Ms Florence ‘Flo’ Ljukuta 70year old female admitted to hospital…

 

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

Patient profile Presenting complaint

Phx Allergies

Ethnicity/language Alcohol use Tobacco use

Drug use

Work environment Stress
Education Economic status

Religion/spirituality ADLs
IADLs

Assessment data

Florence ‘Flo’ Ljukuta 70-year-old female from Alice Springs Pain to right hip unable to ambulate. No facture on x-ray

Hypertension, Type 2 diabetes, Angina, Hypercholesteremia, Asthma, Osteoarthritis. Complete hysterectomy 30years ago for treatment of endometrial cancer.
Nil Known Allergies

Aboriginal. Speaks Waramungu, Walpiri, Eastern and Western Arrentre, English Few wines or beers with family and friend 3-4 times per week
Smoker 1⁄2 packet per day/ whole family smokes. Regular exposure to campfire and passive smoke

Nil

Retired 10 years. Previously manager of community health clinic
Currently eldest daughter has been diagnosed with breast cancer
VET level certificate
Family land and house in remote community but staying in town to be with children and support needs for husband

Baptised Catholic by missionaries when young
Independent prior to fall
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.

  

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.

 

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

   

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

        

 

Cognitive function Diet
Sleep
Health check ups

Physical Assessment Parameter

Vital signs

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.

Assessment data

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 1500words)
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

 

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