Christine Walker 66 year old indigenous female Reason for admission: Fall at home resulting in a fractured Right Neck of Femur (NOF) Had Total Hip Replacement 2 days ago PMH Type 2 Diabetes –...

Christine Walker

66 year old indigenous female

Reason for admission:

Fall at home resulting in a fractured Right Neck of Femur (NOF)

Had Total Hip Replacement 2 days ago

PMH

• Type 2 Diabetes – medication and diet controlled


• Crohns disease- has permanent colostomy


• Osteoarthritis - bilateral knees and hips


• Denies alcohol and illicit drug use


• Non smoker

Nutritional assessment:

Unable to be weighed due to #NOF

Patient states she is approximately 170cms and 83Kg’s

Patient referred to diabetic educator, but has not complaint in attending appointments

Anthropometrics

• BMI 29

Vital signs

T 37.2

HR 90 regular

RR 16 equal air entry

SP02 97% on room air

Pain level 3/10 at rest and 7/10 on movement

BGL 8.7mmol

Allergies

Nil known allergies

Spiritual, cultural needs:

Ethnic group = indigenous

Religion = Methodist

Social history

• Patient lives with her husband in a double storey house located 150kms from the nearest medical facilities. The bedrooms, toilet and shower are all upstair There is also a downstairs toilet


• Patient can transfer independently and is normally mobile with an altered gait and often needs to use a walking stick. However, states that she is currently not walking very much ‘my joints are too sore and stiff’ and needs help from her husband to climb up the stairs.


• She doesn’t drive so social connections are very limited


• Currently reports not being able to sleep properly and only managing 2-3 hours per night due to the pain in her joints


• She has a good appetite and states that she adheres to her diabetic diet


• Her husband does the housekeeping, but the patient is able to cook their meals.


• Is compliant with her prescribed medication but relies heavily on over the counter anti-inflammatory medications and bush remedies


• Relies on her husband to assist her with ADL’s due to her mobility


• Has difficulty at times changing her colostomy, husband assists her


• Patient has no deficits with hearing or communication, but wears glasses


• Has a supportive extended family

How can I provide care to this patient