Patient Case #2
Patient: Edith Jacobson
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Diagnosis: Left hip fracture
Brief Summary :
Edith Jacobson is an 85-year-old white female with a history of osteoporosis. She lives at home by herself where she fell and broke her left hip yesterday evening, after having complaints of dizziness, weakness, and fatigue. She is scheduled to have surgery in 2 days.
· Enoxaparin sodium 40 mg SQ daily
· Docusate sodium 100 mg PO daily
· Morphine sulfate 4 mg IV q4h prn for pain
· Metoprolol 25 mg PO BID
· Furosemide 20mg PO daily
· Vital signs every 4 hours
· Activity: Bed rest
· Anti-embolism stockings on both legs (knee-length)
SBAR Report :
S: 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 in 2 days.
B: Mrs. Jacobson has a 10-year history of osteoporosis and was newly diagnosed with congestive heart failure last year. Her daughter reports that recently Mrs. Jacobson has been having dizzy spells, fatigue, and weakness. Mrs. Jacobson lives alone and is usually able to perform all her ADLs independently. She does have a cane at home but often times refuses to use it because she “doesn’t think she needs it”. Mrs. Jacobson is usually pretty active, but has been much more sedentary lately due to increasing weakness and fatigue due to medication non-compliance with her heart failure medications.
A: Mrs. Jacobson is AOx4 and her vital signs are stable. Her pain level is currently a 7 out of 10, and she describes is as “throbbing and aching” in her left hip. Often times Mrs. Jacobson will moan or cry out in pain, especially whenever she needs to be moved in bed. She is very resistant to let anyone touch or move her left leg. 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. Mrs. Jacobson has limited ROM in her left hip and her muscle strength in her left lower extremity is weak at a 2/5. Mrs. Jacobson has been having some episodes of urinary and bowel incontinence since being admitted to the hospital. She frequently needs to be reminded that she cannot get out of bed due to her activity restriction.
R: 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.