Question

Patient Introduction

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.

Edith Jacobson
Documentation Assignments
Document your focused musculoskeletal assessment of Edith Jacobson.
Document your focused skin assessment of Edith Jacobson.
Document the patient teaching that Edith Jacobson would need related to fall risk and prevention during her hospitalization and upon discharge.
Document the essential elements of proper body alignment for Edith Jacobson and include the specific supplies that would be needed.

Answer 1

Document your focused musculoskeletal assessment of Edith Jacobson

ans:i checked the symmetry of muscles,bones, and joints.assessed if there is any tenderness for that i need to palpate the area.checking symmetry by inspection, there is no swelling or redness.her right leg she can move easily.and on left side.cant move because of fracture.repositioned every 2nd hourly.

Document your focused skin assessment of Edith Jacobson.

ans:skin is intact.color and sensation around hip area is are within normal limit.no redness and signs of infections.

Document the patient teaching that Edith Jacobson would need related to fall risk and prevention during her hospitalization and upon discharge.

ans:educated jacobson related to fall risk.educate her to call using the call bell near bed side.put both side rails while is alone.ask her daughter to help her if she need any assistance .educate daughter only doing activity when she is comfortable or when there is no dizzy.reminded her she is at high risk to fall because she is on medications.

Document the essential elements of proper body alignment for Edith Jacobson and include the specific supplies that would be needed.

providesed pillows

abduction pillows

trochanter roll

bed with air or water filled

side rails

adjustable bed

leg stockings

side table

ortho bed

trapez bar