Mr George McFarlane is a 53 year old Male,  He was brought to the…

Mr George McFarlane is a 53 year old Male, 

He was brought to the Emergency Department by ambulance at 2130hrs on Saturday evening, after sustaining a fall at home. Mr McFarlane lives with his wife, who was not present at the time of the fall. On Mrs McFarlane’s arrival home, she found Mr McFarlane on the floor and called the ambulance. 

Mr McFarlane is experiencing pain in his Left knee, he is unable to weight bear on his left leg and is unsteady. He states he is feeling dizzy and unstable when attempting to stand upright. It is unclear if he hit his head in the fall as he states he “Felt dizzy when going to the bathroom and I think I blacked out”. 

Mr McFarlane past Medical History (PMHx) include:

• Type ll Diabetes needing close management
• Osteoarthritis in L) Knee
• Peripheral vascular Disease (PVD)
• Chronic Obstructive Airway disease (COPD)

Mr. McFarlane uses glasses for reading and driving. He also has partial dentures (lower)

Social History (SHx):

• Occupation Long Haul truck driver
• ETOH (Alcohol) usage on a regular basis
• Smoker, averages 15/20 cigarettes per day
• Often consumes take away/ fast food diet as away from home regularly

Mr McFarlane is 135kg and 170cm in height. Current vital signs Resp 17, O₂ SPO₂ 96% on room air (RA), BP 150/100, HR 99 and regular, Temp 36.9, BGL 7.8mmol/L ,  GCS 15, Pain score 8/10 (last pain relief was Endone 10mg o..y@22:10).

 

Further orders include;

X-Ray of L) Knee shows significant advancement of Osteoarthritis. Further investigation of Osteoarthritis in L) knee needs to be arranged. Referrals for the Physiotherapist, dietician, social worker, diabetic educator and endocrinologist are to be arranged according to organisational processes. 

• 2/24 Vital signs
• 2/24 Neurological observations
• 2/24 neurovascular observations on L) leg
• Regular pain relief as charted
• Non weight bearing on L) Leg
• Assistance with ADL`s
• TED`s to be applied
• Braden score to be assessed

Mr McFarlane was transferred to the Med/Surgical ward at 0730hrs and you have received handover for this patient in your morning shift (0700-1530)

Based on above scenario, please Specify four (4) nursing diagnoses/problems (actual/ potential) or risk factors associated with the client’s current health presentations. 

• Note at least one (1) expected outcomes that you would hope for as a result of each intervention (Consider SMART goals when discussing outcomes).
• Record two (2) nursing interventions with rationale that could be applied for each diagnosis/problem. These interventions must be in line with current best practices.
• Specify at least one (1) member of the multi – disciplinary team that may be able to support your suggested interventions.

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