustic breathing is characterized by prolonged, gasping inhalations followed by extremely short and inadequate exhalations. This pattern results from upper pons injury, often due to stroke or trauma, signifying severe brain injury and a poor prognosis. Temporary induction can occur by the administration of ketamine. Cerebral palsy is attributed to multifactorial nonprogressive disturbances in the fetus or infant’s brain, which may occur before, during, or after the baby’s birth. Risk factors and causes of cerebral palsy include: Congenital brain malformations. Chromosomal abnormalities. Intrauterine infections.

These injuries are very similar but have slightly different causes. A hypoxic injury occurs when the brain is still able to receive some amount of oxygen, but does not get enough. An anoxic injury occurs when oxygen is cut off completely from the brain. Like all parts of the body, the brain needs oxygen in order to function.Jul 10, 2021 · Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its ... Jun 8, 2023 · Elevate the head of the bed to promote venous drainage and reduce ICP. Administer prescribed medications, such as osmotic diuretics or anticonvulsants, to manage ICP and prevent seizures. Collaborate with the healthcare team to ensure prompt diagnostic imaging, such as a CT scan, to assess for brain injury and guide treatment. Volunteering at a nursing home is a great idea for someone who's outgoing. Learn what it's like and how to get started volunteering at a nursing home. Advertisement Honored war vet...Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its ...TBI/ABI/Stroke Support Group Cary, NC. 1st Monday of each month, 6:30 – 8 pm WakeMed Cary Hospital Conference Center Board Room 1900 Kildaire Farm Road Contacts: …Impaired Swallowing (Dysphagia) Nursing Care Plan & Management. Updated on April 30, 2024. By Gil Wayne BSN, R.N. Utilize this comprehensive nursing care plan and management guide to provide exceptional care for clients diagnosed with dysphagia or those with impairment in swallowing. This guide equips you with valuable insights into conducting ... Anoxic-ischemic brain injury is the most common proximate cause of death in nonsurvivors (Table 7.1 ). Fortunately, for those discharged with a favorable neurological outcome, long-term survival is excellent. Table 7.1. C7.T1 Patient Outcomes After Cardiac Arrest. Patient Outcome. One of the organs affected in sepsis is the brain, and sepsis-associated brain dysfunction (SABD) is probably the most common type of encephalopathy in the ICU. SABD is defined as diffuse brain dysfunction caused by infection outside the central nervous system (CNS) and is a diagnosis of exclusion. There should be no other diagnoses …

Leaving the game and getting quick treatment after TBI are important to recovery. Trusted Health Information from the National Institutes of Health For children and teens, getting ...

Nursing Diagnosis. The most common nursing diagnosis for opioid toxicity includes: Impaired gas exchange related to decreased ventilatory rate. ... In high doses, opiates decrease the respiratory drive, causing apnea which … These injuries are very similar but have slightly different causes. A hypoxic injury occurs when the brain is still able to receive some amount of oxygen, but does not get enough. An anoxic injury occurs when oxygen is cut off completely from the brain. Like all parts of the body, the brain needs oxygen in order to function. The presence of focal neurologic findings or mental status changes is predictive of complications following trauma. A neurologic examination helps to localize and lateralize lesions due to traumatic head or spine injury. The physical examination in the setting of significant trauma must be assessed rapidly, is individualized based on the …Stroke NCLEX Review and Nursing Care Plans. Stroke is a medical emergency that occurs when a part of the brain’s blood supply is cut off causing oxygen deprivation and death to brain tissues. It is also known as cerebrovascular accident CVA. Stroke can affect the brain’s functions and the effect depends on which part of the brain …View Care plan 2 - Risk for infection r:t improper toileting 2:2 to anoxic brain injury .docx from NURS MISC at Delgado Community College. 1 Name here Nursing Diagnosis AI Homework Help Expert HelpAnoxic brain injury can cause diffuse injury to the brain resulting in widespread neurological, behavioural and cognitive impairments. In this article, the authors describe the principal clinical manifestations of anoxic brain injury and illustrate this with two case histories. anoxia is typically associated with gross dete-rioration in brain ...While sudden loss of perfusion is responsible for ischemia, failure to supply the required amount of oxygen to the tissues is defined as hypoxia. Among several pathological conditions that can impair brain perfusion and oxygenation, cardiocirculatory arrest is characterized by a complete loss of perfusion to the brain, determining a whole brain …An example is seen in prolonged cardiac arrest causing diffuse anoxic brain injury. The basis for prognosis in milder forms is usually the diagnosis and underlying cause (i.e., tumor, stroke, traumatic brain injury, infection, etc.) and early recognition and treatment. ... Nursing care must pay close attention to changes in neurologic status ...Contents: Head Injury Overview. Nursing Diagnosis. Care Plans. Pathophysiology. Head injury involves trauma to the skull leading to temporary or permanent brain damage. There are several different types of traumatic brain injuries (TBIs): Reference: Saunders comprehensive review for the NCLEX-RN examination. Causes.The diagnosis given these people depends on whether their eyes are always closed or whether they have periods when their eyes are open. ... These people may go directly to a skilled nursing facility, a sub-acute rehabilitation program, a nursing home, or even home with family. ... On 12/08/21 My 26 year old son got a anoxic brain …

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Elevate the head of the bed to promote venous drainage and reduce ICP. Administer prescribed medications, such as osmotic diuretics or anticonvulsants, to manage ICP and prevent seizures. Collaborate with the healthcare team to ensure prompt diagnostic imaging, such as a CT scan, to assess for brain injury and guide treatment.Paroxysmal sympathetic hyperactivity (PSH) is a disorder in the regulation of autonomic function most commonly observed in patients with acute brain injury, most notably severe traumatic brain injury (TBI) [ 1,2 ]. It manifests with recurrent episodes of excessive sympathetic activity that start rapidly, are often induced by stimulation, and ...After brain injury, both noxious and non-noxious stimuli then have the ability to drive a positive feedback loop that produces PSH. These stimuli may include common nursing interventions, such as suctioning, turning, repositioning, and bathing, as well as physiologic triggers such as constipation, urinary retention, and pain.2. Pathophysiology of Posttraumatic DI (PTDI) Traumatic brain injury (TBI) is a significant public health problem. It is associated with high mortality, as well as acute and chronic morbidity with many survivors being severely disabled physically and psychologically [4,5,6].It is more frequent in children, young adults and the elderly [] and …If we combine all these terms, a TME diagnosis would follow when toxic cells in the body do not allow the healthy breakdown of substances leading to inflammation of the brain cells. This can cause an altered mental status, changes with …Anoxic brain injury is damage to the brain due to a lack of oxygen supply (an: absence; oxia: oxygen). The brain is a vital organ with a high oxygen requirement. Its oxygen requirement is about 3.5 mL per 100 grams of brain tissue per minute . This translates to about 20 percent of total oxygen consumed by the body while at rest.Rehabilitation Nursing, 42(6), 341 346. doi: 10.1002/rnj.289. –. November/December 2017 Volume 42 Number 6. nursing interventions, especially reading, for agitated patients with anoxic brain injury. Case Report. A 48-year-old divorced teacher was admitted to the hos-pital for gynecologic surgery.Cerebral hypoxia happens when your brain doesn’t get enough oxygen. Symptoms include confusion, difficulty speaking and seizures. It’s a medical emergency that can be fatal and can cause lifelong brain damage. Healthcare providers can treat some of the issues that cerebral hypoxia causes but they can’t reverse the brain damage that it can ...This chapter provides an overview of traumatic brain injury (TBI), including how it is defined, its mechanisms of injury, and its neuropathology. The chapter also provides a conceptual model on the recovery trajectories after TBI and intrinsic factors related to the variability in its presentation and diagnosis and in recovery from TBI. There is a discussion of the complexity of establishing a ... ….

8 Tracheostomy Nursing Care Plans. Updated on April 30, 2024. By Paul Martin, BSN, R.N. Utilize this comprehensive nursing care plan and management guide to provide nursing care for patients with tracheostomy. Enhance your knowledge of nursing assessment, interventions, goals, and nursing diagnosis, all meticulously tailored to …11125 MDS 3.0 Chapter 3 Section I v1.17.1. Intent: The items in this section are intended to code diseases that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to ...Volunteering at a nursing home is a great idea for someone who's outgoing. Learn what it's like and how to get started volunteering at a nursing home. Advertisement Honored war vet...Without treatment, a typical prognosis for a patient with brain lymphoma is life expectancy of less than two months, according to the New York Times Health Guide.Evidence-Based Review: Nursing Care of Adults with Severe Traumatic Brain Injury. 8735 W. Higgins Road, Suite 300 Chicago, IL 60631-2738 888.557.2266 International phone: 847.375.4733 Fax: 847.375.6430 [email protected] | www.AANN.org. Evidence-Based Review: Nursing Care of Adults with Severe Traumatic Brain Injury. Anoxic brain injury is defined by a one-time event that causes harm to the brain. This harm can cause oxygen deprivation to the brain, which leads to brain cell death within minutes. This can lead to complications with a variety of brain functions, including cognitive (mental), physiological (physical) and emotional. Neuroplasticity may mean your brain can grow and heal on its own. If you're living with a mental health condition, your brain's ability to regenerate can help. Brain plasticity all...Paroxysmal sympathetic hyperactivity (PSH) is a pattern of recurrent bursts of dysregulated sympathetic activity, resulting from severe brain injury. These episodes of sympathetic activation are short, dramatic, and often triggered by stimulation. PSH can be a challenging diagnosis, which may easily be confused with seizure, respiratory failure ...Encephalopathy is a broad term used to describe abnormal brain function or brain structure. The hallmark of encephalopathy is altered mental status. The abnormality may be transient, recurrent, or permanent. There are numerous types of encephalopathy and brain disorders with a variety of different etiologies. Some types are permanent, … Anoxic brain injury nursing diagnosis, Disclosures: Fabienne Saint-Preux, MD: Nothing to disclose Case Description: 32-year-old male with history of unintentional heroin overdose complicated by cardiac arrest and anoxic brain injury presenting with functional decline, mutism, catalepsy, rigidity and negativism consistent with catatonia. Marked improvement with …, Anoxic Brain Injury. Anoxic brain injury is a type of brain injury that isn't usually caused by a blow to the head. Instead, anoxic brain injury occurs when the brain is deprived of oxygen. Left without oxygen for too long, neural cells begin to die through a process called apoptosis. And though cell death is a normal part of the human ... , Anoxic Brain Injury. Anoxic brain injury is a type of brain injury that isn't usually caused by a blow to the head. Instead, anoxic brain injury occurs when the brain is deprived of oxygen. Left without oxygen for too long, neural cells begin to die through a process called apoptosis. And though cell death is a normal part of the human ..., May 19, 2009 · May 20, 2009. nursing diagnosis is based upon the abnormal assessment data you have collected about the patient. an anoxic brain injury is a traumatic event that has produced symptoms, none of which you have mentioned. you need to research anoxic brain injuries and make a listing of this patient's symptoms. from those symptoms nursing diagnoses ... , Brain injury after resuscitation, a common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. ... Out-of-hospital cardiac arrest: 30-day survival and 1-year risk of anoxic brain damage or nursing home admission according to consciousness status at hospital arrival ..., Anoxic encephalopathy, or hypoxic-ischemic brain injury, is a process that begins with the cessation of cerebral blood flow to brain …, Components of a risk nursing diagnosis include (1) risk diagnostic label, and (2) risk factors. Examples of risk nursing diagnosis are: Risk for injury; Risk for infection; Health Promotion Diagnosis. Health promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about motivation and desire to increase well-being. It is …, TBI/ABI/Stroke Support Group Cary, NC. 1st Monday of each month, 6:30 – 8 pm WakeMed Cary Hospital Conference Center Board Room 1900 Kildaire Farm Road Contacts: Norman Case: (919) 244–6221 [email protected] and Brooke Hinnant: [email protected]., Rehabilitation-Specific Treatment. Anoxia is defined by the total absence of oxygen to the tissues or a particular organ such as the brain. The term anoxic brain …, 1 Name here Nursing Diagnosis 2 Assessment Nursing Diagnosis Objectives Evaluations . ... BP: 104/71 O: Pulse OX: 98% O: Pain: Ø Risk for infection r/t improper toileting 2/2 to anoxic brain injury AEB elevated urinary WBC casts and incontinence. STO 1: Pt. will comply with antibiotic treatment throughout the shift., Vestibular neuritis is a condition in the inner ear caused by infection or swelling (inflammation) of a nerve. The vestibular nerve sends your brain messages about your balance and..., When you're asked questions – either on an application or in an interview – for a nursing scholarship, be ready with meaningful answers. Try to learn why the grantor is giving scho..., Glasgow Coma Scale. This 15-point test helps a doctor or other emergency medical personnel assess the initial severity of a brain injury by checking a person's ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues. Abilities are scored from three to 15 in the Glasgow Coma Scale., Do you know how to get your nursing assistant renewal certification? Learn how to get your renewal certification in this article from HowStuffWorks. Advertisement As the elderly po..., Jun 8, 2023 · Elevate the head of the bed to promote venous drainage and reduce ICP. Administer prescribed medications, such as osmotic diuretics or anticonvulsants, to manage ICP and prevent seizures. Collaborate with the healthcare team to ensure prompt diagnostic imaging, such as a CT scan, to assess for brain injury and guide treatment. , wikipedia. Nursing Diagnosis for Brain Injury. Ineffective airway clearance and impaired gas exchange related to brain injury. Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures. Deficient fluid volume related to decreased LOC and hormonal dysfunction. Imbalanced nutrition, less than body ..., Dhuʻl-Q. 21, 1435 AH ... Of these, only 27 papers utilized diagnostic criteria, and 9 sets of diagnostic criteria were newly developed. Most papers agreed that the core ..., Patients with neurological diseases may be eligible for hospice when they experience the following signs or symptoms: Severely compromised breathing, marked by inability to clear respiratory secretions, persistent cough, or recurring aspiration pneumonia. Increased shortness of breath, even at rest or on oxygen., Some of the professionals that work most with helping people with schizophrenia are nurses. There are so many Some of the professionals that work most with helping people with schi..., Magnetic resonance imaging (MRI) can show brain lesions that are not visible by computed tomography, including early cytotoxic oedema after ischaemic stroke, diffuse axonal injury after traumatic brain injury and cortical laminar necrosis after cardiac arrest. Thus, MRI increases the accuracy of neurological diagnosis in critically ill patients., Jan 28, 2023 · Anoxic encephalopathy, or hypoxic-ischemic brain injury, is a process that begins with the cessation of cerebral blood flow to brain tissue, which most commonly results from poisoning (for example, carbon monoxide or drug overdose), vascular injury or insult, or cardiac arrest. Many patients who suffer anoxic brain injury expire without ... , The effects of hypoxic or anoxic brain injury, where the brain is starved of oxygen, can range from mild, short-term symptoms such as dizziness or concentration problems, through to severe, long-term issues including vision, speech and memory. The body will respond to cerebral anoxia by increasing blood flow to the brain in an attempt to ... , One of the organs affected in sepsis is the brain, and sepsis-associated brain dysfunction (SABD) is probably the most common type of encephalopathy in the ICU. SABD is defined as diffuse brain dysfunction caused by infection outside the central nervous system (CNS) and is a diagnosis of exclusion. There should be no other diagnoses …, For example, following anoxic brain injury, lack of a cough reflex after 24 hours carries a likelihood ratio of 85 for poor neurologic outcome. causes of an absent cough reflex include. Damage to the medulla (e.g., tonsillar herniation, brain death). Extremely profound toxic/metabolic coma (e.g., barbiturate or baclofen overdose)., Anoxic brain injuries are caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation. …, May 9, 2023 · Confusion. Restlessness. Palpitations and a rapid heartbeat. Blue or purple lips or skin (cyanosis) Symptoms of anoxia can include: Loss of consciousness. Seizures. Signs of brain damage. The severity of symptoms can depend on the duration and degree of oxygen deprivation. , Anoxic Brain Injury Anoxic brain injury is a component of multiple diagnoses, but it is rarely identified in the list of comorbidities. The diagnoses of cardiac arrest, stroke, anesthesia accident, electrocution, prolonged seizure, asthma exacerbation, at-temptedsuicide,carbonmonoxidepoisoning,neardrown-ing, and massive hemorrhage are quite ... , Evidence-Based Review: Nursing Care of Adults with Severe Traumatic Brain Injury. 8735 W. Higgins Road, Suite 300 Chicago, IL 60631-2738 888.557.2266 International phone: 847.375.4733 Fax: 847.375.6430 [email protected] | www.AANN.org. Evidence-Based Review: Nursing Care of Adults with Severe Traumatic Brain Injury., TBI/ABI/Stroke Support Group Cary, NC. 1st Monday of each month, 6:30 – 8 pm WakeMed Cary Hospital Conference Center Board Room 1900 Kildaire Farm Road Contacts: Norman Case: (919) 244–6221 [email protected] and Brooke Hinnant: [email protected]. , Management of the client with a submersion injury is based on the degree of cerebral insult. The first priority is to restore oxygen delivery to the cells and prevent further hypoxic damage. 9. Provide oxygenation as ordered. If the client has spontaneous breathing, supplemental oxygenation is administered by mask., An E.R. nurse has managed to turn her Etsy side hustle into a full-time job that has earned her millions of dollars in profits. * Required Field Your Name: * Your E-Mail: * Your Re..., Hypoxic-anoxic brain injuries can cause long-lasting damage. The sooner that you recognize the symptoms of hypoxia and anoxia and seek treatment, the more likely that you’ll successfully recover ..., 1. Monitor vital signs. Abnormal vital signs could put the patient at risk of falls resulting in injury due to low blood pressure. 2. Monitor mental status. Altered mental status could increase a patient’s risk of injury as the patient may not be fully aware of their surroundings and what is considered safe. 3.