A 70 year old female named Marjory

A 70 year old female named Marjory lives with her 78 year old husband Tom. Tom appears to be in the early stages of dementia but has not been formally diagnosed. They live in a retirement home in a rural municipality outside of an urban centre. They have lived in the facility for over a year. They sold their house in the city because they could no longer manage the day to day activities and upkeep of their home. The 70 year old female has limited mobility and uses a walker for short distances, is type II insulin dependent diabetic, with a history of heart failure, breast cancer and has been diagnosed with non-alcoholic cirrhosis of the liver (etiology NAFLD). She presents to the ER via ambulance alone because she fell at home and hit her head. She has a history of falling and has been through the ER several times for same issue. The facility staff called the ambulance because the husband could not help her up and did not think to call an ambulance. Upon arrival to the ER, the 70 year old female doesn’t remember to bring her medication list. Upon assessment it was discovered that she has a BP is 90/50, HR is 99 bpm, R-22, T-37°C, blood glucose is 18mmol/L and she is oriented times 3 and states she has been very tired and weak for several months and she has been bleeding rectally on and off for about 2 months. Pedal pulses present bilaterally. No pitting edema noted. Lungs clear – no adventitious sounds noted. 2. Use the following questions to help you develop your report: a. Explain why is this case significant? Why should we, as nurses, look closer at this case? b. Describe all significant facts about the patient and the situation. c. Define some important considerations regarding this case. d. Explain was done wrong in this situation and/or what was done well. e. Consider standard protocol for dealing with this patient’s main issues. f. State some recommendations one would make in this situation. 3. Organization for Report: Title: Must be descriptive, clear, direct Introduction: Must describe the purpose for report Description: Provides a detailed description of case, includes all relevant information Discussion: States significant findings, compares/contrasts to research/protocols. Conclusions: Draw conclusions and make further recommendations SCIENCE HEALTH SCIENCE NURSING

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