The patient has a Glasgow Coma Scale (GCS) score of 14, indicating alertness and wakefulness but disorientation to the situation. They follow commands and have missing teeth and impaired hearing. Chest expansion is symmetrical, and cardiac rhythm is regular. Capillary refill time is less than 3 seconds, with no edema present. Bowel sounds are audible in all quadrants. The skin is appropriately colored, even-toned, dry, and warm. There is bruising on the coccyx, with fragile and blanchable skin. The patient has a Braden Scale score of 19, suggesting a low risk of pressure ulcers, and a Morse Fall Risk score of 75, indicating a high risk of falls. There is weakness in the right lower extremity (RLE) and left lower extremity (LLE). write me NANDA
nursing diagnosis