Question

DESCRIBE YOUR FOCUS FOCUS SKIN ASSESSMENT

Time: 0730

Report from the night shift nurse:

Situation: Edith Jacobson is an 85-year-old white female who was admitted last evening after having a dizzy spell, resulting in a fall where she fractured her hip and hit her head. An x-ray has been taken and shows a left intertrochanteric hip fracture. She also had a CT of her head, and those results showed that there was no intracranial bleeding. There was a concern regarding her orientation during the night, when she had a score of 14 on the Glasgow Coma Scale. Mrs. Brown is scheduled for surgery today. Her daughter has gone home but will return later.

Background: Mrs. Jacobson has a 10-year history of osteoporosis and a recent history of dizzy spells.

Assessment: Mrs. Jacobson's vital signs from 0700 were: respiration rate 12, saturations 96% on room air, heart rate 76, blood pressure 125/80, and temperature 37 °C (98.6 °F). Her pain is under control with morphine every 4 hours. I medicated her at 0600 for a pain level of 8. Her pain level is a 2 after the morphine. I just turned her, and assessed the fractured hip. The skin is intact, and the color, motion, and sensation around hip area are within normal limits. She has no visible wounds to her head. A fall risk assessment was completed on admission, and her Morse Fall Scale score was 45. Fall precautions were implemented. Her Glasgow Coma Scale was 15 on admission but was 14 at 0400. Her neuro checks have been normal, and she has been oriented to person, place, and time this morning.

Recommendation: Her provider has ordered a Mini-Cog™ assessment. I would like you to perform another Glasgow Coma Scale. You should also reinforce safety and provide fall risk education.

Answer 1

Ans) Inspect patient’s skin and change the her postion every 2 hours to prevent skin breakdown.

- Fall Precautions were put in place. Besides the fact that she now has a broken hip, the patient kept stating to me that she keeps feeling dizzy and was dizzy before falling. The dizziness may be an issue that is precipitating falls and should be addressed.

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Keep moving. Physical activity can go a long way toward fall prevention. Such activities reduce the risk of falls by improving strength, balance, coordination and flexibility. If you avoid physical activity because you're afraid it will make a fall more likely, tell your doctor.

- 5 Proven Approaches to Reduce Fall Risk
• Medications Review: Certain types of medications are known to increase falls in seniors, and many of them are surprisingly common.
• Check Blood Pressure While Sitting and Standing.
• Gait and Balance Evaluation.
• Home Safety Assessment and Modification.
• Vitamin D, 1000 IU per day