Alert & Oriented x2 (recognizes she is hospital but not city location, is able to tell the month and can follow simple commands sometimes, cannot recall DOB)

No known allergies

Independent mobility

Experiences nausea

Clear breaths on all sides

Non-productive cough

Symmetrical chest expansion

Regular heart sounds

Capillary refill less than/equal to 2s

No impaired sensory perception

Rarely moist

Walks occasionally.

Bowels sounds present and active on all quadrants.

No incontinence

Abdomen soft and non-tender

No lines, drains or wounds

Skin complexion appropriate for ethnicity

History of Alzheimer’s dementia, anxiety, cataract, depression, diplopia, glaucoma, hearing loss, stroke, diverticulitis.

Vital Signs

Hr – 75 Regular, Monitor

Rr – 16

BP – 93/62 LA, Automatic, Lying

Temperature – 36.8 Oral

Spo2 – 94% RA

Pain – on and off on LLQ

Pedal pulses present

Brachial and radial pulses are equal.

MEDICATIONS

–        Acetylsalicylic acid (ASA) TAB chewable 80mg, oral, daily

–        Amoxicillin – clavulanate (clavulin) 875-125 mg per TAB1, oral, daily

–        Cholecalciferol (Vitamin D3) tab 4000 units, oral, daily

–        Duloxetine (Cymbalta) delayed release capsule 30mg, oral, daily.

–        Enoxaparin prefilled syringe 40mgMagnesium (Tecta), delayed release, tab 40mg, Subcut, Nightly

–        Mirtazapine (REMERON) TAB 15mg, oral, Nightly

–        Pantoprazole magnesium (TECTA) delayed released tablet 40mg, oral, daily.

–        Potassium chloride (K-10) solution 40 mmol, oral, daily

PRN

–        Acetaminophen (Tylenol) suppository 650mg, rect, q4h

–        Acetaminophen (Tylenol) suppository 650mg, oral, q4h

–        Acetaminophen (Tylenol) suppository 650mg, EN, q4h

–        Melatonin sublingual (SL) TAB 3mg, nightly

–        Melatonin sublingual (EN) TAB 3mg, nightly

–        Ondansetron (Zofran) 2mg/mL injection Subcut, 4mg, q8h

–        Ondansetron TAB 4mg, oral, q8h

–        Ondansetron TAB 4mg, EN, q8h

Subjective”

“I don’t remember.”

“It was hurting before, it stopped but now it’s hurting again.”

“Looking at the food makes me want vomit.”

“I can’t eat, or I’ll vomit.”

“If I rest it will go away”

Risk for falls as evidenced by history of anxiety and depression, nausea and ability to follow or understand simple commands only sometimes.

Risk for impaired skin integrity as evidenced by Intra-abdominal abscess.

Goal

Short term – Review home safety and free from hazards that could increase falls risk, educate patient about what does hazards could be and how to minimize or remove altogether to reduce fall risk by the day prior to discharge date.

Long term – Encourage movement of the patient after sitting and lying for hours muscles and improve balance. Review with other healthcare professionals’ medications that could be increasing patients fall risk.

Nursing Interventions

1.     Fall proof home.

2.     Educate patient on importance of good sleep, extra caution, free hands, and right footwear.

3.     Educate patient on staying or on how to stay as calm as possible in case of a fall.

–        Have patient stand up slowly and check BP.

–        Plan an exercise program along side a physiotherapist that is right for the patient.

–        Find out side effects of medications

Rationale

1.     Check out changes that can be made to patients home to ensure safety.

2.     Tiredness increases likelihood of falls, taking extra caution especially around slippery surfaces can help avoid falls, having hands free allows for the ability to hold onto railings and the right footwear can assist in supporting feet.

3.     Staying calm allows people to get over shock and make more rational decision about their next steps

–        Standing to quickly can cause a drop in BP resulting in dizziness.

–        Exercise helps keep joints, tendons, and ligaments flexible and mild weight-bearing activities may slow bone loss from diseases like osteoporosis.

–        If a medication causes nausea or dizziness review with a physician other available options to decrease falls risk.

Short Term – Not met, patient was discharged before education could be provided or home reviewed.

Long term – mostly not met, BP was often checked and medication side effects were explored but was unable to contact a physiotherapist to organize an exercise plan and a physician to review meds with.