Question

Mrs Chan is found lying at the bottom of her stairs by her daughter at 09:00 on 14/06/2016. Mrs Chan is dressed in a nightgown; the last thing she remembers is rushing to the toilet at about 10pm. She has no memory of falling, she recalls “waking up” on the floor feeling cold because she was incontinent and her night gown was wet. She was unable to get up due to a penetrating wound to her left leg from falling on a glass coffee table that has broken and become embedded in her upper thigh. She also has pain in her hip and pelvis. Her right leg is shorter than the left and it is internally rotated.

Mrs Chan’s past medical history includes:

• Urinary incontinence
• Osteoporosis
• Compression fractures to her spine due osteoporosis
• Chronic pain

Regular medications:

• Fosamax
• Vitamin D
• Calcium
• Fentanyl patch
• PRN Endone

• Question 1

  Describe the initial assessment of Mrs Chan, including the following points in your answer:

  Describe the process of completing a primary survey on Mrs Chan

Answer 1

1. The initial assessment includes:

-Assessing of ability of client to move the extremity.

-Altered appearance of involved body part.

-Assessing shortening and external rotation of leg.

-Assessing degree and nature of pain.

-Neurovascular assessment includes pain, pulselessness,pallor,parasthesias,paralysis, soft tissue injury or edema may compromise circulatory or neurologic functioning.

-Other health problems that may affect.

-Assessing urinary frequency and assessing the spine .

Clinical assessment involves: Subjective data :- Pain and changes in sensation, pain aggravated by motion ,tenderness,neurovascular changes, numbness.

Objective data :- affected leg appears appears shorter and external rotation of affected limb,edema, muscle spasm,loss of function,X-ray examination reveals break in continuity of bone,imapired local circulation.

2. Primary survey involves obtaining patient history and vital signs. It mainly focuses on medical complaint or about any injuries. By taking past medical history about Mrs Chan , helps to know:

- about fracture of spine,urinary incontinence ,pain ,about medications.Then Vital signs are checked to to know blood pressure,respiration ,skin integrity,pulse,pupils ,airway ,breathing ,and circulation. The assessment mainly focuses on medical complaint and specific injury. Assessing the mental status of the patient helps to determine reponsive or unresponsive a which helps to decide patient's condition based on her distress . Also utilizing the information given by caregivers helps to obtain baseline information about patient.