Hey nurses! 👋
Last week we looked after Mary Byrne, a 75 year old patient admitted after a fall at home, an increase in her confusion and a decrease in her ability to perform her ADLs. The answers to our critical thinking questions are below!
Name: Mary Byrne
DOB: 10/02/1944, Age 75
Allergies: Nil Known
Admission: Due to fall at home. Admitted 1 week ago. Bruising noted to right arm and right hip on fall. No head injury noted. Skin not broken or damaged due to fall.
PMHx: Dementia, HTN regular falls, increased wandering in the past few weeks.
Social: Lives at home with daughter who works full-time. Current services at home are: Meals on Wheels and a carer visiting the house 2 mornings a week. Family finding it harder to cope and manage Mary's care at home.
- Height 160cm, Weight 46kg, BMI 18. Patient is underweight.
- Mary is more confused since admission
- She can be verbally aggressive at times, particularly in the evening.
- Not oriented to time or place.
- Decrease in appetite reported by family over past few weeks. Tolerating her lunch and cups of tea during the day. Refusing breakfast and evening meals.
- Increase in incontinence of urine. Before admission, occasionally incontinent overnight. Now Mary is incontinent throughout the day and night of urine.
- Requires full assistance with ADLs; showering, changing, and prompting to eat as she forgets to do these tasks. This has become more apparent since admission.
Observations this AM completed by AIN:
RR 22, 02 Sats 98% RA, BP 140/ 85, HR 110 regular, Temp 38.2, BSL 3.5 (taken due to decrease in intake)
Critical Thinking Questions:
1) What are your main concerns or issues arising from this scenario?
Mary's increase in confusion, disorientation, RR22, Temp 38.2, BSL 3.5.
2) What could be a possible cause for Mary's acute increase in confusion?
Disorientation and confusion, BP medication, Infection (UTI), BSL low due to poor appetite.
3) Should we complete a GCS on Mary? What would you expect it to be if so?
Yes, her GCS would be 13/15. We should complete one to continue monitoring changes/ deterioration in neurological status of patient
4) Are Mary's observations BTF? What other tests do you think should be run on Mary?
Concerned re RR 22, and Temp 38.2. Could be an indication of a possible UTI. We should run a urinalysis and MSU on Mary. BSL less than 4. Hypoglycaemic management should be put in place
5) What would be your plan of care for Mary?
Manage BSL, GCS assessment, Urine sample, Full assistance with ADLS, Assistance with meals and prompting, dietician review and follow up on observations more frequently
Remember, if you have any questions about the case or the above questions, post them in the comments below and we can have a discussion this week! We will be posting the answers to the Case Study on our blog next Friday!