Question

An 80 year old lady named Mary presented admitted to a unit came in with a fractured leg. She is 5 foot 7 and 165 pounds. Vital signs on arrival are is:

Blood pressure: 162/84

Heart rate: 92

Respiratory rate: 24

Temperature taken orally: 99.2

SpO2: 96% on room air (RA)

1. Document sings of physical examination

2. What information is missing from the situation? And ask patient.

3. What concerns would you have with the patient?

4. What nursing interventions would you start?

5. What discharge concerns?

Answer 1

1. Signs of physical examination:

HR-92/min- high normal

BP-162/82- hypertension,could be due to inadequate analgesia

RR-24/min - tachypnoea

SPO2- 96% on room air - normal

Temp-99.2°F- normal

2. History of injury is very important. Elderly are especially prone for intracranial bleeds. Mode of trauma can help rule out other injuries

Glasgow coma scale should be noted at time of admission and any deterioration should be investigated immediately

Elderly are also susceptible for hypoglycemia. Document blood sugar. In this case, especially because patient might be kept fasting before surgery.

History of coexisting illnesses not mentioned. Elderly are highly likely to have comorbidities like diabetes, hypertension etc

Patient's rise in BP could be due to to hypertension or inadequate analgesia.

Tachypnoea could be due to conditions like COPD or it can be also be due to fat embolism.

3. Elevated BP and Tachypnoea

Patient could be in pain. Other conditions like head injury, fat embolism should also be ruled out

4. Start adequate analgesia

Supplemental oxygen to reduce work of breathing and prevent respiratory fatigue

Document pain with scales like Visual analogue scale or numerical scales.

Ensure adequate fluid intake and urine output

Observe GCS intermittently

5. Early mobilization, supportive care, wound care and dressing, analgesia.