Question

Location: Orthopedic unit 1555

SBAR report from day shift nurse:

Situation: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery tomorrow.

Background: Mrs. Jacobson has a 10-year history of osteoporosis, and her daughter reports that recently Mrs. Jacobson has been having dizzy spells.

Assessment: Mrs. Jacobson's vital signs are stable. Her pain is under control with morphine every 4 hours, and I medicated her at 1400. Her pain level was 2 after the morphine. The skin is intact; color and sensation around the hip area are within normal limits. A Morse Fall Scale assessment was completed on admission, and her score was 45. Fall precautions were implemented.

Recommendation: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed.

1. Assessment - 2 subjective & 2 objective

2. Nursing diagnosis (1) using related to as evidence by

3. Goals - 2 long term & 2 short terms

4. Interventions - interventions w rationales (4)

5. Evaluation - 4 evaluations of interventions

Answer 1

1. Assessment :

Subjective:

• Faint pain around the hip
• Feeling a bit dizzy

Objective

• Looks confused
• Looks weak

2. Gait and balance assessment should be done. At a minimum, a gait assessment means that the doctor carefully watches the way the older person is walking. There are also some simple ways to check balance.

3.

Short term goals

• Her surgery goes well and she is in no pain anymore
• Her dizziness stops

Long term goals:

• Regular physical activity to reduce future falls.
• The patient and caregiver will implement strategies to increase safety and prevent falls in the home.

4.

Intervention:Assess for circumstances associated to increase the level of fall risk upon admission, following any alteration in the patient’s physical condition or cognitive status, whenever a fall happens, systematically during a hospital stay, or at defined times in long-term care settings:

Rationale:Using standard assessment tools, the level of risk and subsequent fall precautions can be determined. These tools incorporate the intrinsic and extrinsic factors.

Intervention: Mental status changes

Rationale: An individual is more likely to fall again if he or she has sustained one or more falls in the past 6 months.

Intervention: History of falls

Rationale: Confusion and impaired judgment increase the patient’s chance of falling.

Intervention: Age-related physical changes

Rationale: Older people with weak muscles are more likely to fall than are those who maintain their muscle strength, as well as their flexibility and endurance. These changes include reduced visual function, impaired color perception, change in center of gravity, unsteady gait, decreased muscle strength, decreased endurance, altered depth perception, and delayed response and reaction times.