Jan 76-year-old female, is being admitted to your ward from emergency department with acopia and falls for investigation following a fall at home.
Vital signs on admission: blood pressure 150/95, heart rate 110
beats per minute, respirations 20 breaths per minute, SpO2 90% on
room air.
On examination in emergency department Jan was found to have haematomas to her left eye and bilaterally on her knees and a small superficial laceration to her left eye that was sutured in emergency department. A CT of her head and x-rays shows no apparent fractures or abnormalities.
Prior to admission
Jan has been having an increasing number of falls at home over the past few months. She denies dizziness, pain or loss of consciousness contributing to the falls. She states she” just goes weak and falls down”. She reports she sometimes feels quite anxious and breathless post fall. Jan has a medical history of hypertension and hypercholesteraemia. Jan, however, is a poor historian claiming “my memory is not quite as good as it once was”. Jan lives with her supportive husband, Joe who assists her as needed. Joe states “we have always looked after each other” since coming to Australia from Poland forty years ago. They have never had children and have very few friends or social supports preferring to rely on each other.
They try to cook healthy meals a few times a week but are increasingly relying on heating frozen meals or snack foods for convenience.
Joe states he has to assist Jan a bit more than usual as she seems to be “slowing down “and is becoming increasingly tired and fatigued. He is finding it especially difficult when she falls and is having to rely on the
ambulance service to assist to get her up.
Question 1
Patient assessment – 300 Words
Assessment is one of the major roles of the registered nurse and is
the first step in the nursing process to assist in planning and to facilitate mutually established goals and evaluate outcomes. In reality the nurse is continually assessing and reassessing the patient throughout the continuity of care.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice
• Identify 3 specific nursing assessments that you would conduct as apriority for Jan’s nursing care that you will undertake on Jan’s admission to your ward.
