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    Case Note 1: Patient Details

    Uploaded by

    BINCY
    Ms. Cindy Shaw, a 75-year-old woman, was admitted to the hospital on September 23, 2018 after fracturing her left hip in a fall. She underwent a hip replacement surgery and was discharged on September 28. She has diabetes that was well-controlled prior to surgery but became stressed after. Her mobility improved with a walker before discharge. Her daughter, who she lives with, is leaving for a year for her husband's job, so Ms. Shaw will be moving to a self-contained flat with steps. The discharge plan includes physical therapy, scar massage once healed, balance exercises, and a home safety assessment by occupational therapy since she will be living alone.

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    Case Note 1: Patient Details

    Uploaded by

    BINCY
    802 views3 pages
    Ms. Cindy Shaw, a 75-year-old woman, was admitted to the hospital on September 23, 2018 after fracturing her left hip in a fall. She underwent a hip replacement surgery and was discharged on September 28. She has diabetes that was well-controlled prior to surgery but became stressed after. Her mobility improved with a walker before discharge. Her daughter, who she lives with, is leaving for a year for her husband's job, so Ms. Shaw will be moving to a self-contained flat with steps. The discharge plan includes physical therapy, scar massage once healed, balance exercises, and a home safety assessment by occupational therapy since she will be living alone.

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    Ms. Cindy Shaw, a 75-year-old woman, was admitted to the hospital on September 23, 2018 after fracturing her left hip in a fall. She underwent a hip replacement surgery and was discharged on September 28. She has diabetes that was well-controlled prior to surgery but became stressed after. Her mobility improved with a walker before discharge. Her daughter, who she lives with, is leaving for a year for her husband's job, so Ms. Shaw will be moving to a self-contained flat with steps. The discharge plan includes physical therapy, scar massage once healed, balance exercises, and a home safety assessment by occupational therapy since she will be living alone.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    802 views3 pages

    Case Note 1: Patient Details

    Uploaded by

    BINCY
    Ms. Cindy Shaw, a 75-year-old woman, was admitted to the hospital on September 23, 2018 after fracturing her left hip in a fall. She underwent a hip replacement surgery and was discharged on September 28. She has diabetes that was well-controlled prior to surgery but became stressed after. Her mobility improved with a walker before discharge. Her daughter, who she lives with, is leaving for a year for her husband's job, so Ms. Shaw will be moving to a self-contained flat with steps. The discharge plan includes physical therapy, scar massage once healed, balance exercises, and a home safety assessment by occupational therapy since she will be living alone.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    CASE NOTE 1

    You are Charge nurse at the hospital where a patient Ms Shaw was treated.she is ready for discharge.

    Patient details

    Ms Cindy Shaw, 75 years old


    Height 5’2”, weight 118ibs

    Admitted on; 23 September 2018


    Discharge; 28 September 2018
    Diagnosis; Left hip replacement following fracture sustained after fall (referred by her GP)

    Medical history
     Diabetes mellitus (diagnosed 20 years)
     Precise-25mg
     No other co-morbid conditions

    Social background

     Lives with daughter and son-in-law (30s; no children) in a granny flat


     Spouse dead-10 years
     Daughter-leaving overseas next week (4/10) for a year(husband’s job)
     To move into a self-contained flat.Flat has steps.Okay for walker?
     All routine activities-independent
     Exercise-regular (walking 30min/day-5days/wk)

    Nursing management

    16/09/2018

    Pre-operative;

     HbA1c; 6.5
     Fasting ;125mg/dl
     Post-Prandial (pp); 170mg/dl9reading=good control)

    23/09/2018

    Post-operative;

     HbA1c;7.5
     Fasting ;160 mg/dl PP;250 mg/dl(cause: stress hyperglycemia)
    Given 2 units of insulin
    Catheter and IV fluids w/pain relief medication

    24/09/2018

     Decreased mobility
     Compression stockings for blood flow
     Precose increased to 50 mg post-operatively

    25/09/2018

     Able to walk the bathroom with a walker-catheter removed


     Vicodin 7.5mg (twice daily) for pain (orally)

    27/09/2018

     Compression stockings removed

    28/09/2018

    Readings at discharge

    o 130mg/dl
    o PP;150 mg/dl

     Pain described as 5/10.Increases after walking for 5 mins (7/10)


     Moderate mobility-walk approx. 50-60 steps with the aid
     Incision site –slow healing
     Daily dressing required
     Staples removed in two wks (on 09/10)
     Monitor blood sugar (2/day)

    Discharge plan;

     Physio;ROM and strengthening exercises(weak arms)


     Scar tissue massage (myofascial release technique)-can be considered after incision heals
     Balance exercises-decrease risk of falling
     Occupational therapy ;complete a home hazard assessment since she will be living alone
     Discussed with patient;Non-slip mat for bathroom ?Rails?Worried,needs help from daughter for
    cost
     Sock &shoe horn,reacher,dressing stick and raised toilet (purchased by daughter)
     Needs to be shown how to cook meals ,i.e.using reacher,no bending ,etc.Placement of food items
    important
     Can resume mild exercise after 12 weeks subject to physio review of progress
     Yearly X-rays.
    Writing task

    1 .write a letter to home health nurse Mr Minsub Park who will be visiting Ms Shaw every day. Use the
    information given in the case notes to outline the home care treatment plan and management for Ms Shaw

    2. Write a letter to occupational therapist Claudia Mayhem to outline the home assessment and
    management for Ms Shaw

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