Reference no: EM133175790
Read the clinical scenario and the answer the assessment questions in an essay format.
Clinical Scenario
Ms Florence ‘Flo' Ljukuta 70 year old female admitted to hospital post fall with soft tissue injury to right hip still unable to ambulate. Flo can not recall the event and up to 2-3mins post fall.
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Parameter
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Assessment data
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Patient profile
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Florence 'Flo' Ljukuta 70-year-old female from Alice Springs
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Presenting complaint
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Pain to right hip unable to ambulate. No fracture on x-ray
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History of complaint
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Tripped on the back steps leading into the house after hanging cloths on the line. Landed on the concrete pathway on her right side. Following the fall, Flo experienced pain on movement and was unable to ambulate independently. Assisted to community health clinic and referred to hospital.
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Phx
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Hypertension, Type 2 diabetes, Angina, Hypercholesteremia, Asthma, Osteoarthritis. Complete hysterectomy 30years ago for treatment of endometrial cancer.
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Allergies
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Nil Known Allergies
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Medications
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- GTN 600mcg tablets S/L PRN
- Paracetamol osteo MR 1330mg TDS
- Salbutamol inhaler 2-4 puffs PRN
- ? add in Simvastatin 20mg OD
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Ethnicity/language
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Aboriginal. Speaks Waramungu, Walpiri, Eastern and Western Arrernte, English
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Alcohol use
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Few wines or beers with family and friend 3-4 times per week
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Tobacco use
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Smoker ½ packet per day/ whole family smokes. Regular exposure to campfire and passive smoke
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Drug use
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Nil
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Home environment
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Currently lives in town camp in 3brd house with extended family. Approximately 13 family members staying at the house.
Flo's husband who requires assistance due to physical deficits from a stroke.
Adult daughter and her 4 teenage boys
Adult daughter and her 2 toddlers
Adult son and his partner and their new baby
Adult son
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Work environment
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Retired 10 years. Previously manager of community health clinic
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Stress
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Currently eldest daughter has been diagnosed with breast cancer
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Education
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VET level certificate
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Economic status
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Family land and house in remote community but staying in town to be with children and support needs for husband
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Religion/spirituality
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Baptised Catholic by missionaries when young
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ADLs
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Independent prior to fall
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IADLs
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Does not drive anymore due to decreased vision (diabetic retinopathy). Starting to develop cataracts. Had glasses a few years ago but they don't help much now.
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Cognitive function
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No concerns identified
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Diet
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Diabetic diet when able
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Sleep
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7-8 hours per night but currently broken sleep due to caring for others
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Health check ups
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Regular check ups every few months with diabetic doctors/clinics.
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Physical Assessment
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Parameter
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Assessment data
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Vital signs
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Temp: 36OC, HR: 100bpm regular, RR: 22bpm, SpO2: 94% RA, BP: 150/95, BGL: 7.8mmol/L, Pain: 7/10
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CNS
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GCS 13
Pupils equal and reactive to light
Lethargic, eyes open when spoken to, follows commands, orientated to place and person not time/date
Unable to test muscle strength due to pain from injury
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CVS
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Both feet pale in colour
No sacral or ankle oedema
Feet bilateral cool skin temperature/ hands warm
Peripheral pulses present, dorsalis weal bilaterally
Capillary refill feet and hand >3seconds
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Resp
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Shallow and regular
Palpation: no pain
Chest expansion symmetrical
Percussion: bilateral resonance in all areas
Auscultation: mild wheeze on exhalation
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MSK
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Blue/red coloured haematoma to right hip extends to right buttock
Swelling evident
Skin intact
Decreased range of movement
Very tender on palpation
Reluctant to walk or move due to pain
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GIT
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Loss of appetite and mild nausea over last few days
No vomiting
Regular bowel movements, constipation last 2 days
Generalised distention
Bowel sounds present
Mild tenderness lower abdominal area
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Urinary
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No pain on passing urine
2-3 days increased urinary frequency/urgency
Passed cloudy, malodorous urine approx. 1hour prior to fall
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Assessment two:
Task: Clinical case scenario
Task Instructions:
This assessment is in two parts. After reading the clinical notes and attached patient notes, you are required to answer the parts 1- Nursing assessment then 2- Plan and implementation. You do NOT need an introduction or conclusion.
Clinical Scenario:
Clinical notes:
Ms Florence ‘Flo' Ljukuta 70year old female admitted to hospital post fall with soft tissue injury to right hip, still unable to ambulate. Flo cannot recall the event and up to 2-3mins post fall. Please refer to above tables below for more information of patient history and physical examination findings.
Part 1-Nursing assessments (1500 words)
Using the information provided in the clinical notes, identify and discuss three assessments to be completed on the patient's admission to the ward.
For each assessment students are required to:
1. Detail the goal or purpose of the assessment
2. Provide an example of an assessment tool used in Australian hospitals including the frequency it should be completed
3. Explain how the assessment relates to Flo's presentation
4. Explain how abnormal findings are managed by the nurse
Part 2: Plan and implementation (500 words)
The following four (4) factors have contributed to the patient's recent fall and current health status:
1. Normal age-related changes
2. Comorbidities
3. Cute illness
4. Medication
Students are required to:
1. Choose one (1) of the factors and identify the health promotion or education you would provide in preparation for discharge.
2. Suggest two (2) referrals to support services and your rationale for each referral.
For this assignment, support your assessment and plan with a minimum of 5 references from academic resources [journals, books, academic or professional websites] from the last 10 years.
The following format is recommended:
• Assessment (1500 words); 500 for each assessment
• Plan and implementation (500 words)
• References