Geriatric Nursing Diagnosis & Care Plan

Caring for the elderly grows more complex as more people reach their senior years. Elderly people in the community setting are susceptible to serious physical and mental health problems. Socially, geriatric patients might have trouble surviving on their own and might need to move into a retirement community.

Geriatric adults need to feel that they are part of something bigger. A sense of community can lessen the discomfort of loneliness and increase levels of autonomy. Because the care given to elderly clients affects every aspect of their life, the treatment of each elderly client as a full person is crucial.

Elderly nursing care in the community involves managing and preventing both physical and mental distress. The community nurse plays an important role in helping the elderly maintain an independent life in the community for as long as possible.

This can be done by emphasizing preventive geriatric medicine, the provision of supportive care services, and ensuring emotional and physical support for nurses. Indeed, nurses have played a major role in developing and leading care management programs for geriatric care in community practice.

In line with this, other members of the community health care team such as doctors, social workers, health visitors, and other allied health professionals play an important role and work together to ensure that appropriate services are provided for the varied needs of the elderly in the community.

The goals of effective community-based care for the elderly should be the adequate provision of healthcare services, followed by the effective use of resources.

Common Illnesses of the Elderly in the Community

  1. Chronic health conditions. Two-thirds of deaths each year are attributable to some of the most prevalent and expensive chronic health problems, including diabetes, cancer, heart disease, and stroke. The prevalence of obesity among older persons is rising, and adopting certain lifestyle habits can help lower obesity and its related chronic diseases.
  2. Cognitive Health. A person’s capacity for thought, learning, and memory is the focus of cognitive health. Dementia, or the loss of certain cognitive abilities, is the most prevalent cognitive health problem affecting the elderly. Alzheimer’s disease, which affects up to five million people over the age of 65 in the United States, is the most prevalent type of dementia.
  3. Mental Health. Depression is a frequent mental illness among seniors, affecting 7% of the elderly population. Regrettably, underdiagnosis and inadequate treatment are common for this mental illness. Moreover, depression can be treated by encouraging a healthy lifestyle, such as improving living conditions and receiving social support from family, friends, or support groups.
  4. Physical Injury. Seniors are more prone to losing their balance, bruising, and breaking a bone because aging causes bones to shrink and muscles to lose strength and flexibility. Osteoporosis and osteoarthritis are two conditions that make people more prone to frailty. Falls, though, are not always inevitable. These can frequently be avoided with knowledge, greater physical exercise, and useful housing improvements.
  5. Malnutrition. Malnutrition can be brought on by various medical conditions such as despair, drunkenness, dietary limitations, decreased social interaction, and low income. Nutritional problems in the elderly can be helped by making small dietary modifications, such as consuming more fruits and vegetables while consuming less salt and saturated fat. For older persons who struggle to prepare meals or cannot afford food, there are food services accessible.

Nursing Needs of the Elderly in the Community

  1. Community Participation. It has emerged as a crucial factor for healthy aging as a result of the aging population and rising demands on healthcare services. Increased mortality and social isolation have been linked to low levels of community involvement.
  2. Social Awareness. Elderly individuals rely on others for help and on home-care service providers to mediate the service to their satisfaction when they are in less-than-ideal health and financial conditions.
  3. Shared Decision-Making. Involving older patients with multiple health conditions in decision-making during primary care consultations is beneficial. Examples of patient involvement in decision-making about their health care include patient workshops and coaching, as well as individual patient coaching.
  4. Promoting Independence. Encouraging independence in self-care can give older individuals the opportunity to preserve their independence longer and can give them a sense of accomplishment when they finish a task without assistance. The risk of losing independence with self-care duties is higher for older persons who need help with everyday activities since dependent personal behaviors are frequently reinforced by nurses.
  5. Improving Physical Mobility. Treatment aimed at enhancing mobility in elderly individuals typically focuses on identifying and correcting certain problems, such as diminished strength or unstable balance.

Tips for Excellent Nursing Care of the Elderly in the Community

  1. Communicate effectively. By removing potential barriers to communication and conveying complete attention to the patient, sitting directly across from the patient enhances interaction. Establishing eye contact is crucial because it grabs patients’ attention and makes it easier for them to interpret facial cues.
  2. Exercise patience. When providing care for elderly patients, nurses must be patient. Talking points may need to be repeated numerous times by healthcare professionals before patients completely comprehend them. For the elderly client to understand fully, nurses should speak more slowly and clearly if speaking needs too much repetition.
  3. Show respect. Although the adage “respect your elders” is common, it is essential when receiving therapy. Providers need to keep in mind that senior clients can have different perspectives on current events. It’s crucial to recognize the variety of experiences that seniors have to offer. This understanding can facilitate communication across generational divides.
  4. Practice active listening. When caring for seniors, it’s crucial to pay attention to what they have to say and keep in mind that both sides may find it challenging to communicate their thoughts. Moreover, nurses should acknowledge discussions with the client through body language, such as affirmative nods, without interrupting them. Clarifying inquiries should be asked if the care provider does not comprehend what the patient is attempting to convey.
  5. Build rapport. Health organizations must ensure that all staff members have pleasant encounters with patients to develop patient rapport. Any employee who interacts with clients should begin by properly introducing themselves and learning the patients’ preferred names. It establishes a sense of familiarity and sets the framework for patients.

Nursing Diagnosis for Elderly in the Community

Nursing Care Plan for Elderly in the Community 1

Risk for Falls

Nursing Diagnosis: Risk for Falls related to disorientation secondary to age-related memory problems

Desired Outcome: The patient and caregiver will put precautions in place to increase safety and prevent falls in the community.

Risk for Falls Nursing Interventions

Assess the patient’s surroundings for elements that raise the risk of falls. If a patient is unsure of where the furniture is located in a room or if the residence has insufficient lighting, they are more susceptible to falling.

Make any assistive equipment and everyday goods accessible. This makes personal care products and assistive technologies easily accessible. To avoid constant reaching, keep water and other necessities close.

Urge the patient to participate in a routine exercise and gait-training program. Exercise can improve your muscle strength, balance, coordination, and response time. Fall injuries are less likely to occur and can be prevented with physical fitness.

Work together with other healthcare teams to evaluate and examine the patient’s prescriptions, which may increase their risk of falling. Determine the medication’s peak effects that have the potential to affect the patient’s awareness. Reviewing the patient’s prescriptions will help identify any side effects or drug combinations that could increase the risk of a fall injury. Orthostatic hypotension, vertigo, confusion, urine incontinence, and altered gait and balance are just a few of the adverse effects and drug interactions that are more likely to occur as a patient takes more prescription drugs. The use of many medications increases the risk of falling in older people.

Nursing Care Plan for Elderly in the Community 2

Failure to Thrive (Adult)

Nursing Diagnosis: Failure to Thrive related to loss of independence secondary to chronic health illness, as evidenced by difficulty in performing self-care activities.

Desired Outcome: The patient will exhibit improvement in at least one of the following: enhanced functional capacity, optimism, weight gain, greater appetite, and peaceful death.

Failure to Thrive Nursing Interventions

Collect key details about the patient’s past; engage the caregiver if necessary. Consider important factors like the passing of a spouse or family member. It will be necessary to take the patient’s medical history, pay close attention to the timing of the change in behavior and hunger, administer drugs, and reduce activities of daily living to identify the contributing factors to the decline in function. A few of these include pain, dementia, depression, and a diminished sense of taste or smell.

Let the elderly patient express their sentiments of dread, rage, despair, frustration, and worries about being admitted to the care facility and their health. By supporting the elderly client and letting them know that these feelings are normal, distress can frequently be reduced.

Inform the patient and any important people about changes that come with age. When a person ages normally, their physiologic reserve declines, which affects many of their body systems. Failure to thrive can result from a combination of physical frailty, disability or a loss of functional ability, and poor neuropsychiatric function.

Nursing Care Plan for Elderly in the Community 3

Disturbed Sleep Pattern

Nursing Diagnosis:Disturbed Sleep Pattern related to urinary incontinence, as evidenced by verbal complaints of difficulty falling asleep due to multiple trips to the toilet.

Desired Outcome: The patient will report having enough sleep within 24 hours of intervention. The patient’s mental state will not change.

Disturbed Sleep Pattern Nursing Interventions

Observe and document the patient’s sleeping patterns using data from the patient’s close friends or caretaker. The average amount of sleep that elderly people get is often less than it was when they were younger, and they wake up more frequently at night.

Find out the patient’s customary nighttime regimen and try to follow it. Omit caffeinated coffee, cola, or tea after six o’clock in the evening. Find out the patient’s customary nighttime regimen and try to follow it. Caffeinated coffee, cola, or tea can increase urine frequency and the caffeine can keep them alert at night.

Reduce disruptions at a time when people are sleeping and create a peaceful and quiet environment. Bright lighting, unnecessary noises, snoring roommates, and loud talking can all contribute to insomnia.

Nursing Care Plan for Elderly in the Community 4


Nursing Diagnosis:Constipation related to a decreased level of mobility and low intake of fluids and fibrous foods as evidenced by straining with defecation and Type 1 to 2 stool

Desired Outcome: The patient will avoid straining when using the bathroom and will have a Type 3 to 5 stool on the Bristol stool chart.

Constipation Nursing Interventions

Inform the patient of the link between fluid consumption and constipation. Promote drinking fluids unless it is contraindicated, and monitor bowel movements. Increasing fluid intake can soften the stool and reduce the likelihood of constipation. Fluid restriction may be necessary for patients with renal, cardiac, or hepatic disorders.

Tell the patient to try to get some roughage in every meal. Encourage the consumption of bran through cereals, bread, and muffins for patients who have a low tolerance for raw foods. Roughage (raw fruits and vegetables, whole grains, legumes, nuts, and fruits with skin) reduces constipation episodes because it gives the stool more weight.

Inform the patient about the link between physical activity and constipation. Also abide by the rule, “start slow, go slow.” Frequent physical activity encourages peristaltic movement, which helps to relieve or avoid constipation. Aggressive straining can also affect bowel movements and constipation.

Nursing Care Plan for Elderly in the Community 5

Disturbed Thought Process

Nursing Diagnosis: Disturbed Thought Process related to aging asevidenced by disorientation to person, place, and time

Desired Outcome: The patient will exhibit re-orientation and will be able to make simple decisions in their activities of daily living.

Disturbed Thought Process Nursing Interventions

Evaluate the decision-making and attention-span skills of the patient. This determines the patient’s capacity to take part in the development and implementation of care. This also helps determine the degree of impairment.

Keep patient belongings in the same locations. It helps lower the patient’s uncertainty and frustration by establishing a constant and stable environment.

Talk clearly and slowly. Give the patient enough time to answer. This lessens ambiguity and facilitates task completion.

Prevent sensory overstimulation and permit periodic rest periods for the sufferer. Confusion may increase due to sensory overload. Regular rest times prevent patient fatigue.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon


Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna Curran. RN, BSN, PHN

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.

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