Chart Analysis Hip Fracture Patient

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Paula MezaChart Analysis

91 years oldAllergic to AromasinDNR

History of Present Illness:Hip Fracture - patient fell in her home and broke her hip (admitting diagnosis). Vascular Dementia brought on by several TIA’s (Etiology/Pathology) Pts. progressive cognitive deficits led to her fall, and inabilility to perform normal ADL’s and self care. Since being admitted to Thompson, pt. has had consults with oncology in regards to her breast cancer diagnosis, with a GI specialist in regards to her dysphagia, and with a social worker in regards to her mental acuity and appropriate social activities related to her cognitive level.

PMH (Past Medical History)/Co-Morbidities: Breast Cancer, Rheumatoid Arthritis, anhedonia, depression, gout, anemia, hypertension, dysphagia

Psychosocial HistoryPt. was married for a long time, husband deceased. Pt. worked on a farm and as a customer service clerk at several stores. Has 4 children, 3 that live in the area and are involved. Pt. has a high school diploma and worked on a farm and as a customer service employee at several stores.

Nursing Care and Treatments:Pt. was assessed using the Braden Pressure Ulcer Risk Assessment scale due to immobility – pt. requires a full mechanical lift and spends the time she is not in bed in a wheelchair. Clinical pathways – monitor pt. for changes in level of cognitive impairment by conducting mental assessments. Oncologist has recommended pt. have periodic evaluations for spread of breast cancer that is currently being treated palliatively. Pts. functional capabilities allow her to be verbal and is able to speak and make her needs known

Therapies prescribed: Pt. has also seen an Occupational Therapist to determine the best way to incorporate pt. on the floor and in her surroundings related to her baseline. They have recommended that pt. spend time among the residents to keep her actively involved in the floor and engaged with others.

Medical Tests:...
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