Reference no: EM133125954 , Length: word count:2000
NUR341 - Assignment Task
Read the clinical scenario and the answer the assessment questions in an essay format.
Clinical scenario
Ms Florence ‘Flo' Ljukuta 70year 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.
Patient profile - Florence ‘Flo' Ljukuta 70-year-old female from Alice Springs
Presenting complaint- Pain to right hip unable to ambulate. No facture on x-ray
History of complaint- 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, Floexperienced pain on movement and unable to ambulate independently. Assisted to community health clinic and referred to hospital.
Phx - Hypertension, Type 2 diabetes, Angina, Hypercholesteremia, Asthma, Osteoarthritis. Complete hysterectomy 30years ago for treatment of endometrial cancer.
Allergies - Nil Known Allergies.
Medications
• Aspirin 100mg mane
• Perindopril 2mg mane
• Metformin XR 2g mane
• GTN 600mcg tablets S/L prn
• Osteo paracetamol 1330mg TDS
• Salbutamol inhaler 2-4 puffs PRN
Ethnicity/language- Aboriginal. Speaks Waramungu, Walpiri, Eastern and Western Arrentre, English
Alcohol use - Few wines or beers with family and friend 3-4 times per week
Tobacco use - Smoker ½ packet per day/ whole family smokes. Regular exposure to campfire and passive smoke
Drug use - Nil
Home environment- 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
Work environment- Retired 10 years. Previously manager of community health clinic
Stress - Currently eldest daughter has been diagnosed with breast cancer
Education - VET level certificate
Economic status- Family land and house in remote community but staying in town to be with children and support needs for husband
Religion/spirituality - Baptised Catholic by missionaries when young
ADLs - Independent prior to fall
IADLs-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
Cognitive function - No concerns identified
Diet-Diabetic diet when able
Sleep -7-8 hours per night but currently broken sleep due to caring for others
Health check-ups- Regular check-ups every few months with diabetic doctors/clinics.
Physical Assessment
Vital signs- Temp: 36OC, HR: 100bpm regular, RR: 22bpm, SpO2: 94% RA, BP: 150/95, BGL: 7.8mmol/L, Pain: 7/10
CNS - 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.
CVS - Both feet pale in colour No sacral or ankle oedema Feet bilateral cool skin temperature/ hands warm Peripheral pulses present, dorsalis weak bilaterally Capillary refill feet and hand >3seconds
Resp - Shallow and regular Palpation: no pain Chest expansion symmetrical Percussion: bilateral resonance in all areas Auscultation: mild wheeze on exhalation.
MSK- 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.
GIT - 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.
Urinary - No pain on passing urine 2-3 days increased urinary frequency/urgency Passed cloudy, malodorous urine approx. 1hour prior to fall.
Assessment Questions
Question 1: Assessments (recommend 1500 words)
Hospital policy requires Flo to receive the following assessments completed on admission to the ward.
• Falls assessment
• Functional assessment
• Pressure injury risk assessment
Students must:
• Detail the goal or purpose of each assessment
• Provide an example of a tool used in Australian hospitals including the frequency it should be completed
• Explain how each assessment relates to Flo's presentation
Explain how abnormal findings are managed by the nurse
Question 2: Plan and implementation (recommend 500 words)
The following four (4) factors have contributed to Flo's current fall and health status:
1. Normal age-related changes
2. Comorbidities
3. Acute illness
4. Medication
Students must choose one (1) of the factors (above) and identify the health promotion or education you as the nurse would provide in preparation for discharge. This must include two (2) referrals to support services and your rationale for each referral.
Please note: if a student details more than one factor, the marker will address and mark only the first factor outlined.
Presentation guidelines
• Complete the footer with last name_student number_NUR341_ Assessment 2
• Format your assessment with size 12 Arial/Calibri or similar font, 1.5 spacing
• Complete spelling and grammar check using English (Australia) default
• A minimum of 5 peer reviewed journals or texts no more than 5 years old
• Use APA 7th referencing style
• 2000 word limit: recommend Part 1 (1500 words) and Part 2 (500 words).
Attachment:- Clinical scenario.rar