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Case Note 1: Patient Details

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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1K views3 pages

Case Note 1: Patient Details

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.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Case Note for Ms Shaw
  • Writing Task

CASE NOTE 1

You are Charge nurse at the hospital where a patient Ms Shaw was [Link] 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 [Link] has [Link] 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/[Link] 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 ,[Link] reacher,no bending ,[Link] 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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