Mrs. Bohne is an 85-year-old woman who was admitted to the surgical…Mrs. Bohne is an 85-year-old woman who was admitted to the surgical…
Question Answered step-by-step Mrs. Bohne is an 85-year-old woman who was admitted to the surgical… Mrs. Bohne is an 85-year-old woman who was admitted to the surgical unit on January 25, 2021, after a fall at home. Mrs. Bohne was a schoolteacher for 40 years of her life. She is now widowed and lives at home with her son. Prior to admission she used a walker to ambulate but could only walk short distances around her home due to her severe osteoarthritis. Mrs. Bohne rarely left the house and spent most days in a recliner watching television. She loves to watch the Catholic service on Sunday as this is one way, she practices her faith. Her son has been providing three meals for her and snacks as requested, but her intake has been decreasing. Her son has been providing “soft” foods because of her complaints about her dentures hurting but she has been eating very little. When he would question her about her intake, she always responded “I’m just not that hungry.” Mrs. Bohne has a past medical history of hypertension, osteoarthritis and osteoporosis. Her past surgical history included a cholecystectomy at age 53 yrs. Mrs. Bohne has no known allergies and is a DNR status. She takes Bisoprolol 5mg, PO daily, Alendronate 70mg, PO once a week, and Tylenol, 1g, PO q6h PRN for pain.You are the nurse on the surgical unit when Mrs. Bohne and her son arrive.Mrs. Bohne’s son, Mark stated that he returned home after work to find his mother on the floor complaining of left-sided hip pain. When the paramedics lifted her off the floor, a red spot on her left hip was evident. In the emergency department, Mrs. Bohne was diagnosed with a left fractured hip. She has an IV of 2/3 & 1/3 running at 80 mL/hr in her right hand.On assessment her vital signs were Temperature -36.9 degrees Celsius, Pulse (radial) – 102 bpm, Respirations – 24 breaths/min, Blood Pressure-148/98 mmHg, O2 sat-93% on room air. She currently rates her pain in her left hip as 7/10 on a numerical pain scale, which is worse on moving.Mrs. Bohne speaks English well and reports that she often has pain at home but takes pain medication sparingly as she is afraid, she will become dependent on it. She does not sleep well due to her joint pain but does not want to move in bed because it causes more pain to move. On examination her left leg is externally rotated and shorter than her right leg. She has strong peripheral pulses to bilateral legs. She is now unable to mobilize due to her fracture and will need assistance to turn in bed.Her skin is dry and has poor turgor, with a red spot on her left hip, however it is currently intact, and her Braden Scale score is 13.She has a Hendrick II Fall Risk of 4.Her son was surprised and embarrassed to learn that his mother’s weight had decreased from approximately 140 pounds a year ago to 117 pounds, which was determined from bed scales on admission. Her son said he knew she had lost weight but did not realize how much. Mrs. Bohne stated her height to be 5’7″. Her BMI is 18.3. Her abdomen is firm and slightly distended with hypoactive bowel sounds present in all four quadrants. She says she has not had a bowel movement for several days and the last one was dry and hard.Her laboratory results were mostly unremarkable except for her serum albumin at 3.2 g/dl. An X-ray of her hip showed a fracture in the upper portion of her femur. Assessment DataNursing Diagnosis/Problem StatementShort Term Goal/OutcomeNursing InterventionsRationaleEvaluation Health Science Science Nursing PNC 121 Share QuestionEmailCopy link Comments (0)
