- Clinical Scenario Ms Florence Flo Ljukuta 70year Old Female Admitted To Hospital Post Fall With Soft Tissue Injury To 1 (144.96 KiB) Viewed 37 times
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
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. . . . Parameter Assessment data 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, Flo experienced 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 1 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.
NUR341 - Assignment 2 Written Assignment Task Cognitive function Diet Sleep Health check ups No concerns identified Diabetic diet when able 7-8 hours per night but currently broken sleep due to caring for others Regular check ups every few months with diabetic doctors/clinics. Physical Assessment Parameter Vital signs CNS CVS Resp Assessment data Temp: 36°C, HR: 100bpm regular, RR: 22bpm, SpO2: 94% RA, BP: 150/95, BGL: 7.8mmol/L, Pain: 7/10 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 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 >3 seconds Shallow and regular Palpation: no pain Chest expansion symmetrical Percussion: bilateral resonance in all areas Auscultation: mild wheeze on exhalation 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 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 No pain on passing urine 2-3 days increased urinary frequency/urgency Passed cloudy, malodorous urine approx. 1hour prior to fall MSK GIT Urinary