Assessment 1- Case Study
Incident: 72 yr old female Mrs Geraldine Berry sustained left fractured neck of femur (#NOF) and laceration to her head 5cm while walking her dog. Tripped on an uneven pathway.
PMH: Hypertension and depression
Current Medications: Coversyl 5mg
Doxepin 25mg daily Atorvastatin 40mg daily
SHx: Lives with elderly husband. Is the primary carer for elderly husband who has had a stroke previously and is mildly impaired. Attends church every Sunday and is responsible for arranging flowers for every Sunday service. She has started volunteering at the St Vincent De Paul’s Meals on Wheels distribution centre two days a week. She lost two children 5 years ago in a car accident.
Geraldine is concerned who will look after her husband and their dog Nala. Geraldine and her husband have no children or relatives nearby.
Day 3 post op left total hip replacement, increasing pain in hip unable to weight bear, pain score currently 7/10. Geraldine has been prescribed oral tramadol tds, Ibroprofen prn, paracetamol prn, IV Amoxicillin 1000mg tds and Clexane 40mg SC BD. Suture line on hip appears red and swollen.
|Observations – 10am Day 3|
|Pulse Rate - 120|
|Respiratory rate - 22|
|Blood pressure - 120/80|
|Pain score - 7/10|
|Sa02 - 96%|
|Temperature – 39.1|
|BGL – 6.8 mmol/l|
|Glasgow Coma Score 15|
|Heat, pain and redness at suture site|
|Refusing to mobilise due to pain|
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