NURS13141 - Acute Alterations in Complex Care Environments Assignment

Assignment Task

Aim

The aim of this assessment is for you to demonstrate your knowledge regarding the management of a person with an acute alteration in health.

Case Study - Mrs Alison Smithson

You are a graduate RN assigned to the care of Mrs Alison Smithson. The night duty nurse gives you the following ISBAR handover at the bedside.

Identity: This is Mrs Alison Smithson, a 79-year-old lady who identifies as female and uses she/her pronouns. Her UR number is 123456 and her Date of Birth is 01/01/1945.

Situation: Alison was admitted to the Orthopaedic ward at 2200 hours yesterday for routine post operative management of an open reduction and internal fixation of fractured left neck of femur (NOF), following a fall at home. She also has fractured the third and fourth ribs on her left side. She is currently in a stable condition but due to her age and surgery she may be at risk of deterioration.

Background: Alison lives at home alone. She was brought into the Emergency Department by ambulance and pre operation it was noted that she had mild confusion with a Glasgow Coma Score of 14. She had been incontinent of urine post fall and has a small graze on her left forehead. She has a history of hypertension which is managed by medication. Alison has a drain in her left leg, and she has an indwelling catheter (IDC) in situ which is on free drainage. She has a 14g Intravenous cannula in her Right antecubital fossa (ACF) which has Sodium Chloride 0.9% running 12th hourly. She has a Patient Controlled Analgesia (PCA) prescribed for pain relief. Alison is tolerating oral fluids and can commence a light diet today. Alison currently has knee high Thrombo-Embolic Deterrent (TED) stockings on both legs.

Assessment: Alison has been stable and comfortable overnight, all observations are within normal limits, her Glasgow Coma Score (GCS) is 15. Alison’s wound is clean and dry, and her drain tube drained a small amount of frank blood overnight.

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