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Transcript of Case Study
Mr X Now
Nursing assessment & Documentation
Falls risk; moderate* according to JHC
Pt moved closer to nurses station
77 year old
Symptoms & Diagnostic test
Post MI CT revealed at SCGH
JHC Policy; Interventions from FALLS RISK
Pt reminded to call for assistance
Pin point pupils => raised ICP
Alteration in limb movement or LOC => further bleed
(Chadwick Optical, 2009)
Loss of vision
in either the right or left sides of both eyes; a common
side effect of
; Hemianopia (vision loss)
> Causes serious problems with mobility, bumping into objects,
increased incidence of falls and accidents
and reading problems.
Chadwick Optical, 2009
He is doing well at home, things are
"getting better, slowly, each day"
He has started
Walks with his wife
when mobilising due to
tendency to divert right
Malnutrition Screening Tool
10kg weight loss
=> Symptom of
Weight loss interventions
Referred to dietician
soft N/Fluids =>soft/normal diet
Parietal Craniotomy &
= scored 3
No decreased appetite
Firestein, G.S., Budd, R.C., Harris, E.D., et al, eds. (2008). Kelley's Textbook of Rheumatology (8th ed.). Philadelphia, Pa: Saunders Elsevier.
(Firestein, Budd, & Harris, et al, 2008)
TA => Sudden vision loss or eye muscle weakness
Decrease in speech generation & comprehension
Difficulty in comprehension of language, reading & writing
focusing visual attention
Poor visual perception
Lack of awareness of certain body parts &/ surrounding spaces
LOC / GCS
- 'normal power'
Balance & coordination
No jugular vein distension
Normal S1 &S2 heart sounds at APETM
No audible heat murmurs
Low BP (varies)
Pulses palpable; weak & regular
NOTE; No tenderness of temporal arteries
no current AF
cap. refill <3sec
Acute Myocardial Infarction
12 days post op
CT at JHC 1 day post admission
Stroke/ cerebrovascular accident
Coronary artery stenosis
Coloxyl & Senna
Poly tears- eye drops
American Accreditation HealthCare Commission (2013). Temporal Arteritis. New york.
Shower chair on D/C
Regular mild exercises; inc. balance & coordination
-Medical Devices were not warranted
-On top of daily allied health, visitors would stay for hours.
-This was taking a toll on the pt's health - very tired
-Nursing spoke to pt & wife, who later limited time for friends to visit
Pt has been incredibly positive throughout the experience and feels
his situation has to be handled one day at a time.
Reading, Writing & Word Pronunciation/ recognition
Wife visited daily. Very supportive family.