Lucille Mckenzie Case Summary

Lucille Mckenzie, a 72 year old female accompanied by her stepdaughter/ sole carer Marjorie Wilson was admitted to the ward on the 17th January via Accident and Emergency (A&E), following a fall at home. X-rays revealed healing fractures of several ribs and arthritic changes, but no bony injury of her right hip.
Presenting features included, a recent history of unexplained falls spanning over 9 months, mild confusion, a productive cough with yellow sputum, dyspnoea, indigestion and acute urinary incontinence over the last 3 days. Abnormal observations included an increased respiration rate of 24 per minute and mild pyrexia of 37.8 degrees Celsius (Kozier et al., 2008). A Modified Early Warning Score was charted as 2 and hourly observations scheduled. I n addition lying and standing blood pressure were taken as postural hypotension is an intrinsic risk factor for falls (DOH 2001).
Baseline urinalysis confirmed the presence of Leukocytes, protein and keotones, which could indicate possible infection, dehydration or malnutrition. Nazarko (2009) believes Urinary tract infections (UTI’s) may be a transient cause of incontinence and confusion additionally, yellow sputum could indicate infection. A
The tool I have chosen is lengthy but thorough and includes a symptom profile with facilitates which care pathway to use. It involves a physical and external vaginal examination to help rule out retention, abdominal mass and oestrogen deficiency, this is not evident in the assessment tool itself but is explained in the care pathway. It also helps identify any fluid restriction the patient has placed upon themselves. This was evident in Lucille due to cracked lips, increased pulse and dry mucus membranes. Particularly advantageous is the use of a bladder scanner to measure post void