Case Scenario:
An 86-year-old female was transported by ambulance to theemergency department (ED) for evaluation after experiencing anunwitnessed fall in a local nursing home. The patient resided atthe nursing home and had a medical history of severe dementia andosteoporosis. The patient arrived to the ED alone without family orstaff from the local nursing home.
Upon arrival to the ED, the patient was triaged by nursingstaff. The triage documentation noted the patient’s vital signswere stable, that she was a poor historian and complained of“hurting all over”. After triage was completed, the patient wastaken to a bed in the ED treatment area, which was locatedapproximately 20 feet from the nurses’ station, but not in directview of the station.
The registered nurse assigned to the patient documented that thepatient was confused, uncooperative and incontinent. The nursingassessment was completed and noted the patient to be an elderlymale at risk for falls. Specific interventions were also documentedto implement fall interventions, to include side rails up, placecall bell within reach of patient, maintain bed in low position,and consider patient placement close to nursing station.
Two hours later, the patient was evaluated by the ED practitioner.The practitioner noted the patient was restless and ordered asedation medication in preparation for diagnostic tests whichincluded a CT scan of the head, and imaging studies of the knee,pelvis and ribs. The assigned nurse administered the orderedsedative and the tests were completed in the diagnostic imagingdepartment. The patient was returned to her bed in the ED treatmentarea. The results of the diagnostic tests were reported asnegative.
Following the patient’s return to the ED, the nurse assisted thepatient to the bathroom, noting that she was able to walkindependently, but had an unsteady gait. The nurse left the roomafter returning the patient to her bed, placing the side rails upand the call bell within reach of the patient.
Thirty minutes later, housekeeping staff found the patientyelling, laying on the floor on her right side, next to her bed.Staff immediately responded and the patient was assessed by the EDpractitioner. Following the department protocol, staff applied acervical collar to the patient’s neck, placed her on a backboardand then lifted her to a stretcher. The patient complained of painin his right hip, and his right leg was noted to be shortened andinternally rotated. The patient underwent additional diagnostictests, and the hip x-rays results confirmed a fractured right hip.Following her return from the imaging, the patient was moved to abed closer to the nursing station.
The patient was later admitted to the hospital from the ED andevaluated by an orthopedic surgeon the following morning. Surgicalintervention for the hip fracture was recommended by the surgeonand the patient’s son provided consent for the procedure. Thepatient underwent an open reduction and internal fixation of hiship fracture.
Post-operatively, the patient developed pneumonia which requiredantibiotic therapy and lengthened his hospitalization. She wassubsequently discharge back to the nursing home. Despite having thediagnosis of dementia, the patient was able to ambulate prior tothis hospitalization, but her activity level is now limited to awheelchair.
Admitting Diagnosis:
Cues Nursing Diagnosis
Objective of Care
Nursing Intervention
Rationale
Evaluation
Subjective cue:
Objective cue:
