AN ASSIGNMENT ON MRS. AUDREY SMITH
STD NAME : VIPIN ABRAHAM VARUGHESE GROUP : THIRD DUE DATE : 07/06/2013 STUDENT NO : 12185
INTRODUCTION
During my duty time at 1400 l had taken hand over about Mrs. Audry Smith,she is a 75 year old lady admitted to emergency department and she was diagnosed with fractured left NOF, soft tissue injury,brusng left shoulder and small hematoma to her left fore head,she was also scheduled surgery for arthroplasty- L hip after three hour
Nursing documentation
Identification data
Name : Mrs. Audrey Smith
Address : 440 Collins St. Melbourne Vic 3000
DOB : 31/12/38
Age : 75 years old
Diagnosis : Fractured left NOF (neck of femur)
Past Medical History 1 AF 2 Hypertension 3 L CVA -2008 4 NIDDM - 2OO8 5 GORD 6 Osteoporosis 7 Total hysterectomy – 1995 8 Depression -2011
Allergies
Bactrim.
Social history 1 Husband died in 2010. 2 One adult daughter sees infrequently. 3 Council home care once per fortnight. 4 Attends Senior Citizens once per week with her neighbor. 5 Social drinker. 6 Non-smoker x 25 years.
NURSING INTERVENTIONS
I. COMFORT AND SAFETY.
1. Assess the patient level of consciousness, the positioning of limb and spine ,site where the pain is experienced