Document your FOCUS SKIN ASSESSMENT
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.
There are some steps one have to adopt to prevent falls and ensure safety.
Try to follow the given steps when you are outside:
Wear low healed sandals with rubber soles. Wear warm boots in winter.
Try to walk in grass for more solid footing.
In winter carry some rock salt with you and sprinkle on sidewalk or street when you feel slippery.
Stay on carpet runners in the slippery surface.
Keep your porch, deck, walkways and driveway free leaves, snow or trash.
Use shoulder bags or backpacks to leave your hands free.
Consider wearing hip protector for added protection should you fall.
When you are inside the home try following the given steps:
Place all the items you use frequently in easy reach place.
Use assistive device to avoid strain or injuries. Long handled grasping device can be used to pick up items
Keep the floor free of clutter.
Wear a personal emergency response system.
Document your FOCUS SKIN ASSESSMENT Situation: Edith Jacobson is an 85-year-old white female who was admitted...
Document your FOCUS SKIN ASSESSMENT 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...
Document your FOCUS SKIN ASSESSMENT 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...
Describe your 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...
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...
Sensory-Neurologic System Case Study You are caring for a 67-year-old female patient who was admitted to the hospital for headache and vertigo. When you enter the patient’s room she is lying in her bed and appears to be sleeping. She does not respond when you address her by name and looks pale, her significant other is at the bedside. Assessment Findings Mental Status: No verbal response, flexes right arm to pain, no eye opening Airway: Open and clear Breathing: RR...
Mrs. Schaffer is an 82-year-old obese female admitted to the rehabilitation center after undergoing surgery for repair of the right hip fracture from a fall at home. At 72 hours postsurgery, she is receiving morphine patient controlled anesthesia (PCA) for moderate post-operative pain, with results of reduction in reported pain. She has no significant past medical history and no known drug allergies (NKDA). Her DNR documentation specifies a full code. Mrs. Schaffer’s vital signs are: T 98.9°, P 70 and...
You are assigned to Mrs. Z. a 72-year-old woman who fell at home and was admitted to your unit for a fracture of the right hip. She was alert and oriented on admission. After the initial workup, she was taken to surgery for an open reduction with internal fixation (ORIF) of her right hip. This is her first postop day. Her right hip dressing has a small amount of dried dark red drainage. Handoff Report for Mrs. Z: Patient has...
Mrs. Tyler is an 84-year-old white woman with a past medical history of breast cancer, mastectomy, dementia, osteoporosis, depression, and a right hip fracture and repair 1 month ago. She also has a history of anxiety. Her home medications include Prozac (fluoxetine hydrochloride), 20 mg qd; Os-Cal (calcium carbonate), 500 mg tid; Aricept (donepezil hydrochloride), 10 mg qd; Zantac (ranitidine), 150 mg qd; Ecotrin (aspirin EC), 81 mg qd; Mellaril (thioridazine HCl), 10 mg qd; and Valium (diazepam), 10 mg...
Mrs. Brady is a 58 year old woman who is admitted to your unit post op from an ORIF (open reduction internal fixation) of the left hip. She is now three days post-op and has started physiotherapy. Her pain has been manageable since her surgery and she is keen to go home. Her Foley catheter was removed yesterday evening. You arrive for your day shift and find Mrs. Brady in the bathroom. She tells you that she feels as though...
Mrs. Jones is a 72 year old female, who was admitted to the hospital for after having a small stroke. She is widowed and lives independently, with the assistance of her 7 children. She has a history of HTN and type two diabetes. Medications include a She takes a diuretic. A complication of her stroke is extreme constipation. Mrs. Jones had a Foley catheter inserted in the ED at the time of her stroke and it was removed yesterday. ...