An elderly male develops bradycardia and has a pacemaker surgically implanted
Although he was lucid preoperatively and has no history of dementia, at 10:00 PM on the night of his surgery, he becomes disoriented to place and time and insists on going home. When placed in soft restraints, he becomes hostile and is later caught trying to burn his way out of the restraints with a cigarette lighter. Which nursing diagnosis should be the priority diagnosis? a. Disturbed thought processes
b. Sleep deprivation
c. Risk for injury
d. Ineffective coping
C
Although all of the diagnoses listed have some application in this situation, the priority diagnosis when there is a safety concern should be focused on the patient's safety. In this case, there are at least three safety concerns: leaving while medically unstable; presence of delirium and the medical problem that underlies it; and impaired judgment as seen in the effort to burn his way out of the restraints. The nursing diagnosis that would best address these concerns is Risk for injury; the others are less important at this stage.
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