Lisa Rae, a 78-year-old Caucasian female, was admitted throughthe emergency department Monday at 9 am with complaints ofcontinued dizziness following a fall at her assisted livingfacility.Has history of falls, hypertension and takes medication tocontrol her BP. While in the ER , Mrs. Rae was found to behypotensive and IV fluids were initiated. Experienced urinaryincontinence since admission.
She is supine in bed with the head of bed at 60 °. Requests siderails be lowered so she can get up to go to the bathroom byherself, she is embarrassed of her urinary incontinence.
She states, “My bottom is sore. I hope that being wet has notcaused a rash down there. I hate not being able to get up andmove.”
T = 98.2 F (36.8 C) BP = 92/74 P = 86 RR = 18 O2 Sat = 98% (roomair) Heart sounds: Regular Lung sounds: Clear Abdominal sounds:Present Pulses: Normal (2+) Pain: 3/10
She asks, “Sweetie, can you put these side rails down so that Ican get out of bed when I need to go to the bathroom?”
Now it is
T = 98.4 F (36.9 C) BP = 96/72 P = 82 RR = 18 O2 Sat = 97% (roomair)
Mrs. Rae states, “I really can take care of myself pretty well. I’mstrong and able to get around. I don’t want to bother you. You haveplenty to do already.” A loud crashing noise, signaling that Mrs.Rae has fallen.
– Six nursing interventions. List them in order ofpriority.
– With SBARR tool give a full report to the physician in writing onwhat occurred.
